Search

High-intensity statins, beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and antiplatelet agents (ie, intensive medical management) reduce coronary heart disease (CHD) risk after myocardial infarction (MI). The objective of the study was to determine the risk of CHD events or death despite receiving intensive medical management after MI. We studied 16,853 United States adults with health insurance in the MarketScan and Medicare databases who underwent percutaneous coronary intervention while hospitalized for MI between January 1, 2014 and June 30, 2015 and received intensive medical management within 30 days after hospital discharge. MI, CHD, and all-cause mortality rates from 30 days after hospital discharge through December 31, 2015 were compared with 67,412 individuals in each of three groups: (1) the general MarketScan and Medicare populations, (2) with diabetes, and (3) with a CHD history. Among beneficiaries intensively medically managed after their MI, recurrent MI, CHD events, and all-cause mortality rates were 47.1, 72.0, and 57.5 per 1000 person-years, respectively. The multivariable-adjusted hazard ratio (95% CI) comparing intensively medically managed beneficiaries after MI to the general population, those with diabetes, and those with a history of CHD were 8.54 (7.52–9.70), 7.40 (6.61–8.28), and 5.45 (4.92–6.05), respectively, for recurrent MI; 7.82 (7.07–8.64), 6.27 (5.74–6.86), and 4.45 (4.10–4.82), respectively, for CHD events; and 1.15 (1.05–1.25), 1.05 (0.97–1.14), and 1.06 (0.97–1.15), respectively, for all-cause mortality. Substantial residual risk for MI and CHD events remains despite intensive medical management after MI. • Risk after myocardial infarction is high despite intensive secondary prevention. • AHA/ACC guideline risk-enhancing factors predict risk after myocardial infarction. • New therapies targeting residual risk after myocardial infarction are warranted. [ABSTRACT FROM AUTHOR]

Objective: To determine the concordance in the prevalence of hypertension and pharmacological antihypertensive treatment recommendations for U.S. adults with diabetes using definitions from the 2017 American College of Cardiology/American Heart Association (ACC/AHA) blood pressure (BP) guideline and the 2017 American Diabetes Association (ADA) diabetes and hypertension position statement.Research Design and Methods: We analyzed data for U.S. adults with diabetes in the U.S. National Health and Nutrition Examination Survey (NHANES), 2011-2016 (n = 2,266). Diabetes was defined by treatment with glucose-lowering medication, glycosylated hemoglobin ≥6.5%, fasting serum glucose ≥126 mg/dL, or nonfasting serum glucose ≥200 mg/dL. BP was measured three times and antihypertensive medication use was self-reported.Results: The prevalence (95% CI) of hypertension among U.S. adults with diabetes was 77.1% (73.9, 80.0) and 66.3% (63.4, 69.1) according to the ACC/AHA and ADA definitions, respectively. Also, 22.9% (20.0, 26.1) did not have hypertension according to either definition, and the concordance in hypertension status was 89.2% (87.2, 91.0). Among U.S. adults with diabetes not taking antihypertensive medication, 52.8% (47.7, 57.8) were not recommended to initiate antihypertensive medication by either the ACC/AHA or the ADA document and 22.4% (19.2, 25.9) were recommended to initiate it by both documents (overall concordance 75.2% [70.4, 79.4]). Among those taking antihypertensive medication, 45.3% (41.3, 49.4) and 50.4% (46.5, 54.2) had BP above the goal in neither and both documents, respectively (overall concordance 95.7% [93.4, 97.2]).Conclusions: A high percentage of U.S. adults with diabetes are provided identical antihypertensive treatment recommendations by the ACC/AHA BP guideline and the ADA diabetes and hypertension position statement. [ABSTRACT FROM AUTHOR]

Background: Relative risks (RRs) for cardiovascular disease (CVD) by smoking rate exhibit a concave pattern, with RRs in low rate smokers exceeding a linear extrapolation from higher rate smokers. However, cigarettes/day does not by itself fully characterize smoking-related risks. A reexamination of the concave pattern using a comprehensive representation of smoking may enhance insights.Methods: Data were from the Atherosclerosis Risk in Communities (ARIC) Study, a prospective cohort enrolled in four areas of the US in 1987-1989. Follow-up was through 2008. Analyses included 14,233 participants, 245,915 person-years, and 3,411 CVD events.Results: The concave RRs with cigarettes/day were consistent with cigarettes/day modifying a linear RR association of pack-years with CVD (i.e., strength of the pack-years association depended on cigarettes/day, indicating that the manner of pack-years accrual impacted risk). Smoking fewer cigarettes/day for longer duration was more deleterious than smoking more cigarettes/day for shorter duration (P < 0.01). For 50 pack-years (365,000 cigarettes), estimated RRs of CVD were 2.1 for accrual at 20 cigarettes/day and 1.6 for accrual at 50 cigarettes/day. Years since smoking cessation did not alter the diminishing strength of association with increasing cigarettes/day. Analyses that accounted for competing risks did not affect findings.Conclusion: Pack-years remained the primary determinant of smoking-related CVD risk; however, accrual influenced RRs. For equal pack-years, smoking fewer cigarettes/day for longer duration was more deleterious than smoking more cigarettes/day for shorter duration. This observation provides clues to better understanding the biological mechanisms, and reinforces the importance of cessation rather than smoking less to reduce CVD risk. [ABSTRACT FROM AUTHOR]

Smoking is the leading cause of preventable death in the United States. Studies have shown that smoking status tends to be concordant within spouse pairs. This study aimed to estimate the association of spousal smoking status with quitting smoking in US adults. We analyzed data from 4,500 spouse pairs aged 45–64 years from the Atherosclerosis Risk in Communities Study cohort, sampled from 1986 to 1989 from 4 US communities and followed up every 3 years for a total of 9 years. Logistic regression with generalized estimating equations was used to calculate the odds ratio of quitting smoking given that one's spouse is a former smoker or a current smoker compared to a never smoker. Among men and women, being married to a current smoker decreased the odds of quitting smoking (for men, odds ratio (OR) = 0.37, 95% confidence interval (CI): 0.29, 0.46; for women, OR = 0.54, 95% CI: 0.43, 0.68). Among women only, being married to a former smoker increased the odds of quitting smoking (OR = 1.26, 95% CI: 1.04, 1.53). In conclusion, spouses of current smokers are less likely to quit, whereas women married to former smokers are more likely to quit. Smoking cessation programs and clinical advice should consider targeting couples rather than individuals. [ABSTRACT FROM PUBLISHER]

Background: Several fast food companies have made commitments to reduce the levels of salt in the foods they serve, but technical issues are often cited as a barrier to achieving substantial reductions. Our objective was to examine the reported salt levels for products offered by leading multinational fast food chains. Methods: Data on salt content for products served by six fast food chains operating in Australia, Canada, France, New Zealand, the United Kingdom and the United States were collected by survey in April 2010. Mean salt contents (and their ranges) were calculated and compared within and between countries and companies. Results: We saw substantial variation in the mean salt content for different categories of products. For example, the salads we included in our survey contained 0.5 g of salt per 100 g, whereas the chicken products we included contained 1.6 g. We also saw variability between countries: chicken products from the UK contained 1.1 g of salt per 100 g, whereas chicken products from the US contained 1.8 g. Furthermore, the mean salt content of food categories varied between companies and between the same products in different countries (e.g., McDonald's Chicken McNuggets contain 0.6 g of salt per 100 g in the UK, but 1.6 g of salt per 100 g in the US). Interpretation: The salt content of fast foods varies substantially, not only by type of food, but by company and country in which the food is produced. Although the reasons for this variation are not clear, the marked differences in salt content of very similar products suggest that technical reasons are not a primary explanation. In the right regulatory environment, it is likely that fast food companies could substantially reduce the salt in their products, translating to large gains for population health. [ABSTRACT FROM AUTHOR]

Despite reportedly having less tobacco exposure compared with whites, African Americans account for a disproportionate number of smoking-related deaths. The purpose of this study was to compare the prospective associations between smoking and cardiovascular risk in whites and African Americans. Smoking status was obtained on 14,200 participants from the Atherosclerosis Risk in Communities Study. Incidence of cardiovascular disease (CVD) was ascertained from 1987 through 2007. Adjusted Cox proportional hazard models were used to estimate the CVD incidence associated with smoking behavior. Over 17 years’ follow-up, there were 2,777 cardiovascular events. In men, compared with never smoking, current smoking was independently associated with 67% (95% confidence interval (CI): 43, 95) and 72% (95% CI: 30, 126) greater risk of CVD in whites and African Americans, respectively. In women, the smoking-related cardiovascular risk was higher: 136% (95% CI: 88, 196) and 169% (95% CI: 126, 219) in African-American and white women, respectively. Early age at smoking initiation was independently associated with increased risk among all participants irrespective of race. Smoking cessation during follow-up was equally beneficial in both whites and African Americans. African Americans who smoke incur a similar level of cardiovascular risk as white smokers and would derive the same benefits from quitting as whites. [ABSTRACT FROM PUBLISHER]

The article presents a study on medication trends among U.S. adults with diabetes mellitus and the impact of glycemic control on cardiovascular diseases (CVD). It examines the treatment priorities for U.S adults with diabetes by studying the use of antihypertensive and antidiabetes medications. The use of antidiabetes medications exceeded the proportion of adults taking hypertensives, and highlights the concerns in controlling hyperglycemia at the expense of reducing and controlling CVD.

The article presents perspectives shared by physicians on the use of comparative effectiveness research (CER) in the U.S. A survey was randomly conducted on 6000 physicians from the American Medical Association (AMA). Results show that only 50% of respondents agreed that guidelines should be developed for CER to improve quality care, while only 35% disagreed.

Background: Rates for recurrent coronary heart disease (CHD) events have declined in the United States. However, few studies have assessed whether this decline has been similar among women and men.Methods: Data were used from 770 408 US women and 700 477 US men <65 years of age with commercial health insurance through MarketScan and ≥66 years of age with government health insurance through Medicare who had a myocardial infarction (MI) hospitalization between 2008 and 2017. Women and men were followed up for recurrent MI, recurrent CHD events (ie, recurrent MI or coronary revascularization), heart failure hospitalization, and all-cause mortality (Medicare only) in the 365 days after MI.Results: From 2008 to 2017, age-standardized recurrent MI rates per 1000 person-years decreased from 89.2 to 72.3 in women and from 94.2 to 81.3 in men (multivariable-adjusted P interaction by sex <0.001). Recurrent CHD event rates decreased from 166.3 to 133.3 in women and from 198.1 to 176.8 in men (P interaction <0.001). Heart failure hospitalization rates decreased from 177.4 to 158.1 in women and from 162.9 to 156.1 in men (P interaction=0.001). All-cause mortality rates decreased from 403.2 to 389.5 in women and from 436.1 to 417.9 in men (P interaction=0.82). In 2017, the multivariable-adjusted rate ratios comparing women with men were 0.90 (95% CI, 0.86-0.93) for recurrent MI, 0.80 (95% CI, 0.78-0.82) for recurrent CHD events, 0.99 (95% CI, 0.96-1.01) for heart failure hospitalization, and 0.82 (95% CI, 0.80-0.83) for all-cause mortality.Conclusions: Rates of recurrent MI, recurrent CHD events, heart failure hospitalization, and mortality in the first year after an MI declined considerably between 2008 and 2017 in both men and women, with proportionally greater reductions for women than men. However, rates remain very high, and rates of recurrent MI, recurrent CHD events, and death continue to be higher among men than women. [ABSTRACT FROM AUTHOR]

Purpose: Many adults with atherosclerotic cardiovascular disease (ASCVD) who are recommended to take a statin, ezetimibe and/or a proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) by the 2018 American Heart Association/American College of Cardiology cholesterol guideline do not receive these medications. We estimated the percentage of recurrent ASCVD events potentially prevented with guideline-recommended cholesterol-lowering therapy following a myocardial infarction (MI) hospitalization., Methods: We conducted simulations using data from US adults with government health insurance through Medicare or commercial health insurance in the MarketScan database. We used data from patients with an MI hospitalization in 2018-2019 to estimate the percentage receiving guideline-recommended therapy. We used data from patients with an MI hospitalization in 2013-2016 to estimate the 3-year cumulative incidence of recurrent ASCVD events (i.e., MI, coronary revascularization or ischemic stroke). The low-density lipoprotein cholesterol (LDL-C) reduction with guideline-recommended therapy was derived from trials of statins, ezetimibe and PCSK9i, and the associated ASCVD risk reduction was estimated from a meta-analysis by the Cholesterol-Lowering Treatment Trialists Collaboration., Results: Among 279,395 patients with an MI hospitalization in 2018-2019 (mean age 75 years, mean LDL-C 92 mg/dL), 27.3% were receiving guideline-recommended cholesterol-lowering therapy. With current cholesterol-lowering therapy use, 25.3% (95%CI: 25.2%-25.4%) of patients had an ASCVD event over 3 years. If all patients were to receive guideline-recommended therapy, 19.8% (95%CI: 19.5%-19.9%) were estimated to have an ASCVD event over 3 years, representing a 21.6% (95%CI: 20.5%-23.6%) relative risk reduction., Conclusion: Implementation of guideline-recommended cholesterol-lowering therapy could prevent a substantial percentage of recurrent ASCVD events., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: The cardiovascular disease risk reduction benefits of proprotein convertase subtilisin/kexin type 9 inhibitor monoclonal antibodies (PCSK9i mAb) and ezetimibe are dependent on remaining on treatment and being persistent and adherent. We estimated the percentage of patients on therapy, persistent and adherent at 182 and 365 days among US adults with health insurance who initiated a PCSK9i mAb (n = 16,588) or ezetimibe (n = 83,086) between July 2015 and December 2019., Methods: Using pharmacy fill claims, being on therapy was defined as having a day of medication supply in the last 60 of 182 and 365 days following treatment initiation, being persistent was defined as not having a gap of 60 days or more between the last day of supply from one prescription fill and the next fill, and being adherent was defined by having medication available to take on ≥ 80% of the 182 and 365 days following treatment initiation. We estimated multivariable-adjusted risk ratios for being persistent and adherent comparing patients initiating PCSK9i mAb versus ezetimibe using Poisson regression., Results: At 182 days following initiation, 80% and 68% were on therapy and 76% and 64% were persistent among patients who initiated a PCSK9i mAb and ezetimibe, respectively. Among patients who were on therapy and persistent at 182 days following initiation, 88% and 81% of those who initiated a PCSK9i mAb and ezetimibe, respectively, were on therapy at 365 days. Among those on therapy and persistent at 182 days following initiation, being persistent and being adherent at 365 days were each more common among PCSK9i mAb versus ezetimibe initiators (persistent: 82% versus 76%, multivariable-adjusted risk ratio 1.07; 95% confidence interval [CI] 1.06-1.08; adherent: 74% versus 71%, multivariable-adjusted risk ratio 1.02; 95% CI 1.01-1.03)., Conclusions: These data suggest approaches to increase persistence and adherence to PCSK9i mAb and ezetimibe should be implemented prior to or within 182 days following treatment initiation., (© 2024. The Author(s).)

Purpose: Adults with atherosclerotic cardiovascular disease (ASCVD) are recommended high-intensity statins, with those at very high risk for recurrent events recommended adding ezetimibe and/or a proprotein convertase subtilisin/kexin type 9 inhibitor if their low-density lipoprotein cholesterol (LDL-C) is ≥70 mg/dL. We estimated the number of recurrent ASCVD events potentially averted if all adults in the United States (US) ≥45 years of age with ASCVD achieved an LDL-C <70 mg/dL., Methods: The number of US adults with ASCVD and LDL-C ≥70 mg/dL was estimated from the National Health and Nutrition Examination Survey 2009-2016 (n = 596). The 10-year cumulative incidence of recurrent ASCVD events was estimated from the REasons for Geographic And Racial Differences in Stroke study (n = 5390), weighted to the US population by age, race, and sex. The ASCVD risk reduction by achieving an LDL-C <70 mg/dL was estimated from meta-analyses of lipid-lowering treatment trials., Results: Overall, 14.7 (95% CI, 13.7-15.8) million US adults had ASCVD, of whom 11.6 (95% CI, 10.6-12.5) million had LDL-C ≥70 mg/dL. The 10-year cumulative incidence of ASCVD events was 24.3% (95% CI, 23.2-25.6%). We projected that 2.823 (95% CI, 2.543-3.091) million ASCVD events would occur over 10 years among US adults with ASCVD and LDL-C ≥70 mg/dL. Overall, 0.634 (95% CI, 0.542-0.737) million ASCVD events could potentially be averted if all US adults with ASCVD achieved and maintained LDL-C <70 mg/dL., Conclusion: A substantial number of recurrent ASCVD events could be averted over 10 years if all US adults with ASCVD achieved, and maintained, an LDL-C <70 mg/dL., (© 2021. Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Understanding how statins, ezetimibe, and PCSK9i (proprotein convertase subtilisin/kexin type 9 serine protease inhibitors) are prescribed after a myocardial infarction (MI) or elective coronary revascularization may improve lipid-lowering therapy (LLT) intensification and reduce recurrent atherosclerotic cardiovascular disease events. We described the use and intensification of LLT among US veterans who had a MI or elective coronary revascularization between July 24, 2015, and December 9, 2019, within 12 months of hospital discharge., Methods: LLT intensification was defined as increasing statin dose, or initiating a statin, ezetimibe, or a PCSK9i, overall and among those with an LDL-C (low-density lipoprotein cholesterol) ≥ 70 or 100 mg/dL. Poisson regression was used to determine patient characteristics associated with a greater likelihood of LLT intensification following hospitalization for MI or elective coronary revascularization., Results: Among 81 372 index events (mean age, 69.0 years, 2.3% female, mean LDL-C 89.6 mg/dL, 33.8% with LDL-C <70 mg/dL), 39.7% were not taking any LLT, and 22.0%, 37.2%, and 0.6% were taking a low-moderate intensity statin, a high-intensity statin, and ezetimibe, respectively, before MI/coronary revascularization during the study period. Within 14 days, 3 months, and 12 months posthospitalization, 33.3%, 41.9%, and 47.3%, respectively, of veterans received LLT intensification. LLT intensification was most common among veterans taking no LLT (82.5%, n=26 637) before MI/coronary revascularization. Higher baseline LDL-C, having a lipid test, and attending a cardiology visit were each associated with a greater likelihood of LLT intensification, while age ≥ 75 versus <65 years was associated with a lower likelihood of LLT intensification within 12 months posthospitalization., Conclusions: Less than half of veterans received LLT intensification in the year after MI or coronary revascularization suggesting a missed opportunity to reduce atherosclerotic cardiovascular disease risk.

Importance: Women remain underrepresented among editors of scientific journals, particularly in senior positions. However, to what extent this applies to medical journals of different specialties remains unclear., Objective: To investigate the gender distribution of the editors in chief at leading medical journals., Design, Setting, and Participants: Cross-sectional study of the editors in chief at the top 10 international medical journals of 41 categories related to the medical specialties of the Clarivate Analytics Web of Science Journal Citation Reports in 2019., Main Outcomes and Measures: Proportion of women as editors in chief., Results: This study found that, overall, women represented 21% (94 of 44) of the editors in chief, with wide variation across medical specialties from 0% to 82%. There were 5 categories for which none of the editors in chief were women (dentistry, oral surgery and medicine; allergy; psychiatry; anesthesiology; and ophthalmology) and only 3 categories for which women outnumbered men as editors in chief (primary health care, microbiology, and genetics and heredity). In 27 of the 41 categories, women represented less than a third of the editors in chief (eg, 1 of 10 for critical care medicine, 2 of 10 for gastroenterology and hepatology, and 3 of 10 for endocrinology and metabolism)., Conclusions and Relevance: This study found that women are underrepresented among editors in chief of leading medical journals. For the benefit of medical research, a joint effort from editorial boards, publishers, authors, and academic institutions is required to address this gender gap.

Background: Adults who have experienced multiple cardiovascular disease (CVD) events have a very high risk for additional events. Diabetes and chronic kidney disease (CKD) are each associated with an increased risk for recurrent CVD events following a myocardial infarction (MI)., Methods: We compared the risk for recurrent CVD events among US adults with health insurance who were hospitalized for an MI between 2014 and 2017 and had (1) CVD prior to their MI but were free from diabetes or CKD (prior CVD), and those without CVD prior to their MI who had (2) diabetes only, (3) CKD only and (4) both diabetes and CKD. We followed patients from hospital discharge through December 31, 2018 for recurrent CVD events including coronary, stroke, and peripheral artery events., Results: Among 162,730 patients, 55.2% had prior CVD, and 28.3%, 8.3%, and 8.2% had diabetes only, CKD only, and both diabetes and CKD, respectively. The rate for recurrent CVD events per 1000 person-years was 135 among patients with prior CVD and 110, 124 and 171 among those with diabetes only, CKD only and both diabetes and CKD, respectively. Compared to patients with prior CVD, the multivariable-adjusted hazard ratio for recurrent CVD events was 0.92 (95%CI 0.90-0.95), 0.89 (95%CI: 0.85-0.93), and 1.18 (95%CI: 1.14-1.22) among those with diabetes only, CKD only, and both diabetes and CKD, respectively., Conclusion: Following MI, adults with both diabetes and CKD had a higher risk for recurrent CVD events compared to those with prior CVD without diabetes or CKD.

Background: Women have lower age-specific rates of incident coronary heart disease (CHD) than men. It is unclear whether women remain at lower risk for CHD events versus men following a myocardial infarction (MI)., Objectives: This study assessed sex differences in recurrent MI, recurrent CHD events, and mortality among patients with MI and compared these associations with sex differences in a control group without a history of CHD., Methods: This study analyzed data for 171,897 women and 167,993 men age 21 years or older with health insurance in the United States who had a MI hospitalization in 2015 or 2016. Patients with a MI were frequency matched by age and calendar year to 687,588 women and 671,972 men without CHD. Beneficiaries were followed until December 2017 for MI, CHD (i.e., MI or coronary revascularization), and in Medicare for all-cause mortality., Results: Age-standardized rates of MI per 1,000 person-years were 4.5 in women and 5.7 in men without CHD (hazard ratio [HR]: 0.64; 95% confidence interval [CI]: 0.62 to 0.67) and 60.2 in women and 59.8 in men with MI (HR: 0.94; 95% CI: 0.92 to 0.96). CHD rates in women versus men were 6.3 versus 10.7 among those without CHD (HR: 0.53; 95% CI: 0.51 to 0.54) and 84.5 versus 99.3 among those with MI (HR: 0.87; 95% CI: 0.85 to 0.89). All-cause mortality rates in women versus men were 63.7 versus 59.0 among those without CHD (HR: 0.72; 95% CI: 0.71 to 0.73) and 311.6 versus 284.5 among those with MI (HR: 0.90; 95% CI: 0.89 to 0.92)., Conclusions: The lower risk for MI, CHD, and all-cause mortality in women versus men is considerably attenuated following a MI., (Copyright © 2020. Published by Elsevier Inc.)

Background: In recent decades, the rates of incident acute myocardial infarction (AMI) have declined in the United States, yet disparities by sex remain. In an integrated healthcare delivery system, we examined temporal trends in incident AMI among women and men., Methods: We identified hospitalized AMI among members ≥35 years of age in Kaiser Permanente Southern California. The first hospitalization for AMI overall, and for ST-segment-elevation MI and non-ST-segment-elevation MI was identified by International Classification of Diseases, Ninth Revision, Clinical Modification primary discharge diagnosis codes in each calendar year from 2000 through 2014. Age- and sex-standardized incidence rates per 100 000 person-years were calculated by using direct adjustment to the 2010 US Census population. Average annual percent changes (AAPCs) and period percent changes were calculated, and trend tests were conducted using Poisson regression., Results: We identified 45 331 AMI hospitalizations between 2000 and 2014. Age- and sex-standardized incidence rates of AMI declined from 322.4 (95% CI, 311.0-333.9) in 2000 to 174.6 (95% CI, 168.2-181.0) in 2014, representing an AAPC of -4.4% (95% CI, -4.2 to -4.6) and a period percent change of -46.6%. The AAPC for AMI in women was -4.6% (95% CI, -4.1 to -5.2) between 2000 and 2009 and declined to -2.3% (95% CI, -1.2 to -3.4) between 2010 and 2014. The AAPC for AMI in men was stable over the study period (-4.7% [95% CI, -4.4 to -4.9]). The AAPC for ST-segment-elevation MI hospitalization overall was -8.3% (95% CI, -8.0% to -8.6%).The AAPC in ST-segment-elevation MI changed among women in 2009 (2000-2009: -10.2% [95% CI, -9.3 to -11.1] and in 2010-2014: -5.2% [95% CI, -3.1 to -7.3]) while remaining stable among men (-8.0% [95% CI, -7.6 to -8.4]). The AAPC for non-ST-segment-elevation MI hospitalization was smaller than for ST-segment-elevation MI among both women and men (-1.9% [95% CI, -1.5 to -2.3] and -2.8% [95% CI, -2.5 to -3.2], respectively)., Conclusions: These results suggest that the incidence of hospitalized AMI declined between 2000 and 2014; however, declines in AMI have slowed among women in comparison with men in recent years. Determining unmet care needs among women may reduce these sex-based AMI disparities.

Importance: High-intensity statin use after myocardial infarction (MI) varies by patient characteristics, but little is known about differences in use by hospital or region., Objective: To explore the relative strength of associations of region and hospital and patient characteristics with high-intensity statin use after MI., Design, Setting, and Participants: This retrospective cohort analysis used Medicare administrative claims and enrollment data to evaluate fee-for-service Medicare beneficiaries 66 years or older who were hospitalized for MI from January 1, 2011, through June 30, 2015, with a statin prescription claim within 30 days of discharge. Data were analyzed from January 4, 2017, through May 12, 2019., Exposures: Beneficiary characteristics were abstracted from Medicare data. Hospital characteristics were obtained from the 2014 American Hospital Association Survey and Hospital Compare quality metrics. Nine regions were defined according to the US Census., Main Outcomes and Measures: Intensity of the first statin claim after discharge characterized as high (atorvastatin calcium, 40-80 mg, or rosuvastatin calcium, 20-40 mg/d) vs low to moderate (all other statin types and doses). Trends in high-intensity statins were examined from 2011 through 2015. Associations of region and beneficiary and hospital characteristics with high-intensity statin use from January 1, 2014, to June 15, 2015, were examined using Poisson distribution mixed models., Results: Among the 139 643 fee-for-service beneficiaries included (69 968 men [50.1%] and 69 675 women [49.9%]; mean [SD] age, 76.7 [7.5] years), high-intensity statin use overall increased from 23.4% in 2011 to 55.6% in 2015, but treatment gaps persisted across regions. In models considering region and beneficiary and hospital characteristics, region was the strongest correlate of high-intensity statin use, with 66% higher use in New England than in the West South Central region (risk ratio [RR], 1.66; 95% CI, 1.47-1.87). Hospital size of at least 500 beds (RR, 1.15; 95% CI, 1.07-1.23), medical school affiliation (RR, 1.11; 95% CI, 1.05-1.17), male sex (RR, 1.10; 95% CI, 1.07-1.13), and patient receipt of a stent (RR, 1.35; 95% CI, 1.31-1.39) were associated with greater high-intensity statin use. For-profit hospital ownership, patient age older than 75 years, prior coronary disease, and other comorbidities were associated with lower use., Conclusions and Relevance: This study's findings suggest that geographic region is the strongest correlate of high-intensity statin use after MI, leading to large treatment disparities.

Background: Cardiovascular guidelines include risk prediction models for decision making that lack the capacity to include novel predictors.Methods and Results:We explored a new "predictor patch" approach to calibrating the predicted risk from a base model according to 2 components from outside datasets: (1) the difference in observed vs. expected values of novel predictors and (2) the hazard ratios (HRs) for novel predictors, in a scenario of adding kidney measures for cardiovascular mortality. Using 4 US cohorts (n=54,425) we alternately chose 1 as the base dataset and constructed a base prediction model with traditional predictors for cross-validation. In the 3 other "outside" datasets, we developed a linear regression model with traditional predictors for estimating expected values of glomerular filtration rate and albuminuria and obtained their adjusted HRs of cardiovascular mortality, together constituting a "patch" for adding kidney measures to the base model. The base model predicted cardiovascular mortality well in each cohort (c-statistic 0.78-0.91). The addition of kidney measures using a patch significantly improved discrimination (cross-validated ∆c-statistic 0.006 [0.004-0.008]) to a similar degree as refitting these kidney measures in each base dataset., Conclusions: The addition of kidney measures using our new "predictor patch" approach based on estimates from outside datasets improved cardiovascular mortality prediction based on traditional predictors, providing an option to incorporate novel predictors to an existing prediction model.

Background: Improvements have been made in the treatment and control of some but not all major cardiovascular risk factors in the United States. It remains unclear whether women and men have benefited equally., Methods: Data from the 2001 to 2002 through the 2015 to 2016 US National Health and Nutrition Examination Survey on adults aged 20 to 79 years were used. We assessed sex differences in temporal trends in the levels of systolic blood pressure, body mass index, smoking status, high-density lipoprotein and total cholesterol, and hemoglobin A 1c . Trends in treatment and control rates of hypertension, diabetes mellitus, and dyslipidemia were also assessed., Results: Overall, 35 416 participants (51% women) were included. Trends in systolic blood pressure, smoking status, high-density lipoprotein cholesterol, and hemoglobin A 1c were similar between the sexes. Body mass index increased more in women than men ( P=0.006). Mean levels were 28.1 and 29.6 kg/m 2 in women and 27.9 and 29.0 kg/m 2 in men in 2001 to 2004 and 2013 to 2016, respectively. Total cholesterol decreased more in men than women ( P=0.002): mean levels in 2001 to 2004 and 2013 to 2016, respectively, were 203 and 194 mg/dL in women and 201 and 188 mg/dL in men. Improvements in the control of hypertension, diabetes mellitus, and dyslipidemia were similar between the sexes; however, sex differences persisted. In 2013 to 2016, control rates in women versus men were 30% versus 22% for hypertension, 30% versus 20% for diabetes mellitus, and 51% versus 63% for dyslipidemia., Conclusions: Temporal trends in cardiovascular risk factor levels were broadly similar between the sexes, except for total cholesterol and body mass index. Sex differences in the control of hypertension, diabetes mellitus, and dyslipidemia persist, and further efforts are required to reduce this differential.

Background: Cause of death is often not available in administrative claims data., Objective: To develop claims-based algorithms to identify deaths due to fatal cardiovascular disease (CVD; ie, fatal coronary heart disease [CHD] or stroke), CHD, and stroke., Methods: Reasons for Geographic and Racial Differences in Stroke (REGARDS) study data were linked with Medicare claims to develop the algorithms. Events adjudicated by REGARDS study investigators were used as the gold standard. Stepwise selection was used to choose predictors from Medicare data for inclusion in the algorithms. C-index, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were used to assess algorithm performance. Net reclassification index (NRI) was used to compare the algorithms with an approach of classifying all deaths within 28 days following hospitalization for myocardial infarction and stroke to be fatal CVD., Results: Data from 2,685 REGARDS participants with linkage to Medicare, who died between 2003 and 2013, were analyzed. The C-index for discriminating fatal CVD from other causes of death was 0.87. Using a cut-point that provided the closest observed-to-predicted number of fatal CVD events, the sensitivity was 0.64, specificity 0.90, PPV 0.65, and NPV 0.90. The algorithms resulted in positive NRIs compared with using deaths within 28 days following hospitalization for myocardial infarction and stroke. Claims-based algorithms for discriminating fatal CHD and fatal stroke performed similarly to fatal CVD., Conclusion: The claims-based algorithms developed to discriminate fatal CVD events from other causes of death performed better than the method of using hospital discharge diagnosis codes., (Copyright © 2018 John Wiley & Sons, Ltd.)

Background: Debate over the cardiometabolic risk associated with metabolically healthy obesity (MHO) continues. Many studies have investigated this relationship by examining MHO at baseline with longitudinal follow-up, with inconsistent results., Objectives: The authors hypothesized that MHO at baseline is transient and that transition to metabolic syndrome (MetS) and duration of MetS explains heterogeneity in incident cardiovascular disease (CVD) and all-cause mortality., Methods: Among 6,809 participants of the MESA (Multi-Ethnic Study of Atherosclerosis) the authors used Cox proportional hazards and logistic regression models to investigate the joint association of obesity (≥30 kg/m 2 ) and MetS (International Diabetes Federation consensus definition) with CVD and mortality across a median of 12.2 years. We tested for interaction and conducted sensitivity analyses for a number of conditions., Results: Compared with metabolically healthy normal weight, baseline MHO was not significantly associated with incident CVD; however, almost one-half of those participants developed MetS during follow-up (unstable MHO). Those who had unstable MHO had increased odds of CVD (odds ratio [OR]: 1.60; 95% confidence interval [CI]: 1.14 to 2.25), compared with those with stable MHO or healthy normal weight. Dose response for duration of MetS was significantly and linearly associated with CVD (1 visit with MetS OR: 1.62; 95% CI: 1.27 to 2.07; 2 visits, OR: 1.92; 95% CI: 1.48 to 2.49; 3+ visits, OR: 2.33; 95% CI: 1.89 to 2.87; p value for trend <0.001) and MetS mediated approximately 62% (44% to 100%) of the relationship between obesity at any point during follow-up and CVD., Conclusions: Metabolically healthy obesity is not a stable or reliable indicator of future risk for CVD. Weight loss and lifestyle management for CVD risk factors should be recommended to all individuals with obesity., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Historically, women have been less likely than men to receive guideline-recommended statin therapy for the secondary prevention of myocardial infarction (MI)., Objectives: The authors examined contemporary sex differences in prescription fills for high-intensity statin therapy following an MI, overall and across population subgroups, and assessed whether sex differences were attenuated following recent efforts to reduce sex disparities in the use of cardiovascular disease preventive therapies., Methods: The authors studied 16,898 (26% women) U.S. adults <65 years of age with commercial health insurance in the MarketScan database, and 71,358 (49% women) U.S. adults ≥66 years of age with government health insurance through Medicare who filled statin prescriptions within 30 days after hospital discharge for MI in 2014 to 2015. The authors calculated adjusted women-to-men risk ratios and 95% confidence intervals (CIs) for filling a high-intensity statin prescription (i.e., atorvastatin 40 to 80 mg, and rosuvastatin 20 to 40 mg) following hospital discharge for MI., Results: In 2014 to 2015, 56% of men and 47% of women filled a high-intensity statin following hospital discharge for MI. Adjusted risk ratios for filling a high-intensity statin comparing women with men were 0.91 (95% CI: 0.90 to 0.92) in the total population, 0.91 (95% CI: 0.89 to 0.92) among those with no prior statin use, and 0.87 (95% CI: 0.85 to 0.90) and 0.98 (95% CI: 0.97 to 1.00) for those taking low/moderate-intensity and high-intensity statins prior to their MI, respectively. Women were less likely than men to fill high-intensity statins within all subgroups analyzed, and the disparity was largest in the youngest and oldest adults and for those without prevalent comorbid conditions., Conclusions: Despite recent efforts to reduce sex differences in guideline-recommended therapy, women continue to be less likely than men to fill a prescription for high-intensity statins following hospitalization for MI., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Both sodium reduction and the Dietary Approaches to Stop Hypertension (DASH) diet lower blood pressure (BP); however, the patterns of their effects on BP over time are unknown. In the DASH-Sodium trial, adults with pre-/stage 1 hypertension, not using antihypertensive medications, were randomly assigned to either a typical American diet (control) or DASH. Within their assigned diet, participants randomly ate each of 3 sodium levels (50, 100, and 150 mmol/d, at 2100 kcal) over 4-week periods. BP was measured weekly for 12 weeks; 412 participants enrolled (57% women; 57% black; mean age, 48 years; mean systolic BP [SBP]/diastolic BP [DBP], 135/86 mm Hg). For those assigned control, there was no change in SBP/DBP between weeks 1 and 4 on the high-sodium diet (weekly change, -0.04/0.06 mm Hg/week) versus a progressive decline in BP on the low-sodium diet (-0.94/-0.70 mm Hg/week; P interactions between time and sodium <0.001 for SBP and DBP). For those assigned DASH, SBP/DBP changed -0.60/-0.16 mm Hg/week on the high- versus -0.42/-0.54 mm Hg/week on the low-sodium diet ( P interactions between time and sodium=0.56 for SBP and 0.10 for DBP). When comparing DASH to control, DASH changed SBP/DBP by -4.36/-1.07 mm Hg after 1 week, which accounted for most of the effect observed, with no significant difference in weekly rates of change for either SBP ( P interaction=0.97) or DBP ( P interaction=0.70). In the context of a typical American diet, a low-sodium diet reduced BP without plateau, suggesting that the full effects of sodium reduction are not completely achieved by 4 weeks. In contrast, compared with control, DASH lowers BP within a week without further effect thereafter., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000608., (© 2017 American Heart Association, Inc.)

Objective: Traditional predictors suboptimally predict cardiovascular disease (CVD) in individuals with chronic kidney disease (CKD). This study compared 5 nontraditional cardiac and kidney markers on the improvement of cardiovascular prediction among those with CKD., Approach and Results: Among 8622 participants aged 52 to 75 years in the Atherosclerosis Risk in Communities (ARIC) Study, cardiac troponin T, N-terminal pro-B-type natriuretic peptide, cystatin C, β2-microglobulin, and β-trace protein were compared for improvement in predicting incident CVD after stratifying by CKD status (940 participants with CKD [kidney dysfunction or albuminuria]). During a median follow-up of 11.9 years, there were 1672 CVD events including coronary disease, stroke, and heart failure (336 cases in CKD). Every marker was independently associated with incident CVD in participants with and without CKD. The adjusted hazard ratios (per 1 SD) were larger for cardiac markers than for kidney markers, particularly in CKD (1.61 [95% confidence interval, 1.43-1.81] for cardiac troponin T, 1.50 [1.34-1.68] for N-terminal pro-B-type natriuretic peptide, and <1.26 for kidney markers). Particularly in CKD group, cardiac markers compared with kidney markers contributed to greater c-statistic increment (0.032-0.036 versus 0.012-0.015 from 0.679 with only conventional predictors in CKD and 0.008-0.011 versus 0.002-0.010 from 0.697 in non-CKD) and categorical net reclassification improvement (0.086-0.127 versus 0.020-0.066 in CKD and 0.057-0.077 versus 0.014-0.048 in non-CKD). The superiority of cardiac markers was largely consistent in individual CVD outcomes., Conclusions: A greater improvement in cardiovascular prediction was observed for cardiac markers than for kidney markers in people with CKD. These results suggest that cardiac troponin T and N-terminal pro-B-type natriuretic peptide are useful for better CVD risk classification in this population., (© 2014 American Heart Association, Inc.)

Background and Purpose: Although low glomerular filtration rate (GFR) and albuminuria are associated with increased risk of stroke, few studies compared their contribution to risk of ischemic versus hemorrhagic stroke separately. We contrasted the association of these kidney measures with ischemic versus hemorrhagic stroke., Methods: We pooled individual participant data from 4 community-based cohorts: 3 from the United States and 1 from The Netherlands. GFR was estimated using both creatinine and cystatin C, and albuminuria was quantified by urinary albumin-to-creatinine ratio (ACR). Associations of estimated GFR and ACR were compared for each stroke type (ischemic versus intraparenchymal hemorrhagic) using study-stratified Cox regression., Results: Among 29,595 participants (mean age, 61 [SD 12.5] years; 46% men; 17% black), 1261 developed stroke (12% hemorrhagic) during 280,549 person-years. Low estimated GFR was significantly associated with increased risk of ischemic stroke, but not hemorrhagic stroke, whereas high ACR was associated with both stroke types. Adjusted hazard ratios for ischemic and hemorrhagic stroke at estimated GFR of 45 (versus 95) mL/min per 1.73 m2 were 1.30 (95% confidence interval, 1.01-1.68) and 0.92 (0.47-1.81), respectively. In contrast, the corresponding hazard ratios for ACR of 300 (versus 5) mg/g were 1.62 (1.27-2.07) for ischemic and 2.57 (1.37-4.83) for hemorrhagic stroke, with significantly stronger association with hemorrhagic stroke (P=0.04). For hemorrhagic stroke, the association of elevated ACR was of similar magnitude as that of elevated systolic blood pressure., Conclusions: Whereas albuminuria showed significant association with both stroke types, the association of decreased estimated GFR was only significant for ischemic stroke. The strong association of albuminuria with both stroke types warrants clinical attention and further investigations., (© 2014 American Heart Association, Inc.)

Background: In the U.S., the incidence of lung cancer varies by race, with rates being highest among black men. There are marked differences in smoking behavior between blacks and whites, but little is known regarding how these differences contribute to the racial disparities in lung cancer., Purpose: To compare the lung cancer risk associated with smoking in 14,610 blacks and whites in the prospective cohort Atherosclerosis Risk in Communities study., Methods: Smoking characteristics were ascertained at baseline and three follow-up visits in 1990-1992, 1993-1995, and 1996-1998 (response rates were 93%, 86%, and 80%, respectively), as well as from annual telephone interviews. Data were analyzed in the fall of 2012. Multivariable-adjusted proportional hazards models were used to calculate hazard ratios and 95% CIs for lung cancer., Results: Over 20 years of follow-up (1987-2006), 470 incident cases of lung cancer occurred. Lung cancer incident rates were highest in black men and lowest in black women. However, there was no evidence to support racial differences in the associations of smoking status, intensity, or age at initiation with lung cancer risk (all p(interaction)≥0.25). The hazard ratio for those who started smoking at age ≤12 versus >22 years was 3.03 (95% CI=1.62, 5.67). Prolonged smoking cessation (≥10 years) was associated with a decrease in lung cancer risk, with equivalent benefits in whites and blacks, 84% and 74%, respectively (p(interaction)=0.25)., Conclusions: Smoking confers similar lung cancer risk in blacks and whites., (Copyright © 2014 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: The results of cohort studies relating sodium (Na) intake to blood pressure-related cardiovascular disease (CVD) are inconsistent. To understand whether methodological issues account for the inconsistency, we reviewed the quality of these studies., Methods and Results: We reviewed cohort studies that examined the association between Na and CVD. We then identified methodological issues with greatest potential to alter the direction of association (reverse causality, systematic error in Na assessment), some potential to alter the direction of association (residual confounding, inadequate follow-up), and the potential to yield false null results (random error in Na assessment, insufficient power). We included 26 studies with 31 independent analyses. Of these, 13 found direct associations between Na and CVD, 8 found inverse associations, 2 found J-shaped associations, and 8 found null associations only. On average there were 3 to 4 methodological issues per study. Issues with greater potential to alter the direction of association were present in all but 1 of the 26 studies (systematic error, 22; reverse causality, 16). Issues with lesser potential to alter the direction of association were present in 18 studies, whereas those with potential to yield false null results were present in 23., Conclusions: Methodological issues may account for the inconsistent findings in currently available observational studies relating Na to CVD. Until well-designed cohort studies in the general population are available, it remains appropriate to base Na guidelines on the robust body of evidence linking Na with elevated blood pressure and the few existing general population trials of the effects of Na reduction on CVD.

Increased acid excretion may promote renal injury. To evaluate this in African Americans with hypertensive nephrosclerosis, we studied the association between the net endogenous acid production and progression of kidney disease in 632 patients in the AASK trial. Protein and potassium intakes were estimated from 24 h urea nitrogen and potassium excretion, and used to estimate net endogenous acid production, averaged over 2 years, approximating routine intake. The link between net endogenous acid production and the I(125)iothalamate glomerular filtration rate (iGFR) and time to end-stage renal disease or doubling of serum creatinine was analyzed using mixed models and Cox proportional hazards regressions. The trend in higher net endogenous acid production was significantly associated with a faster decline in iGFR over a median of 3.2 years. After adjustment for age, body mass index, baseline iGFR, urine protein-to-creatinine ratio, and randomized treatment group, the trend in higher net endogenous acid production remained significantly associated with a faster decline in iGFR at a rate of 1.01 ml/min per 1.73 m(2) per year faster in the highest compared to the lowest quartile. However, in time-to-event analyses over a median of 7.7 years, the adjusted hazard ratio (1.10) for composite renal events per 25 mEq/day higher net endogenous acid production was not significant. Hence, our findings implicate endogenous acid production as a potential modifiable risk factor for progressive kidney disease.

Hypertension status among spouses is known to be concordant, but previous studies relied on history rather than direct measurement, and few data exist on treatment and control between spouses. The goal of this study was to estimate the spousal association of hypertension status, treatment, and control in adults. The authors identified and analyzed data on 4,500 pairs from the Atherosclerosis Risk in Communities (ARIC) cohort, which sampled middle-aged adults and their spouses in 1986-1989, with 3 follow-up visits 3 years apart. Generalized estimating equations were used in logistic regression analyses to calculate the odds ratio of a spouse's being hypertensive on the basis of the other spouse's hypertension status across 4 visits, adjusting for age, race, body mass index, smoking status, and sodium intake in both individuals. There are marginally increased odds of hypertension for spouses married to someone with hypertension (odds ratio (OR) = 1.15, 95% confidence interval (CI): 1.06, 1.25). Treatment was positively associated between spouses (OR = 1.35, 95% CI: 1.10, 1.67). Control was suggestive of an association, although it was not statistically significant (OR = 1.21, 95% CI: 0.93, 1.56). In middle-aged adults, hypertension status and treatment were moderately associated between spouses after controlling for shared environment. Physicians may target hypertension education and prevention to spouses as a pair rather than as 2 separate patients.

Background and Objectives: Metabolic acidosis may contribute to morbidity and disease progression in patients with chronic kidney disease (CKD). The ratio of dietary protein, the major source of nonvolatile acid, to dietary potassium, which is naturally bound to alkali precursors, can be used to estimate net endogenous acid production (NEAP). We tested the association between estimated NEAP and serum bicarbonate in patients with CKD., Design, Setting, Participants, & Measurements: NEAP was estimated among 462 African American adults with hypertensive CKD using published equations: NEAP (mEq/d) = -10.2 + 54.5 (protein [g/d]/potassium [mEq/d]). Dietary protein and potassium intake were estimated from 24-hour urinary excretion of urea nitrogen and potassium, respectively. All of the eligible measurements during follow-up were modeled using generalized linear regression clustered by participant and adjusted for demographics, 24-hour urinary sodium, kidney function, and selected medications., Results: Higher NEAP was associated with lower serum bicarbonate in a graded fashion (P trend < 0.001). Serum bicarbonate was 1.27 mEq/L lower among those in the highest compared with the lowest quartile of NEAP (P < 0.001). There was a greater difference in serum bicarbonate between the highest and lowest quartiles of NEAP among patients with stage 4/5 CKD (-2.43 mEq/L, P < 0.001) compared with those with stage 2/3 disease (-0.77 mEq/L, P = 0.01; P-interaction = 0.02)., Conclusions: Reducing NEAP, through reduction of dietary protein and increased intake of fruits and vegetables, may prevent metabolic acidosis in patients with CKD.

Background: Several strategies have been proposed to reform physician reimbursement while improving quality of care. Despite much debate, physicians' opinions regarding reimbursement reform proposals have not been objectively assessed., Methods: We conducted a national survey of randomly selected physicians between June 25 and October 31, 2009. Physicians rated their support for several reimbursement reform proposals: rewarding quality with financial incentives, bundling payments for episodes of care, shifting payments from procedures to management and counseling services, increasing pay to generalists, and offsetting increased pay to generalists with a reduction in pay for other specialties. Support for the different reform options was compared with physician practice characteristics., Results: The response rate was 48.5% (n = 1222). Four of 5 physicians (78.4%) indicated that under Medicare, some procedures are compensated too highly and others are compensated at rates insufficient to cover costs. Incentives were the most frequently supported reform option (49.1%), followed by shifting payments (41.6%) and bundling (17.2%). Shifting payments and bundling were more commonly supported by generalists than by other specialists. There was broad support for increasing pay for generalists (79.8%), but a proposal to offset the increase with a 3% reduction in specialist reimbursement was supported by only 39.1% of physicians., Conclusions: Physicians are dissatisfied with Medicare reimbursement and show little consensus for major proposals to reform reimbursement. The successful adoption of payment reform proposals may require a better understanding of physicians' concerns and their willingness to make tradeoffs.

Introduction: Eighty percent of all smokers live in low and middle-income countries of the Asia Pacific region but actual estimates of the burden of disease due to smoking in the region have yet to be quantified., Methods: The burden of lung cancer due to smoking for all countries in the WHO Western Pacific and South East Asian regions was calculated from the population attributable fractions (PAFs). Nationally representative sex-specific prevalences of smoking were obtained from the World Health Organization, MEDLINE and/or national government documents and hazard ratios (HR) for lung cancer due to smoking in Asian and non-Asian populations were obtained from published data. The HR and prevalence were then used to calculate PAFs for lung cancer deaths due to smoking, by gender and by country., Results: The national prevalence of smoking in the Asia Pacific region ranged from 18-65% in men and from 0-50% in women. The fraction of lung cancer deaths attributable to smoking ranged from 0-40% in Asian women and from 21-49% in Asian men. In ANZ, PAFs were as high as 80% for women and 68% for men. Future estimates of the burden of smoking-related lung cancer in Asia were obtained by assuming a continuation of current smoking habits in these populations. By extrapolating the higher HR from the ANZ region to Asia, resulted in an increase in the PAFs to 4-90% in women and from 62-85% in men., Conclusion: The current burden of lung-cancer due to smoking in the Asia-Pacific region is substantial accounting for up to 50% of deaths from the disease in men and up to 40% in women depending on the country. If current smoking habits in Asia remain unchanged then the number of people dying from smoking-related lung cancer over the next couple of decades is expected to double. It is known that the majority of lung cancer is due to smoking. This is the first paper to systematically compare current burdens of lung cancer deaths due to smoking in countries in the Western Pacific and South East Asia and by gender. Findings from this paper demonstrate the number of lung cancer deaths that could be prevented if the prevalence of smoking was eliminated.

Chronic kidney disease (CKD), defined by either microalbuminuria (MA) or a reduced estimated glomerular filtration rate (eGFR), is associated with an increased risk of peripheral arterial disease (PAD). The presence of both abnormalities might identify a subgroup of adults at particularly high risk of PAD. Accordingly, we sought to evaluate the combined effect of a reduced eGFR and MA on the prevalence of PAD among United States adults. United States adults >or=40 years old (n = 6,951) participating in the 1999 to 2004 National Health and Nutrition Examination Survey were cross-classified into 4 groups according to the presence or absence of MA (urinary albumin/creatinine ratio >or=30 mg/g) and reduced eGFR (<60 mL/min/1.73 m(2)). PAD was defined as an ankle-brachial index of <0.9. The prevalence of PAD among adults without MA or a reduced eGFR was 3.6% compared to 9.7%, 14.8%, and 25.4% among adults with MA alone, reduced eGFR alone, and both reduced eGFR and MA, respectively. After multivariate adjustment, the odds ratio for prevalent PAD associated with MA alone, reduced eGFR alone, and both reduced eGFR and MA compared to those without MA or reduced eGFR was 1.72 (95% confidence interval 1.16 to 2.55), 1.58 (95% confidence interval 1.09 to 2.29), and 2.26 (95% confidence interval 1.30 to 3.94), respectively. In conclusion, the coexistence of MA and reduced eGFR was associated with a high prevalence of PAD and might be useful in identifying patients with vascular disease.