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Background— Insured adults receive invasive cardiovascular procedures more frequently than uninsured adults. We examined the impact of healthcare reform in Massachusetts on use of coronary revascularization procedures and in-hospital and 1-year mortality by race/ethnicity, education, and sex. Methods and Results— Using hospital claims data, we compared differences in coronary revascularization rates (coronary artery bypass grafting or percutaneous coronary intervention) and in-hospital mortality by race/ethnicity, education, and sex among Massachusetts residents aged 21 to 64 years hospitalized with a principal discharge diagnosis of ischemic heart disease before (November 1, 2004, to July 31, 2006) and after (December 1, 2006, to September 30, 2008) reform; 1-year mortality was calculated for those undergoing revascularization. Adjusted logistic regression assessed 24 216 discharges before reform and 20 721 discharges after reform. Blacks had 30% lower odds of receiving coronary revascularization than whites in the prereform period. Compared with whites in the postreform period, blacks (odds ratio=0.73; 95% confidence interval, 0.63–0.84) and Hispanics (odds ratio= 0.84; 95% confidence interval, 0.74–0.97) were less likely and Asians (odds ratio=1.29; 95% confidence interval, 1.01–1.65) were more likely to receive coronary revascularization. Patients living in more educated communities, men, and persons with private insurance were more likely to receive coronary revascularization before and after reform. Compared with the prereform period, the adjusted odds of in-hospital mortality were higher in patients living in less-educated communities in the postreform period. No differences in 1-year mortality by race/ethnicity, education, or sex for revascularized patients were observed before or after reform. Conclusions— Reducing insurance barriers to receipt of coronary revascularization procedures has not yet eliminated preexisting demographic and educational disparities in access to these procedures.

Sickle cell disease (SCD) is an inheritable genetic disorder hallmarked by a single point mutation in the β-globin chain resulting in abnormal polymerization of deoxygenated hemoglobin and subsequent sickling of the erythrocyte. Longevity in SCD patients has greatly increased, shifting the paradigm for cause of death from acute to chronic conditions. Endothelial dysfunction attributed to SCD triggers a cascade of inflammatory biomarkers known to mediate several cardiovascular complications, however, the etiology of heart disease in SCD remains unclear. Cardiovascular manifestations resulting in premature mortality include elevated cardiac output, systolic and diastolic dysfunction, pulmonary hypertension, and sudden cardiac death. This review explores relevant biomarkers of inflammation typically observed as mediators or indicators of cardiovascular disease (CVD) as well as current literature on cardiovascular complications found in those with SCD. Additionally, the potential role of CVD treatments to manage the severity of SCD will be explored.

Background: Although psychosocial stressors such as negative life events predict adverse physical and mental health outcomes, significant gaps remain in the literature regarding whether such associations appear with cardiovascular disease (CVD) in middle-aged and older women, a demographic at higher risk for CVD than younger women. Hence, we investigated the relationship of cumulative negative life events and risk of myocardial infarction in the Women’s Health Study (WHS). Methods and Results: We performed a prospective, nested case-control study of apparently healthy post-menopausal women participating in the ongoing follow-up cohort of the Women’s Health Study; 26,763 women were followed for an average of 9 years to ascertain MI risk. Participants answered 12 standardized questions about negative life events within 5 years of survey completion (e.g. death/illness/accidental injury of someone close, fired from job, legal trouble, unemployment, marital infidelity, serious financial problems), and 3 questions about lifetime traumatic events (life-threatening illness, accident involving child or spouse, or victim of serious assault). Our cumulative life events score (CLES) was the count of items endorsed on all 15 questions, whereas our traumatic life events score counted positive responses to the 3 traumatic event questions. Women with a CLES score of zero were compared to women with scores >0 who were divided into tertiles; thus defining 4 categories. Among 267 women with a history of MI and 281 age and smoking matched controls, the median age of participants was 56.0 years old (Interquartile range: 51.3 - 60.6). Logistic regression analyses revealed that while increasing CLES was associated with increasing MI risk [Odds Ratio: OR unadjusted model: 1.00, 1.21, 1.52, 1.87; p-trend 0.16], the trend did not reach statistical significance. In models adjusted for CVD risk factors, there was a significant interaction with household income: CLES was associated with MI only in women with household income < $50,000 yearly (OR = 1.24, 95% CI: 1.05-1.49. The odds of MI was significantly higher in women who reported traumatic life events compared to women who did not (ORtraumatic life event score =1.65: 95% CI: 1.02, 2.68); women with traumatic life event(s) had a 65% increase in odds of MI when compared to women without, after adjusting for CVD risk factors and socio-economic status. In question specific analyses, women reporting serious financial problems as a life event had significantly higher odds of MI than women who did not (OR=2.60, 95% CI: 1.20 - 5.64). Conclusion: In this analysis among middle aged and older women, we found supportive evidence that negative cumulative life events were associated with MI risk, especially in low-income women and those suffering major traumatic life events. Further research is warranted particularly in women who also have limited socioeconomic resources.

Background: Discrimination, a form of chronic psychological stress, is related to certain chronic health conditions such as poor physical health and hypertension. However, little is known about the associations of everyday discrimination with risk of myocardial infarction. Methods and Results: We assessed the association between everyday discrimination (discrimination) and myocardial infarction (MI) using a prospective, nested case control study of 548 women (267 cases, 281 controls), selected from 26,763 women without a history of cardiovascular disease at baseline who participated in the Women’s Heath Study (WHS). Among 267 MI cases, there was a mean follow-up of 8.8 + 4.1 years from date of WHS randomization to date of MI event. At baseline, the mean age of participants was 53.6 + 6.1 years. Cases and controls were matched for age and smoking history. Discrimination was assessed by 5 questions where women reported whether they were: 1) treated with less courtesy/respect than others; 2) treated as not being smart; 3) treated as if others were afraid of them; 4) received poorer service at restaurants/stores; or 5) felt threatened/harassed. Responses were based on a Likert scale of 1=never to 5=at least once/weekly with higher scores indicating more experiences with discrimination. In unadjusted logistic regression models of increasing tertiles of discrimination, we found no significant association between discrimination and odds of MI [Odds Ratios (OR) and 95% confidence intervals (95%CI): 1.00, 1.28 (0.85-1.94), 1.06 (0.69-1.64); p trend =0.5]. Adjustment for cardiovascular disease risk factors (lipid parameters, hsCRP, family history of MI, hypertension, body mass index, diabetes, and alcohol consumption) revealed an inverse-U-shaped relationship [OR, 95%CI: 1.00, 2.14 (1.21-3.77), 1.55 (0.87-2.78); p trend = 0.03], suggesting that these factors obscured the association in unadjusted models. Notably, addition of education and income to the crude model alone [1.00, 1.38 (0.89, 2.15), 0.97 (0.61, 1.54) p trend = 0.2] or to the model with the cardiovascular risk factors [1.00, 2.27 (1.25-4.10), 1.36 (0.73, 2.53); p trend = 0.02] had minimal impact on odds of MI in these women. Conclusion: Among women participating in the WHS follow-up cohort, higher levels of everyday discrimination were related to increased odds of myocardial infarction in an inverse-U-shaped manner, a finding that is obscured by traditional cardiovascular disease risk factors. Access to measures associated with a healthy heart might be important to myocardial infarction risk attenuation among women reporting everyday discrimination. Further research is warranted to elucidate the relationship between everyday discrimination and increased risk of MI.

Background: Discrimination is recognized as a chronic psychological stressor related to poor health outcomes. However, investigations about lifetime discrimination and hypertension (HTN), a major risk factor for cardiovascular disease (CVD) have yielded mixed results. Data are limited by small sample size and lack of studies involving women. Therefore, we assessed the association between unfair treatment (UT), a form of discrimination, and prevalent HTN in women. Methods and Results: In this cross-sectional analysis, we used data from women the Women’s Health Study follow-up cohort who responded to questions about UT (n= 30,873; mean age 69 years). HTN was defined as:a physician’s diagnosis of HTN, the use of anti-hypertensive treatment or self-reported systolic blood pressure (BP) ≥ 140 mmHg, or diastolic BP ≥ 90 mmHg. UT asked about experiences over their lifetime in 4 domains [obtaining housing, getting a job, being fired/not promoted, being stopped/questioned by the police; response (yes/no) to each question was used to compute an UT score (range 0-4; coded in 3 categories: 0 (reference), 1, and 2-4 domains). Logistic regression models estimated the likelihood of HTN if treated unfairly. Among WHS participants, the prevalence of HTN was 67% (20,808 of 30,873); and, 15% (4,614 of 30,873) of women reported UT in at least one domain. In the crude model, increasing UT score was associated with increasing relative odds of HTN (1.01 and 1.26 for 1 and 2-4 domains, vs 0;ptrend=0.03); adjustment for age, race/ethnicity and socioeconomic status (education and income) strengthened the magnitude of observed association (1.00, 1.16, 1.36; ptrend Conclusion: These data are hypothesis generating in that they suggest UT is related to hypertension, a potent risk factor for CVD. Additional research is needed to better understand the influence of UT for cardiovascular health disparities in the United States.