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OBJECTIVE: Ultraprocessed food (UPF) intake is associated with BMI, but effects on regional adipose depots or related to minimally processed food (MPF) intake are unknown. METHODS: Data included 12,297 adults in the National Health and Nutrition Examination Survey (NHANES), 2011 to 2016. This study analyzed associations between usual percentage of kilocalories from UPFs and MPFs and three adiposity indicators: supine sagittal abdominal diameter to height ratio (SADHtR, estimates visceral adiposity); waist circumference to height ratio (WHtR, estimates abdominal adiposity); and BMI, using linear and multinomial logistic regression. RESULTS: Standardized β coefficients per 10% increase in UPF intake were 0.0926, 0.0846, and 0.0791 for SADHtR, WHtR, and BMI, respectively (all p < 0.001; p > 0.26 for pairwise differences). For MPF intake, the β coefficients were −0.0901, −0.0806, and −0.0688 (all p < 0.001; p > 0.18 pairwise). Adjusted odds ratios (95% CI) for adiposity tertile 3 versus tertile 1 (comparing UPF intake quartiles 2, 3, and 4 to quartile 1) were 1.33 (1.22-1.45), 1.67 (1.43-1.95), and 2.24 (1.76-2.86), respectively, for SADHtR; 1.31 (1.19-1.44), 1.62 (1.37-1.91), and 2.13 (1.63-2.78), respectively, for WHtR; and 1.27 (1.16-1.39), 1.53 (1.31-1.79), and 1.96 (1.53-2.51), respectively, for BMI. MPF intake showed inverse associations with similar trends in association strength. CONCLUSIONS: Among US adults, abdominal and visceral adiposity indictors were positively associated with UPFs and inversely associated with MPFs.

Introduction: Family history is an established risk factor for both cardiovascular disease (CVD) and diabetes; however, no study has presented population-based prevalence estimates of family histories of CVD and diabetes and examined their joint impact on prevalence of diabetes, CVD, cardiometabolic risk factors, and mortality risk. Methods: We analyzed data from a representative sample of the US adult population including 29,440 participants from the National Health and Nutrition Examination Survey (2007–2018) and assessed self-reported first-degree family history of diabetes and CVD (premature heart disease before age of 50 years) as well as meeting criteria and/or having risk factors for CVD and diabetes. Results: Participants with joint family history exhibit 6.5 greater odds for having both diseases and are diagnosed with diabetes 6.6 years earlier than participants without family history. Healthy participants without prevalent CVD or diabetes but with joint family history exhibit a greater prevalence of diabetes risk factors compared to no family history counterparts. Joint family history is associated with an increase in all-cause mortality, but with no interactive effect. Conclusion: Over 44% of the US adult population has a family history of CVD and/or diabetes that is comparable in risk to common cardiometabolic risk factors. This wide presence of high-risk family history and its simplicity of ascertainment suggests that clinical and public health efforts should collect and act on joint family history of CVD and diabetes to improve population efforts in the prevention and early detection of these common chronic diseases.

Introduction: Although stroke death rates declined since 1950s, age-adjusted rates remained higher among non-Hispanic Black (NHB) than among non-Hispanic White (NHW) persons. No study has examined changes in disparities of stroke mortality among NHB and NHW before and during the COVID-19 pandemic. Methods: We calculated age-adjusted (US 2000 population) stroke death rates per 100,000 people among NHB and NHW ages ≥35 years from 2015-2021 using CDC WONDER. We compared NHB and NHW stroke death rates from 2015-2019 (before pandemic) to 2020-2021 (during pandemic) with respect to changes in rates, rate ratios (RR) and difference-in-difference in rates. Results: Trends and disparities of overall stroke death rates before the pandemic remained consistent between NHB (100.9 to 101.6 per 100,000 people) and NHW (69.1 to 70.6 per 100,000 people), with an average difference in rates of 31.3/100,000 and RR of 1.45. During the pandemic, stroke death rates increased but with different magnitudes among NHB (110.0 and 113.4 per 100,000) and NHW (72.0 and 73.1 per 100,000). Between pre-pandemic and pandemic periods, the absolute difference in rates increased 25% from 31.3 (95% confidence interval 30.8-31.7) to 39.1 (38.3-39.8) per 100,000 and the relative difference measured by RR increased from 1.45 (1.44-1.46) to 1.54 (1.53-1.55) (p Conclusion: Disparities in stroke death rates between NHB and NHW widened during the COVID-19 pandemic in the United States. Identifying factors associated with the widened disparities and providing the targeted interventions may be necessary to reduce the disparities.

Introduction: Although COVID-19 is associated with increased risk of acute ischemic stroke (AIS), limited evidence exists about the impact of prior COVID-19 on overall survival among older AIS patients. Methods: We analyzed data on Medicare fee-for-service beneficiaries ≥65 years of age hospitalized with AIS from 04/01/2020 to 04/30/2022. Overall survival was defined as time from date of AIS to date of death, or through end of follow-up on 05/31/2022. We used a Cox proportional hazard model to examine the association between history of COVID-19 and all-cause mortality among AIS patients, and obtained age, sex, race/ethnicity, National Institutes of Health Stroke Scale (NIHSS) score, and comorbidity-adjusted survival estimates. Results: Among 294,226 AIS patients, 92,893 died (31.6%) during a median of 268 days (IQR, 81—502 days) and 245,262 person-years of follow-up through 05/31/2022. The crude mortality rates were 792 (95% CI, 770—815), 557 (95% CI, 540—575), and 362 (95% CI, 360—365) per 1000 person-years among AIS patients with history of hospitalized COVID-19, history of non-hospitalized COVID-19, and without COVID-19, respectively. As compared to AIS without history of COVID-19, the adjusted hazard ratios for all-cause mortality were 1.28 (95% CI, 1.25—1.32) for those with history of hospitalized COVID-19, and 1.05 (95% CI, 1.01—1.08) for those with non-hospitalized COVID-19. The pattern of associations between history of COVID-19 and all-cause mortality were largely consistent across age groups, sex, and race/ethnicity. Conclusion: Having a history of COVID-19 was associated with significantly higher risk of all-cause mortality among Medicare beneficiaries hospitalized with AIS, especially among those with a history of severe COVID-19.

Supplemental Digital Content is available in the text., Background and Purpose: Emergency department visits and hospitalizations for stroke declined significantly following declaration of coronavirus disease 2019 (COVID-19) as a national emergency on March 13, 2020, in the United States. This study examined trends in hospitalizations for stroke among Medicare fee-for-service beneficiaries aged ≥65 years and compared characteristics of stroke patients during COVID-19 pandemic to comparable weeks in the preceding year (2019). Methods: For trend analysis, we examined stroke hospitalizations from week 1 in 2019 through week 44 in 2020. For comparison of patient characteristics, we estimated percent reduction in weekly stroke hospitalizations from 2019 to 2020 during weeks 10 through 23 and during weeks 24 through 44 by age, sex, race/ethnicity, and state. Results: Compared to weekly numbers of hospitalizations for stroke reported during 2019, stroke hospitalizations in 2020 decreased sharply during weeks 10 through 15 (March 1–April 11), began increasing during weeks 16 through 23, and remained at a level lower than the same weeks in 2019 from weeks 24 through 44 (June 7–October 31). During weeks 10 through 23, stroke hospitalizations decreased by 22.3% (95% CI, 21.4%–23.1%) in 2020 compared with same period in 2019; during weeks 24 through 44, they decreased by 12.1% (95% CI, 11.2%–12.9%). The magnitude of reduction increased with age but similar between men and women and among different race/ethnicity groups. Reductions in stroke hospitalizations between weeks 10 through 23 varied by state ranging from 0.0% (95% CI, −16.0%–1.7%) in New Hampshire to 36.2% (95% CI, 24.8%–46.7%) in Montana. Conclusions: One-in-5 fewer stroke hospitalizations among Medicare fee-for-service beneficiaries occurred during initial weeks of the COVID-19 pandemic (March 1–June 6) and weekly stroke hospitalizations remained at a lower than expected level from June 7 to October 31 in 2020 compared with 2019. Changes in stroke hospitalizations varied substantially by state.

Objective The purpose of this study was to investigate the association of sodium intake with obesity in US children and adolescents. Methods Cross-sectional data were analyzed for 9,026 children and adolescents in the National Health and Nutrition Examination Survey (NHANES) 2009-2016. Usual sodium intake was estimated from 24-hour dietary recalls using a measurement error model. Logistic regression was used to assess the association of sodium intake with overweight/obesity, obesity, and central obesity (waist to height ratio [WtHR] ≥ 0.5; waist circumferences (WC) ≥ age- and sex-specific 90th percentile). Results Mean (SE) sodium intake was 3,010 (9) and 3,404 (20) mg/d for children and adolescents, respectively. The adjusted odds ratio (AOR) comparing Q4 versus Q1 (87.5th vs. 12.5th percentile of sodium intake) among children was 1.98 (95% CI: 1.19-3.28) for overweight/obesity, 2.20 (1.30-3.73) for obesity, 2.10 (1.12-3.95) for WC ≥ 90th percentile, and 1.68 (0.95-2.97) for WtHR ≥ 0.5, adjusting for demographics, energy, and sugar-sweetened beverage intake. Among adolescents, AOR was 1.81 (0.98-3.37) for overweight/obesity, 1.71 (0.82-3.56) for obesity, 1.62 (0.71-3.66) for WC ≥ 90th percentile, and 1.73 (0.85-3.50) for WtHR ≥ 0.5. Conclusions Sodium intake was positively associated with overweight/obesity, obesity, and central obesity among US children independent of energy and SSB intake, but the association did not reach significance among adolescents.

BACKGROUND Higher intake of ultraprocessed foods (UPFs) might be associated with increased risk of cardiovascular disease. OBJECTIVES Our objective was to examine the association between usual percentage of calories (%kcal) from UPFs and the American Heart Association's "Life's Simple 7" cardiovascular health (CVH) metrics in US adults. METHODS We analyzed data from 11,246 adults aged ≥20 y from the NHANES 2011-2016 (a cross-sectional, nationally representative survey). UPF designation was assigned on the basis of the NOVA classification system, according to the extent and purpose of food processing. Each CVH metric was given a score of 0, 1, or 2 representing poor, intermediate, or ideal health, respectively. Scores of the 6 metrics (excluding diet) were summed, and CVH was categorized as inadequate (0-4), average (5-8), or optimum (9-12). We used the National Cancer Institute's methods to estimate the usual %kcal from UPFs, and multivariable linear and multinomial logistic regression to assess the association between UPFs and CVH, adjusted for age, sex, race and Hispanic origin, education, and poverty. RESULTS The weighted prevalence of inadequate, average, and optimum CVH was 8.0%, 51.7%, and 40.3%, respectively. The mean usual %kcal from UPFs was 55.4%, and midpoint of quartiles of intake ranged from 40.4% (quartile 1) to 70.5% (quartile 4). Every 5% increase in calories from UPFs was associated with 0.14 points lower CVH score (P

Approximately 15.5 million cancer survivors were alive in the United States in 2016 with expected growth to 26.1 million by 2040 (1). Cancer survivors are living longer because of advances in early detection and treatment, but face psychosocial, cognitive, financial, and physical challenges (1,2). Physical challenges include cardiovascular complications, partly because cancer and cardiovascular disease (CVD) share some cumulative risk factors including tobacco use, physical inactivity, obesity, poor diet, hypertension, diabetes, and dyslipidemia (3). In addition, many cancer treatments damage the heart, and some cancer types increase risk for developing CVD (4). The recognition and management of heart disease in cancer survivors has given rise to the discipline of cardio-oncology, which focuses on the cardiovascular health of this population (5). CVD risk has been previously estimated using prediction models, and studies suggest that physician-patient communication using predicted heart age rather than predicted 10-year risk has led to a more accurate perception of excess heart age, encouraged actions to adopt a healthy lifestyle, and improved modifiable CVD risk factors (6,7). Using the nonlaboratory-based Framingham Risk Score (FRS) to estimate 10-year risk for developing CVD, predicted heart age is estimated from the 10-year risk of CVD (predicted by age, sex, diabetes status, smoking status, systolic blood pressure, hypertension treatment status, and body mass index); it is the age of an otherwise healthy person with the same predicted risk, with all other risk factors included in the prediction model at the normal level (systolic blood pressure of 125 mmHg, no hypertension treatment, body mass index of 22.5, nonsmoker, and nondiabetic) (6). Using data from the Behavioral Risk Factor Surveillance System (BRFSS), this study estimates predicted heart age, excess heart age (difference between predicted heart age and actual age), and racial/ethnic and sociodemographic disparities in predicted heart age among U.S. adult cancer survivors and noncancer participants aged 30-74 years using previously published methods (7). A total of 22,759 men and 46,294 women were cancer survivors with a mean age of 48.7 and 48.3 years, respectively. The predicted heart age and excess heart age among cancer survivors were 57.2 and 8.5 years, respectively, for men and 54.8 and 6.5 years, respectively, for women, and varied by age, race/ethnicity, education and income. The use of predicted heart age by physicians to encourage cancer survivors to improve modifiable risk factors and make heart healthy choices, such as tobacco cessation, regular physical activity, and a healthy diet to maintain a healthy weight, can engage survivors in informed cancer care planning after diagnosis.

A high percentage of total calories from ultra-processed foods has been associated with several cardiovascular disease risk factors. No study has examined the association between ultra-processed foods and heart age. This study examines the association between ultra-processed foods and excess heart age (difference between estimated heart age and chronological age) among U.S. adults.The National Health and Nutrition Examination Survey (2009-2016) data for participants aged 30-74 years without cardiovascular disease or stroke (n=12,640) was used. Ultra-processed food was assigned based on NOVA classification of food processing, with ultra-processed food being the highest level. This study estimated the usual percentage of calories from ultra-processed foods and used sex-specific Framingham heart age algorithms to calculate heart age. The multivariable linear or logistic regression was used to examine the association between ultra-processed foods and excess heart age or likelihood of excess heart age being ≥10 years. Data analyses were conducted in 2020.The median usual percentage of calories from ultra-processed foods was 54.5% (IQR=45.8%‒63.1%). Adjusted excess heart age increased from 7.0 years (95% CI=6.4, 7.6) in the lowest quintile (Q1) to 9.9 years (95% CI=9.2, 10.5) in the highest quintile (Q5) (p0.001). Compared with Q1, AORs for excess heart age of ≥10 years were 1.16 (95% CI=1.08, 1.25) in Q2, 1.29 (95% CI=1.14, 1.46) in Q3, 1.43 (95% CI=1.20, 1.71) in Q4, and 1.66 (95% CI=1.29, 2.14) in Q5 (p0.001). The pattern of association was largely consistent across subgroups.U.S. adults consumed more than half of total daily calories from ultra-processed foods. A higher percentage of calories from ultra-processed foods was associated with higher excess heart age and likelihood of excess heart age of ≥10 years.

BackgroundCOVID-19 is associated with an increased risk of venous thromboembolism (VTE). This study examined the prevalence of VTE among acute ischaemic stroke (AIS) patients with and without a history of COVID-19.MethodsWe identified AIS hospitalisations of Medicare fee-for-service (FFS) beneficiaries aged ≥65 years from 1 April 2020 to 31 March 2022. We compared the prevalence and adjusted prevalence ratio of VTE among AIS patients with and without a history of COVID-19.ResultsAmong 283 034 Medicare FFS beneficiaries with AIS hospitalisations, the prevalence of VTE was 4.51%, 2.96% and 2.61% among those with a history of hospitalised COVID-19, non-hospitalised COVID-19 and without COVID-19, respectively. As compared with patients without a history of COVID-19, the prevalence of VTE among patients with a history of hospitalised or non-hospitalised COVID-19 were 1.62 (95% CI 1.54 to 1.70) and 1.13 (95% CI 1.03 to 1.23) times greater, respectively.ConclusionsThere appeared to be a notably higher prevalence of VTE among Medicare beneficiaries with AIS accompanied by a current or prior COVID-19. Early recognition of coagulation abnormalities and appropriate interventions may help improve patients’ clinical outcomes.

This study aimed to determine whether higher intakes of Na, added sugars and saturated fat are prospectively associated with all-cause mortality and CVD incidence and mortality in a diverse population. The nationally representative Canadian Community Health Survey-Nutrition 2004 was linked with the Canadian Vital Statistics – Death Database and the Discharge Abstract Database (2004–2011). Outcomes were all-cause mortality and CVD incidence and mortality. There were 1722 mortality cases within 115 566 person-years of follow-up (median (interquartile range) of 7·48 (7·22–7·70) years). There was no statistically significant association between Na density or energy from saturated fat and all-cause mortality or CVD events for all models investigated. The association of usual percentage of energy from added sugars and all-cause mortality was significant in the base model with participants consuming 11·47 % of energy from added sugars having 1·34 (95 % CI 1·01, 1·77) times higher risk of all-cause mortality compared with those consuming 4·17 % of energy from added sugars. Overall, our results did not find statistically significant associations between the three nutrients and risk of all-cause mortality or CVD events at the population level in Canada. Large-scale linked national nutrition datasets may not have the discrimination to identify prospective impacts of nutrients on health measures.

Introduction: Findings of association between COVID-19 and stroke remain inconsistent, ranging from significant association, absence of association to less than expected ischemic stroke among hospitalized patients with COVID-19. The present study examined the association between COVID-19 and risk of acute ischemic stroke (AIS). Methods: We included 19,553 Medicare fee-for-service (FFS) beneficiaries aged ≥65 years diagnosed with COVID-19 between April 1 and November 30, 2020 and AIS hospitalization from January 1, 2019 through November 30, 2020. We used a self-controlled case series design to examine the association between COVID-19 and AIS and estimated the incident rate ratios (IRR) by comparing incidence of AIS in risk periods (0-3, 4-7, 8-14, 15-28 days after diagnosis of COVID-19) vs. control periods. Results: Among 19,553 Medicare FFS beneficiaries with COVID-19 and AIS, the median age at diagnosis of COVID-19 was 80.5 (interquartile range 73.6-87.3) years and 57.5% were women. IRRs at 0-3, 4-7, 8-14, and 15-28 days following COVID-19 diagnosis were 10.97 (95% confidence interval 10.30-11.68), 1.59 (1.35-1.87), 1.23 (1.07-1.41), and 1.06 (0.95-1.18), respectively. The association appeared to be stronger among younger beneficiaries and among beneficiaries without prior history of stroke but largely consistent across sex and race/ethnicities. Conclusions: Risk of AIS among Medicare FFS beneficiaries was ten times as high during the first 3 days after diagnosis of COVID-19 as during the control period and the risk associated with COVID-19 appeared to be stronger among those aged 65-74 years and those without prior history of stroke.

Introduction: Venous thromboembolism (VTE) is a common medical complication following acute ischemic stroke (AIS). Studies have suggested that VTE rates were higher among patients with a history of COVID-19. We examined the risk of VTE in AIS patients with and without a history of COVID-19 among Medicare beneficiaries. Methods: We identified Medicare fee-for-service (FFS) beneficiaries aged ≥65 years with AIS hospitalizations from 04/01/2020 to 06/30/2021. COVID-19 cases were identified by the first diagnosis of COVID-19 on a claim at any health care setting. We defined AIS with COVID-19 if the dates of COVID-19 diagnoses were earlier than AIS admission dates. To identify VTE for each AIS admission, we used the following secondary diagnoses codes: ICD-CM-10: I80, I81, I82, I26. We compared the prevalence ratio (PR) of VTE between AIS patients with and without a history of COVID-19. Results: Among 178,830 Medicare FFS beneficiaries with AIS admissions, 6.1% had a history of COVID-19 and 2.6% had VTE as a complication. VTE prevalence among AIS patients with a history of COVID-19 was 3.98% (95% confidence interval (CI), 3.62-4.36%) and 2.53% (95% CI, 2.46-2.61%) among patients without a history of COVID-19. The adjusted PR of VTE was 1.55 (95% CI, 1.40-1.70, p50% increased risk of VTE than those without a history of COVID-19 (Adjusted PR, 1.59, 95% CI, 1.42-1.78 for Non-Hispanic White, 1.58, 95% CI, 1.28-1.94 for Non-Hispanic Black, p Conclusion: AIS patients with a history of COVID-19 had an increased risk of VTE compared with patients without COVID-19. Healthcare professionals should be aware of the increased risks of VTE among AIS patients with COVID-19 and implement protocols for early VTE prevention.

INTRODUCTION: Studies documented significant reductions in emergency department visits and hospitalizations for acute stroke during the COVID-19 pandemic. A limited number of studies assessed the adherence to stroke performance measures during the pandemic. We examined rates of stroke hospitalization and adherence to stroke quality-of-care measures before and during the early phase of pandemic. METHODS: We identified hospitalizations with a clinical diagnosis of acute stroke or transient ischemic attack among 406 hospitals who contributed data to the Paul Coverdell National Acute Stroke Program. We used 10 performance measures to examine the effect of the pandemic on stroke quality of care. We compared data from 2 periods: pre-COVID-19 (week 11-24 in 2019) and COVID-19 (week 11-24 in 2020). We used χ2 tests for differences in categorical variables and the Wilcoxon-Mann-Whitney rank test or Kruskal-Wallis test for continuous variables. RESULTS: We identified 64,461 hospitalizations. We observed a 20.2% reduction in stroke hospitalizations (from 35,851 to 28,610) from the pre-COVID-19 period to the COVID-19 period. Hospitalizations among patients aged 85 or older, women, and non-Hispanic White patients declined the most. A greater percentage of patients aged 18 to 64 were hospitalized with ischemic stroke during COVID-19 than during pre-COVID-19 (34.4% vs 32.5%, P < .001). Stroke severity was higher during COVID-19 than during pre-COVID-19 for both hemorrhagic stroke and ischemic stroke, and in-hospital death among patients with ischemic stroke increased from 4.3% to 5.0% (P = .003) during the study period. We found no differences in rates of receiving care across stroke type during the study period. CONCLUSION: Despite a significant reduction in stroke hospitalizations, more severe stroke among hospitalized patients, and an increase in in-hospital death during the pandemic period, we found no differences in adherence to quality of stroke care measures.

Studies of the association between ultraprocessed foods (UPF) and cardiovascular disease risk factors have been mainly focused on the adult population. This study examined the association between usual percentage of calories (%kcal) from UPF and the American Heart Association's seven cardiovascular health (CVH) metrics among U.S. adolescents aged 12-19 years.We used data from the National Health and Nutrition Examination Survey 2007-2018 (n = 5,565). The NOVA food system was used to classify UPF according to the extent and purpose of food processing. Each CVH metric was given a score of 0, 1, or 2 (poor, intermediate, or ideal health, respectively). Scores of six metrics were summed (excluding diet) to categorize CVH as low (0-7), moderate (8-10), or high (11-12). The National Cancer Institute's methods were used to estimate usual %kcal from UPF. Multivariable linear regression and multinomial logistic regression were used to evaluate the association between UPF and CVH.Among youth, 12.1% had low CVH, 56.3% moderate, and 31.6% high. The mean usual %kcal from UPF was 65.7%. Every 5% increase in calories from UPF was associated with .13 points lower CVH scores (p.001). Comparing Q2, Q3, and Q4 to Q1 of UPF intake, the adjusted odds ratios for low versus high CVH were 1.43 (95% confidence interval 1.16-1.76), 1.86 (1.29-2.66), and 2.59 (1.49-4.55), respectively. The pattern of association was largely consistent across subgroups.U.S. adolescents consume about two thirds of daily calorie from UPF. There was a graded inverse association between %kcal from UPF and CVH score.

Background and ObjectivesFindings of association between coronavirus disease 2019 (COVID-19) and stroke remain inconsistent, ranging from significant association to absence of association to less than expected ischemic stroke among hospitalized patients with COVID-19. The current study examined the association between COVID-19 and risk of acute ischemic stroke (AIS).MethodsWe included 37,379 Medicare fee-for-service (FFS) beneficiaries aged ≥65 years diagnosed with COVID-19 from April 1, 2020, through February 28, 2021, and AIS hospitalization from January 1, 2019, through February 28, 2021. We used a self-controlled case series design to examine the association between COVID-19 and AIS and estimated the incidence rate ratios (IRRs) by comparing incidence of AIS in risk periods (0–3, 4–7, 8–14, 15–28 days after diagnosis of COVID-19) vs control periods.ResultsAmong 37,379 Medicare FFS beneficiaries with COVID-19 and AIS, the median age at diagnosis of COVID-19 was 80.4 (interquartile range 73.5–87.1) years and 56.7% were women. When AIS at day of exposure (day = 0) was included in the risk periods, IRRs at 0–3, 4–7, 8–14, and 15–28 days following COVID-19 diagnosis were 10.3 (95% confidence interval 9.86–10.8), 1.61 (1.44–1.80), 1.44 (1.32–1.57), and 1.09 (1.02–1.18); when AIS at day 0 was excluded in the risk periods, the corresponding IRRs were 1.77 (1.57–2.01) (day 1–3), 1.60 (1.43–1.79), 1.43 (1.31–1.56), and 1.09 (1.01–1.17), respectively. The association appeared to be stronger among younger beneficiaries and among beneficiaries without prior history of stroke but largely consistent across sex and race/ethnicities.DiscussionRisk of AIS among Medicare FFS beneficiaries was 10 times (day 0 cases in the risk period) as high during the first 3 days after diagnosis of COVID-19 as during the control period and the risk associated with COVID-19 appeared to be stronger among those aged 65–74 years and those without prior history of stroke.Classification of EvidenceThis study provides Class IV evidence that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is associated with increased risk of AIS in the first 3 days after diagnosis in Medicare FFS beneficiaries ≥65 years of age.

Background and Purpose: Herpes zoster (HZ) is associated with increased risk of stroke, and zoster vaccine live (ZVL, Zostavax) reduces the risk of HZ. No study has examined the association between ZVL (Zostavax) and risk of stroke. Present study examined association between receipt of ZVL (Zostavax) and risk of stroke among older US population. Methods: Our study included 1 603 406 US Medicare fee-for-service beneficiaries aged ≥66 years without a history of stroke and who received ZVL (Zostavax) during 2008 to 2014, and 1 603 406 propensity score-matched unvaccinated beneficiaries followed through to December 31, 2017. We used Cox proportional hazard models to examine association between ZVL (Zostavax) and composite fatal or nonfatal incident stroke outcomes. Results: During a median of 5.1 years follow-up (interquartile range, 3.9–6.7), we documented 64 635 stroke events, including 43 954 acute ischemic strokes and 6727 hemorrhagic strokes, among vaccinated beneficiaries during 8 755 331 person-years. The corresponding numbers among unvaccinated beneficiaries were 73 023, 50 476, and 7276, respectively, during 8 517 322 person-years. Incidence comparing vaccinated to unvaccinated beneficiaries were 7.38 versus 8.57 per 1000 person-years for all stroke, 5.00 versus 5.90 for acute ischemic stroke, and 0.76 versus 0.84 for hemorrhagic stroke ( P P Conclusions: Among Medicare fee-for-service beneficiaries, receipt of ZVL (Zostavax) was associated with lower incidence of stroke. Our findings may encourage people to get vaccinated against HZ to reduce HZ and HZ-associated stroke risk.

Introduction: Emergency department visits and hospitalizations for acute ischemic stroke (AIS) declined significantly following the declaration of COVID-19 as a national emergency on March 13, 2020 in the United States. No study has examined the volume and nature of AIS hospitalizations among older adults in the U.S. amidst the COVID-19 pandemic. This study examined the trend and compared the characteristics of Medicare fee-for-service (FFS) beneficiaries ≥65 years hospitalized with a primary AIS diagnosis in the same timeframe before and after the COVID-19 pandemic. Methods: We included hospitalizations with a primary diagnosis of AIS (ICD-10 I63) among Medicare FFS beneficiaries from week 11 to 24 in 2019 and 2020. We estimated the percent reduction of AIS hospitalizations between 2019 and 2020 by age, sex, race/ethnicity, and state. We tested for difference in distribution by age group, sex and race/ethnicity between 2019 and 2020 based on χ 2 test. Results: During the 14-weeks from March 8 to June 13, 2020, AIS hospitalizations among FFS beneficiaries were reduced by 23.7% compared to weeks 11 to 24 in 2019 (March 10 to June 15) (49,607 in 2019 vs. 37,860 in 2020). A greater percent reduction in AIS hospitalizations was observed with older age (27.2% among ≥85 years vs. 20.6% among persons 65-74 years, p Conclusion: Hospitalizations with a primary AIS diagnosis among Medicare FFS beneficiaries were reduced by 24% during weeks 11 to 24 of the COVID-19 pandemic compared to the previous year in the United States. AIS hospitalization reductions varied substantially by state. Further study is needed to examine the long-term effects of COVID-19 pandemic on stroke outcomes.

Introduction: Studies suggest a significant reduction in emergency department visits and hospitalizations for acute ischemic stroke (AIS) during the COVID-19 pandemic in the United States. Few studies have examined AIS hospitalizations, treatments, and outcomes during the pandemic period. The present study compared the demographic and clinical characteristics of patients hospitalized with AIS before and during the COVID-19 pandemic (weeks 11-24 in 2019 vs. 2020). Method: We identified 42,371 admissions with a clinical diagnosis of AIS, from 370 participating hospitals who contributed data during weeks 11-24 in both 2019 and 2020 to the Paul Coverdell National Acute Stroke Program (PCNASP). Results: During weeks 11-24 of the COVID-19 period, AIS hospitalizations declined by 24.5% compared to the same period in 2019 (18,233 in 2020 vs. 24,138 in 2019). In 2020, the percentage of individuals aged Conclusion: A higher percentage of younger (

Introduction Little information is available about racial/ethnic and geographic variations in long-term survival among older patients (≥65) after acute ischemic stroke (AIS). Methods We examined data on 1,019,267 Medicare fee-for-service (FFS) beneficiaries aged 66 or older, hospitalized with a primary diagnosis of AIS from 2008 through 2012. Survival was defined as the time from the date of AIS to date of death, or an end of follow-up date of December 31, 2017. We used Cox proportional hazard models to estimate 5-year survival after AIS, adjusted for age, sex, race and Hispanic ethnicity, poverty level, Charlson Comorbidity Index, and state. Results Among 1,019,267 Medicare FFS beneficiaries hospitalized with AIS from 2008 through 2012, we documented 701,718 deaths (68.8%) during a median of 4 years of follow-up with 4.08 million person-years. The overall adjusted 5-year survival was 44%. Non-Hispanic Black men had the lowest 5-year survival, and 5-year survival varied significantly by state, from the highest at 49.1% (North Dakota) to the lowest at 40.5% (Hawaii). The ranges between the highest and lowest 5-year survival rates across states also varied significantly by racial/ethnic groups, with percentage point differences of 9.6 among non-Hispanic White, 11.3 among non-Hispanic Black, 17.7 among Hispanic, and 28.5 among other racial/ethnic beneficiaries. Conclusion We identified significant racial/ethnic and geographic variations in 5-year survival rates after AIS among 2008-2012 Medicare FFS beneficiaries. Further study is needed to understand the reasons for these variations and develop prevention strategies to improve survival and racial disparities in survival after AIS.

Background Recent studies reported increasing trends in hospitalization of stroke patients aged 35–64 years. Aim To examine changes in risk factor profiles among patients aged 35–64 years hospitalized with acute ischemic stroke between 2006 and 2017 in the United States. Methods We used data from the National Inpatient Sample of the Healthcare Cost and Utilization Project from 2006 through 2017. Principal ICD-9-CM/ICD-10-CM codes were used to identify acute ischemic stroke hospitalizations, and secondary codes were used to identify the presence of four major stroke risk factors: hypertension, diabetes, lipid disorders, and tobacco use. We used the relative percent change to assess the changes in the prevalence of risk profile between 2006–2007 and 2016–2017 and linear regression models to obtain the p values for the overall trends across six time periods. Results Approximately 1.5 million acute ischemic stroke hospitalizations occurred during 2006–2017. The prevalence of having all four risk factors increased from 4.1% in 2006–2007 to 9.1% in 2016–2017 (relative percent change 122.0%, p Conclusions The prevalence of hospitalized acute ischemic stroke patients aged 35–64 years with all four or any three of four major stroke risk factors increased by 122% and 38%, while those with only one risk factor or no risk factor has declined by 28% and 39%, respectively, from 2006 to 2017. Younger adults are increasingly at higher risk for stroke from preventable and treatable risk factors. This growing public health problem will require clinicians, healthcare systems, and public health efforts to implement more effective prevention strategies among this population.

IMPORTANCE: High salt intake is associated with hypertension, which is a leading modifiable risk factor for cardiovascular disease. OBJECTIVE: To assess the association of a government-led, multisectoral, and population-based intervention with reduced salt intake and blood pressure in Shandong Province, China. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used data from the Shandong–Ministry of Health Action on Salt and Hypertension (SMASH) program, a 5-year intervention to reduce sodium consumption in Shandong Province, China. Two representative samples of adults (aged 18-69 years) were surveyed in 2011 (15 350 preintervention participants) and 2016 (16 490 postintervention participants) to examine changes in blood pressure, and knowledge, attitudes, and behaviors related to sodium intake. Urine samples were collected from random subsamples (2024 preintervention participants and 1675 postintervention participants) for measuring sodium and potassium excretion. Data were analyzed from January 20, 2017, to April 9, 2019. INTERVENTIONS: Media campaigns, distribution of scaled salt spoons, promotion of low-sodium products in markets and restaurants, and activities to support household sodium reduction and school-based sodium reduction education. MAIN OUTCOMES AND MEASURES: The primary outcome was change in urinary sodium excretion. Secondary outcomes were changes in potassium excretion, blood pressure, and knowledge, attitudes, and behaviors. Outcomes were adjusted for likely confounders. Means (95% CIs) and percentages were weighted. RESULTS: Among 15 350 participants in 2011, 7683 (50.4%) were men and the mean age was 40.7 years (95% CI, 40.2-41.2 years); among 16 490 participants in 2016, 8077 (50.7%) were men and the mean age was 42.8 years (95% CI, 42.5-43.1 years). Among participants with 24-hour urine samples, 1060 (51.8%) were men and the mean age was 40.9 years (95% CI, 40.5-41.3 years) in 2011 and 836 (50.7%) were men and the mean age was 40.7 years (95% CI, 40.1-41.4 years) in 2016. The 24-hour urinary sodium excretion decreased 25% from 5338 mg per day (95% CI, 5065-5612 mg per day) in 2011 to 4013 mg per day (95% CI, 3837-4190 mg per day) in 2016 (P

Hypertension is an important modifiable risk factor for cardiovascular morbidity and mortality, and hypertension in adolescents and young adults is associated with long-term negative health effects (1,2).* In 2017, the American Academy of Pediatrics (AAP) released a new Clinical Practice Guideline (3), which updated 2004 pediatric hypertension guidance† with new thresholds and percentile references calculated from a healthy-weight population. To examine trends in youth hypertension and the impact of the new guideline on classification of hypertension status, CDC analyzed data from 12,004 participants aged 12-19 years in the 2001-2016 National Health and Nutrition Examination Survey (NHANES). During this time, prevalence of hypertension declined, using both the new (from 7.7% to 4.2%, p

Introduction The prominent decline in U.S. stroke death rates observed for more than 4 decades has slowed in recent years. CDC examined trends and patterns in recent stroke death rates among U.S. adults aged ≥35 years by age, sex, race/ethnicity, state, and census region. Methods Trends in the rates of stroke as the underlying cause of death during 2000–2015 were analyzed using data from the National Vital Statistics System. Joinpoint software was used to identify trends in stroke death rates, and the excess number of stroke deaths resulting from unfavorable changes in trends was estimated. Results Among adults aged ≥35 years, age-standardized stroke death rates declined 38%, from 118.4 per 100,000 persons in 2000 to 73.3 per 100,000 persons in 2015. The annual percent change (APC) in stroke death rates changed from 2000 to 2015, from a 3.4% decrease per year during 2000–2003, to a 6.6% decrease per year during 2003–2006, a 3.1% decrease per year during 2006–2013, and a 2.5% (nonsignificant) increase per year during 2013–2015. The last trend segment indicated a reversal from a decrease to a statistically significant increase among Hispanics (APC = 5.8%) and among persons in the South Census Region (APC = 4.2%). Declines in stroke death rates failed to continue in 38 states, and during 2013–2015, an estimated 32,593 excess stroke deaths might not have occurred if the previous rate of decline could have been sustained. Conclusions and Implications for Public Health Practice Prior declines in stroke death rates have not continued in recent years, and substantial variations exist in timing and magnitude of change by demographic and geographic characteristics. These findings suggest the importance of strategically identifying opportunities for prevention and intervening in vulnerable populations, especially because effective and underused interventions to prevent stroke incidence and death are known to exist.

No study examined and compared the association between intake of trans-fatty acids (TFAs) and risk of metabolic syndrome before and after significant reduction of TFA intakes in the US population. We hypothesized that the relationship might remain significant after substantial reduction of TFA intakes in the population. We used data on 1442 and 2233 adults aged ≥20 years from the National Health and Nutrition Examination Survey 1999-2000 and 2009-2010, respectively. Multivariable logistic regression analysis was used to assess the association between plasma TFA concentrations and metabolic syndrome, including each of its 5 components. The median plasma TFA concentrations were reduced from 79.8 μmol/L in 1999-2000 to 36.9 μmol/L in 2009-2010. The fully adjusted prevalence ratios comparing the highest vs the lowest quintile of plasma TFA concentrations in 1999-2000 were 3.43 (95% confidence interval, 2.39-4.92) for metabolic syndrome, 1.72 (1.38-2.14) for large waistline, 8.25 (6.34-10.74) for high triglycerides, 1.96 (1.46-2.62) for low high-density lipoprotein cholesterol, 1.14 (0.85-1.55) for high blood pressure, and 1.48 (1.19-1.85) for high fasting glucose, respectively. The corresponding prevalence ratios in 2009-2010 were 2.93 (2.41-3.54), 1.62 (1.39-1.89), 14.93 (9.28-24.02), 3.09 (2.18-4.37), 1.27 (1.11-1.46), and 1.24 (1.06-1.46), respectively. The pattern of association between TFAs and metabolic syndrome and its components did not differ by cycles. The observed associations were consistent across the subgroups examined. Despite a 54% decline in plasma TFA concentrations from 1999-2000 to 2009-2010, it was positively associated with risk of metabolic syndrome and its individual components except for blood pressure in 1999-2000. Our findings support Food and Drug Administration initiatives to remove TFAs from the industrially-produced foods.

Background: The consumption of trans fatty acids (TFAs) is associated with an increased risk of cardiovascular disease, and reducing their consumption is a major public health objective. Food intake studies have provided estimates for TFA concentrations in the US population; however, there is a need for data on TFA blood concentrations in the population.Objective: The objective of this study was to determine plasma TFA concentrations in a nationally representative group of fasted adults in the US population in NHANES samples from 1999-2000 and 2009-2010.Design: Four major TFAs [palmitelaidic acid (C16:1n-7t), trans vaccenic acid (C18:1n-7t), elaidic acid (C18:1n-9t), and linoelaidic acid (C18:2n-6t,9t)] were measured in plasma in 1613 subjects from NHANES 1999-2000 and 2462 subjects from NHANES 2009-2010 by gas chromatography-mass spectrometry. Geometric means and distribution percentiles were calculated for each TFA and their sum by age, sex, and race/ethnicity (non-Hispanic white, non-Hispanic black, Mexican American), and covariate-adjusted geometric means were computed by using a model that included these demographic and other dietary factors, as well as survey year and any significant interaction terms.Results: These nationally representative data for the adult US population show that TFA concentrations were 54% lower in NHANES 2009-2010 than in NHANES 1999-2000. Covariate-adjusted geometric means for the sum of the 4 TFAs were 81.4 μmol/L (95% CI: 77.3, 85.6 μmol/L) and 37.8 μmol/L (95% CI: 36.4, 39.4 μmol/L) in NHANES 1999-2000 and 2009-2010, respectively. Even with the large decline in TFA concentrations, differences between demographic subgroups were comparable in the 2 surveys.Conclusion: The results indicate an overall reduction in TFA concentrations in the US population and provide a valuable baseline to evaluate the impact of the recent regulation categorizing TFAs as food additives.

Background: High intakes of trans-fatty acids (TFAs), especially industrially produced TFAs, can lead to unfavorable lipid and lipoprotein concentrations and an increased risk of cardiovascular disease. It is unknown how this relation might change in a population after significant reductions in TFA intake.Objective: This study, which used a new analytical method for measuring plasma TFA concentrations, clarified the association between plasma TFA and serum lipid and lipoprotein concentrations before and after the US FDA enacted TFA food-labeling regulations in 2006.Methods: Data were selected from the NHANES of 1999-2000 and 2009-2010. Findings on 1383 and 2155 adults, respectively, aged ≥20 y, were evaluated. Multivariable linear regressions were used to examine the associations between plasma TFA concentration and lipid and lipoprotein concentrations. The outcome measures were serum concentrations of total cholesterol (TC), LDL cholesterol, HDL cholesterol, and triglycerides and the ratio of TC to HDL cholesterol.Results: The median plasma TFA concentration decreased from 80.6 μmol/L in 1999-2000 to 37.0 μmol/L in 2009-2010. Plasma TFA concentration continued to be associated with serum lipid and lipoprotein concentrations after significant reductions in TFA intake in the population. For example, by comparing the lowest with the highest quintiles of TFA concentration in 1999-2000, adjusted mean (95% CI) LDL-cholesterol concentrations increased from 118 mg/dL (112, 123 mg/dL) to 135 mg/dL (130, 141 mg/dL) (P-trend < 0.001). The corresponding values for 2009-2010 were 102 mg/dL (97.4, 107 mg/dL) and 129 mg/dL (125, 133 mg/dL) for LDL cholesterol (P-trend < 0.001). Differences between the highest and lowest quintiles were consistent across age groups, sexes, races/ethnicities, and other covariates.Conclusions: Despite a 54% reduction in plasma TFA concentrations in US adults from 1999-2000 to 2009-2010, concentrations remained significantly associated with serum lipid and lipoprotein concentrations. There does not appear to be a threshold under which the association between plasma TFA concentration and lipid profiles might become undetectable.

Introduction: Previous studies reported increasing trends in stroke hospitalizations among adults 35-64 years. Methods: We used data from the National Inpatient Sample to identify stroke hospitalizations (principal ICD-9-CM/ICD-10-CM codes) among adults aged 35-64 years from 2007 through 2016. Four major risk factors (RFs) (hypertension, diabetes, lipid disorder, and tobacco use) were identified using secondary codes for each hospitalization. We used relative percent change (RPC) to assess the changes in prevalence between 2007-08 and 2015-16. Orthogonal polynomial coefficients were calculated by the method of Fisher and Yates for linear trend testing. Results: Approximately 2.4 million stroke hospitalizations occurred during 2007-2016. The prevalence of having all 4 RFs among stroke hospitalizations nearly doubled, from 3.6% in 2007-08 to 7.0% in 2015-16 (p Conclusions: Our findings have important implications for younger adults. Regardless of stroke etiology, younger adults are increasingly at higher risk for stroke from preventable and treatable traditional RFs. This growing public health problem will require clinicians, healthcare systems, and public health efforts to implement more effective prevention strategies to address the rising prevalence of multiple co-existing RFs among this population.

Introduction: Herpes zoster (HZ) is associated with increased risk of stroke, and Zoster Vaccine Live (ZVL) reduces risk of HZ. No study examined the association between ZVL and risk for stroke. The present study examined this association among US older population. Methods: We included 1,382,051 Medicare fee-for-service beneficiaries age ≥66 years without a history of stroke and who received ZVL during 2008-2014, and 1,382,051 matched controls (using a comprehensive list of matching variables) without ZVL followed from ZVL receipt to December 31 2016. We used Cox proportional hazard models to examine the association between ZVL and composite fatal/non-fatal incident stroke outcomes. Results: During a median of 3.9 years follow-up (interquartile range 2.7-5.4), we documented 42,267 stroke events including 33,510 acute ischemic strokes (AIS) and 4,318 hemorrhagic strokes among beneficiaries who received ZVL over 5,890,113 person years. The corresponding numbers for controls were 48,139, 39,334, and 4,713 during 5,693,943 person years. Crude incidence comparing beneficiaries with and without ZVL were 7.18 vs. 8.45 per 1000 person years for all stroke, 5.40 vs. 6.53 for AIS, and 0.73 vs. 0.82 for hemorrhagic stroke (p Conclusion: Among Medicare beneficiaries, receipt of ZVL was associated with lower incidence of stroke. Further study is needed to confirm our findings.

Supplemental material, sj-pdf-1-wso-10.1177_1747493020979379 for Trends of risk profile among middle-aged adults hospitalized for acute ischemic stroke in United States 2006–2017 by Xin Tong, Quanhe Yang, Mary G George, Cathleen Gillespie and Robert K Merritt in International Journal of Stroke

BACKGROUND: Understanding and addressing cardiovascular disease (CVD) risk has implications for maternal and child health outcomes. Heart age, the modeled age of an individual’s cardiovascular system based on risk level, and excess heart age, the difference between a person’s heart age and chronological age, are alternative simplified ways to communicate CVD risk. Among women with a recent live birth, we predicted heart age, calculated prevalence of excess heart age (≥5 years), and examined factors associated with excess heart age. MATERIALS AND METHODS: Data were analyzed in 2017 from 2009 to 2014 Pregnancy Risk Assessment Monitoring System (PRAMS). To calculate heart age we used maternal age, prepregnancy body mass index, systolic blood pressure, smoking status, and diabetic status. Weighted prevalence and prevalence ratios compared the likelihood of excess heart age across racial/ethnic groups by selected factors. RESULTS: Prevalence of excess heart age was higher in non-Hispanic black women (11.8%) than non-Hispanic white women (7.3%, prevalence ratio [PR], 95% confidence interval [CI]: 1.62, 1.49–1.76) and Hispanic women (4.9%, PR, 95% CI: 2.39, 2.10–2.72). Prevalence of excess heart age was highest among women who were without health insurance, obese or overweight, engaged in physical activity less than thrice per week, or were smokers in the prepregnancy period. Among women with less than high school education, non-Hispanic black women had a higher prevalence of excess heart age than Hispanic women (PR, 95% CI: 4.01, 3.15–5.10). CONCLUSIONS: Excess heart age may be an important tool for decreasing disparities and encouraging CVD risk reduction among certain groups of women.

OBJECTIVE: Cardiovascular disease (CVD) is a common cause of morbidity and mortality among persons living with HIV (PLWH). We used individual cardiovascular risk factor profiles to estimate heart age for PLWH in medical care in the United States. DESIGN: Cross-sectional analyses of HIV Outpatient Study (HOPS) data METHODS: Included in this analysis were participants aged 30–74 years, without prior CVD, with at least two HOPS clinic visits during 2010–2017, at least 1-year of follow-up, and available covariate data. We calculated age and race/ethnicity-adjusted heart age and excess heart age (chronological age – heart age), using a Framingham risk score-based model. RESULTS: We analyzed data from 2467 men and 619 women (mean chronologic age 49.3 and 49.1 years, and 23.6% and 54.6% Non-Hispanic/Latino black, respectively). Adjusted excess heart age was 11.5 years (95% confidence interval, 11.1–12.0) among men and 13.1 years (12.0–14.1) among women. Excess heart age was seen among all age groups beginning with persons aged 30–39 years [men, 7.8 (6.9–8.8); women, 7.7 (4.9–10.4)], with the highest excess heart age among participants aged 50–59 years [men, 13.7 years (13.0–14.4); women, 16.4 years (14.8–18.0)]. More than 50% of participants had an excess heart age of at least 10 years. CONCLUSIONS: Excess heart age is common among PLWH, begins in early adulthood, and impacts both women and men. Among PLWH, CVD risk factors should be addressed early and proactively. Routine use of the heart age calculator may help optimize CVD risk stratification and facilitate interventions for aging PLWH.

Introduction Little is known about trends in the overall combined burden of fatal and nonfatal cerebrovascular disease events in the United States. Our objective was to describe the combined burden by age, sex, and region from 2006 through 2014. Methods We used data on adults aged 35 and older from 2006 through 2014 Nationwide Emergency Department Sample, National Inpatient Sample of the Healthcare Cost and Utilization Project, and the National Vital Statistics System. We calculated age-standardized cerebrovascular disease event rates by using the 2010 US Census population. Trends in rates were assessed by calculating the relative percentage change (RPC) between 2006 and 2014, and by using Joinpoint to obtain P values for overall trends. Results The age-standardized rate increased significantly for total cerebrovascular disease events (primary plus comorbid events) from 1,050 per 100,000 in 2006 to 1,147 per 100,000 in 2014 (P < .05 for trend). Treat-and-release emergency department visits with comorbid cerebrovascular disease events increased significantly, from 114 per 100,000 in 2006 to 213 per 100,000 in 2014 (RPC of 87%, P < .05 for trend). Significant rate increases were identified among adults aged 35 to 64 with an RPC of 19% in primary cerebrovascular disease events, 48% in comorbid cerebrovascular disease events, and 36% in total events. Conclusion Our findings have important implications for the increasing cerebrovascular disease burden among adults aged 35 to 64. Focused prevention strategies should be implemented, especially among young adults who may be unaware of existing modifiable risk factors.

ObjectiveTo determine whether increased risk of acute ischemic stroke (AIS) following herpes zoster (HZ) might be modified by the status of zoster vaccine live (ZVL) vaccination and antiviral treatment following HZ.MethodsWe included 87,405 Medicare fee-for-service beneficiaries aged ≥66 years diagnosed with HZ and AIS from 2008 to 2017. We used a self-controlled case series design to examine the association between HZ and AIS, and estimated incidence rate ratios (IRRs) by comparing incidence of AIS in risk periods vs control periods. To examine effect modification by ZVL and antiviral treatment, beneficiaries were classified into 4 mutually exclusive groups: (1) no vaccination and no antiviral treatment; (2) vaccination only; (3) antiviral treatment only; and (4) both vaccination and antiviral treatment. We tested for interaction to examine changes in IRRs across 4 groups.ResultsAmong 87,405 beneficiaries with HZ and AIS, 22.0%, 2.0%, 70.1%, and 5.8% were in groups 1 to 4, respectively. IRRs in 0–14, 15–30, 31–90, and 91–180 days following HZ were 1.89 (95% confidence interval [CI], 1.77–2.02), 1.58 (95% CI, 1.47–1.69), 1.36 (95% CI, 1.31–1.42), and 1.19 (95% CI, 1.15–1.23), respectively. There was no evidence of effect modification by ZVL and antiviral treatment on AIS (p = 0.067 for interaction). The pattern of association between HZ and risk for AIS was largely consistent across age group, sex, and race.ConclusionsRisk of AIS increased significantly following HZ, and this increased risk was not modified by ZVL and antiviral treatment. Our findings suggest the importance of following recommended HZ vaccination in prevention of HZ and HZ-associated AIS.

Objective Associations of overall and regional body fat measured by dual-energy X-ray absorptiometry with total and cause-specific mortality in the National Health and Nutrition Examination Survey (NHANES) 1999-2006 were investigated. Methods This study included 9,471 participants (≥20 years) free of major chronic diseases at baseline. Death information was obtained from the National Death Index (mean follow-up duration: 8.8 years). Results A total of 682 participants died after 12 months since baseline, with 206 and 170 deaths attributed to cardiovascular diseases (CVD) and cancer, respectively. The second quartile of fat mass percentages (FM%) was used as the reference to account for potential nonlinearity. In the multivariate-adjusted model, participants in the highest quartile of total FM% had increased total mortality; hazard ratio (HR; 95% confidence interval, 95% CI) was 1.48 (1.07-2.04; P

Background Five guideline-recommended medication categories are available to treat patients who have heart failure (HF) with reduced ejection fraction. However, adherence to these medications is often suboptimal, which places patients at increased risk for poor health outcomes, including hospitalization. We aimed to examine the association between adherence to these medications and potentially preventable HF hospitalizations among younger insured adults with newly diagnosed HF. Methods and results Using the 2008–2012 IBM MarketScan Commercial database, we followed 26,439 individuals aged 18–64 years with newly diagnosed HF and calculated their adherence (using the proportion of days covered (PDC) algorithm) to the five guideline-recommended medication categories: angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers; beta blockers; aldosterone receptor antagonists; hydralazine; and isosorbide dinitrate. We determined the association between PDC and long-term preventable HF hospitalizations (observation years 3–5) as defined by the United States (U.S.) Agency for Healthcare Research and Quality. Overall, 49.0% of enrollees had good adherence (PDC≥80%), which was more common among enrollees who were older, male, residing in higher income counties, initially diagnosed with HF in an outpatient setting, and who filled prescriptions for fewer medication categories assessed. Adherence differed by medication category and was lowest for isosorbide dinitrate (PDC = 60.7%). In total, 7.6% of enrollees had preventable HF hospitalizations. Good adherers, compared to poor adherers (PDC

Introduction: Herpes zoster (HZ) is associated with increased risk of stroke. No study has simultaneously examined the effect of HZ vaccination and antiviral treatment following HZ on risk of acute ischemic stroke (AIS). Methods: We included 35,186 Medicare fee-for-service beneficiaries ≥66 years of age diagnosed with HZ and AIS from 2007-2015. We used a self-controlled case series design to examine the association between HZ and AIS, and estimated the incident rate ratio (IRR) by comparing the incidence of AIS in risk periods (periods following HZ) vs. control periods (rest periods). To minimize confounding by age, we restricted analyses to ±365 days from the HZ index date. To examine effect modification by HZ vaccination and antiviral treatment following HZ, beneficiaries were classified into four groups: (1) no vaccination and no antiviral treatment; (2) vaccination only; (3) antiviral treatment only; and (4) both vaccination and antiviral treatment. We tested for interaction to examine the changes in IRRs across the 4-groups. Results: Among 35,186 Medicare beneficiaries with HZ and AIS, 60.9%, 11.8%, 22.2% and 5.2% were in groups 1 to 4, respectively. IRRs at 0-14, 15-30, 31-90, and 91-180 days following HZ were 1.48 (95% CI 1.37-1.59), 1.31 (1.21-1.42), 1.18 (1.12-1.24), and 1.07 (1.03-1.13), respectively. There was no evidence of effect modification by HZ vaccination and antiviral treatment on AIS (all p-values for interaction across 4-groups IRRs >0.05 with the smallest p=0.129). The pattern of association between HZ and risk for AIS was consistent across age group (66-74yrs, 75-84yrs, and ≥85yrs), sex, and race (non-Hispanic white, non-Hispanic black, Hispanic, other). Conclusions: Risk of AIS increased significantly following HZ, and this increased risk didn’t appear to be modified by HZ vaccination and antiviral treatment following HZ. Primary prevention of HZ by HZ vaccination might be the most effective approach to prevent HZ-associated AIS.