Publications by authors named "George Howard"

431 Publications

Secondary Stroke Prevention in Polish Adults: Results from the LIPIDOGRAM2015 Study.

J Clin Med 2021 Sep 28;10(19). Epub 2021 Sep 28.

Department of Family Medicine and Public Health, Institute of Medical Sciences, University of Opole, 45-052 Opole, Poland.

Background: The purpose of the study was to evaluate secondary stroke prevention in Poland and its association with sociodemographic factors, place of residence, and concomitant cardiovascular risk factors.

Material And Methods: From all patients in LIPIDOGRAM2015 Study ( = 13,724), 268 subjects had a history of ischaemic stroke and were included.

Results: 165 subjects (61.6%) used at least one preventive medication. Oral antiplatelet and anticoagulation agents were used by 116 (43.3%) and 70 (26.1%) patients, respectively. Only 157 (58.6%) participants used lipid-lowering drugs, and 205 (76.5%) were treated with antihypertensive drugs. Coronary heart disease (CHD) and dyslipidaemia were associated with antiplatelet treatment ( = 0.047 and = 0.012, respectively). A history of atrial fibrillation, CHD, and previous myocardial infarction correlated with anticoagulant treatment ( = 0.001, = 0.011, and < 0.0001, respectively). Age, gender, time from stroke onset, place of residence, and level of education were not associated with antiplatelet or anticoagulant treatment. Only 31.7% of patients were engaged in regular physical activity, 62% used appropriate diet, and 13.6% were current smokers.

Conclusions: In Poland drugs and lifestyle modification for secondary stroke prevention are not commonly adhered to. Educational programmes for physicians and patients should be developed to improve application of effective secondary prevention of stroke.
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http://dx.doi.org/10.3390/jcm10194472DOI Listing
September 2021

A Tunguska sized airburst destroyed Tall el-Hammam a Middle Bronze Age city in the Jordan Valley near the Dead Sea.

Sci Rep 2021 Sep 20;11(1):18632. Epub 2021 Sep 20.

College of Archaeology, Trinity Southwest University, Albuquerque, NM, 87109, USA.

We present evidence that in ~ 1650 BCE (~ 3600 years ago), a cosmic airburst destroyed Tall el-Hammam, a Middle-Bronze-Age city in the southern Jordan Valley northeast of the Dead Sea. The proposed airburst was larger than the 1908 explosion over Tunguska, Russia, where a ~ 50-m-wide bolide detonated with ~ 1000× more energy than the Hiroshima atomic bomb. A city-wide ~ 1.5-m-thick carbon-and-ash-rich destruction layer contains peak concentrations of shocked quartz (~ 5-10 GPa); melted pottery and mudbricks; diamond-like carbon; soot; Fe- and Si-rich spherules; CaCO spherules from melted plaster; and melted platinum, iridium, nickel, gold, silver, zircon, chromite, and quartz. Heating experiments indicate temperatures exceeded 2000 °C. Amid city-side devastation, the airburst demolished 12+ m of the 4-to-5-story palace complex and the massive 4-m-thick mudbrick rampart, while causing extreme disarticulation and skeletal fragmentation in nearby humans. An airburst-related influx of salt (~ 4 wt.%) produced hypersalinity, inhibited agriculture, and caused a ~ 300-600-year-long abandonment of ~ 120 regional settlements within a > 25-km radius. Tall el-Hammam may be the second oldest city/town destroyed by a cosmic airburst/impact, after Abu Hureyra, Syria, and possibly the earliest site with an oral tradition that was written down (Genesis). Tunguska-scale airbursts can devastate entire cities/regions and thus, pose a severe modern-day hazard.
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http://dx.doi.org/10.1038/s41598-021-97778-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8452666PMC
September 2021

Disparities in Cognitive Impairment With Anticholinergic Drug Use: A Population-Based Study.

Neurol Clin Pract 2021 Jun;11(3):e277-e286

Department of Health Outcomes Research and Policy (MMR, JQ, KG, RH), Harrison School of Pharmacy, Auburn University, AL; Department of Biostatistics (GH), Ryals School of Public Health, University of Alabama at Birmingham; and Department of Mathematics and Statistics (AA), Auburn University, AL.

Objectives: We aim to evaluate the association between anticholinergic drug (ACH) use and cognitive impairment and the effect of disparity parameters (sex, race, income, education, and rural or urban areas) on this relationship.

Methods: The analyses included 13,623 adults aged ≥65 years from the REasons for Geographic And Racial Differences in Stroke study (recruited 2003-2007). The ACH use was defined by the 2015 Beers Criteria, and cognitive impairment was measured by the Six-Item Cognitive Screener. Multivariable logistic regression models assessed disparities in cognitive impairment with ACH use, iteratively adjusting for disparity parameters and other covariates. The full models included interaction terms between ACH use and other covariates. A similar approach was used for class-specific ACH exposure and cognitive impairment analyses.

Results: Approximately 14% of the participants used at least 1 ACH listed in the Beers Criteria. Antidepressants were the most frequently prescribed ACH class. A significant sex-race interaction illustrated that females compared with males (in Blacks: odds ratio [OR] = 1.28, 95% confidence interval [CI] 1.10-1.49 and in Whites: OR = 1.96, 95% CI 1.74-2.20), especially White females (Black vs White: OR = 0.71, 95% CI 0.64-0.80), were more likely to receive ACHs. Higher odds of cognitive impairment were observed among ACH users compared with the nonusers (OR = 1.26, 95% CI 1.01-1.58). In our class-level analyses, only antidepressant users (OR = 1.60, 95% CI 1.14-2.25) showed a significant association with cognitive impairment in the fully adjusted model.

Conclusions: We observed demographic and socioeconomic differences in ACH use and in cognitive impairment, individually.
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http://dx.doi.org/10.1212/CPJ.0000000000000952DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8382379PMC
June 2021

Racial Differences in Blood Pressure Control Following Stroke: The REGARDS Study.

Stroke 2021 Sep 2:STROKEAHA120033108. Epub 2021 Sep 2.

Department of Epidemiology, School of Public Health, University of Alabama at Birmingham. (O.P.A., T.L.M., D.H., V.J.H., P.M.).

Background And Purpose: In the general population, Black adults are less likely than White adults to have controlled blood pressure (BP), and when not controlled, they are at greater risk for stroke compared with White adults. High BP is a major modifiable risk factor for recurrent stroke, but few studies have examined racial differences in BP control among stroke survivors.

Methods: We used data from the REGARDS study (Reasons for Geographic and Racial Differences in Stroke) to examine disparities in BP control between Black and White adults, with and without a history of stroke. We studied participants taking antihypertensive medication who did and did not experience an adjudicated stroke (n=306 and 7693 participants, respectively) between baseline (2003-2007) and a second study visit (2013-2016). BP control at the second study visit was defined as systolic BP <130 mm Hg and diastolic BP <80 mm Hg except for low-risk adults ≥65 years of age (ie, those without diabetes, chronic kidney disease, history of cardiovascular disease, and with a 10-year predicted atherosclerotic cardiovascular disease risk <10%) for whom BP control was defined as systolic BP <130 mm Hg.

Results: Among participants with a history of stroke, 50.3% of White compared with 39.3% of Black participants had controlled BP. Among participants without a history of stroke, 56.0% of White compared with 50.2% of Black participants had controlled BP. After multivariable adjustment, there was a tendency for Black participants to be less likely than White participants to have controlled BP (prevalence ratio, 0.77 [95% CI, 0.59-1.02] for those with a history of stroke and 0.92 [95% CI, 0.88-0.97] for those without a history of stroke).

Conclusions: There was a lower proportion of controlled BP among Black compared with White adults with or without stroke, with no statistically significant differences after multivariable adjustment.
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http://dx.doi.org/10.1161/STROKEAHA.120.033108DOI Listing
September 2021

Enhancing U.S. local, state, and federal preparedness through simulated interactive tabletop exercises of a mock antibiotic-resistant gonorrhea outbreak, 2018-2019.

Sex Transm Dis 2021 Sep 9. Epub 2021 Sep 9.

Centers for Disease Control and Prevention, Atlanta, GA Indiana State Department of Health, Indianapolis, IN Illinois Department of Public Health Champaign-Urbana Public Health District, Champaign, IL Marion County Public Health Department, Indianapolis, IN.

Background: Responding effectively to outbreaks of antibiotic-resistant gonorrhea (ARGC) in the future will likely prove challenging. Tabletop exercises (TTXs) may assist local, state, and federal public health officials evaluate existing ARGC outbreak response plans, strengthen preparedness and response effectiveness, and identify critical gaps to address prior to an outbreak.

Methods: In 2018-2019, CDC collaborated with state partners to develop and implement TTXs to simulate a public health emergency involving an ARGC outbreak. Prior to the TTXs, two state-local health department pairs developed ARGC outbreak response plans. During each one-day exercise (in Indiana and Illinois), participants discussed roles, clinical management, public health response, and communication based on pre-developed response plans. Observers identified outbreak response strengths and gaps, and participants completed feedback forms.

Results: Forty-one (Illinois) and 48 people (Indiana) participated in each TTX, including: STD clinical staff, laboratorians, public health infectious disease program staff, and CDC observers. Strengths and gaps varied by jurisdiction, but identified gaps included: (1) local access to gonorrhea culture and timely antimicrobial susceptibility testing (AST), (2) protocols for clinical management of suspected treatment failures, (3) communication plans, and (4) clarity regarding state and local responsibilities. CDC observers identified opportunities to provide national-level technical assistance, foster local AST, and develop further response guidance. TTX summary reports were used to guide modifications to local response plans to address gaps.

Conclusions: The TTXs allowed participants to practice responding to a simulated public health emergency and may have enhanced local response capacity. CDC made TTX implementation materials publicly available.
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http://dx.doi.org/10.1097/OLQ.0000000000001536DOI Listing
September 2021

Baseline Cognitive Impairment in Patients With Asymptomatic Carotid Stenosis in the CREST-2 Trial.

Stroke 2021 Aug 26:STROKEAHA120032972. Epub 2021 Aug 26.

Department of Biostatistics, University of Alabama School of Public Health (G.H.).

Background And Purpose: Studies of carotid artery disease have suggested that high-grade stenosis can affect cognition, even without stroke. The presence and degree of cognitive impairment in such patients have not been reported and compared with a demographically matched population-based cohort.

Methods: We studied cognition in 1000 consecutive CREST-2 (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial) patients, a treatment trial for asymptomatic carotid disease. Cognitive assessment was after randomization but before assigned treatment. The cognitive battery was developed in the general population REGARDS Study (Reasons for Geographic and Racial Differences in Stroke), involving Word List Learning Sum, Word List Recall, and Word List fluency for animal names and the letter F. The carotid stenosis patients were >45 years old with ≥70% asymptomatic carotid stenosis and no history of prevalent stroke. The distribution of cognitive performance for the patients was standardized, accounting for age, race, and education using performance from REGARDS, and after further adjustment for hypertension, diabetes, dyslipidemia, and smoking. Using the Wald Test, we tabulated the proportion of scores less than the anticipated deviate for the population-based cohort for representative percentiles.

Results: There were 786 baseline assessments. Mean age was 70 years, 58% men, and 52% right-sided stenosis. The overall score for patients was significantly below expected for higher percentiles (<0.0001 for 50th, 75th, and 95th percentiles) and marginally below expected for the 25th percentile (=0.015). Lower performance was attributed largely to Word List Recall (<0.0001 for all percentiles) and for Word List Learning (50th, 75th, and 95th percentiles below expected, ≤0.01). The scores for left versus right carotid disease were similar.

Conclusions: Baseline cognition of patients with severe carotid stenosis showed below normal cognition compared to the population-based cohort, controlling for demographic and cardiovascular risk factors. This cohort represents the largest group to date to demonstrate that poorer cognition, especially memory, in this disease.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02089217.
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http://dx.doi.org/10.1161/STROKEAHA.120.032972DOI Listing
August 2021

Safety of the transradial approach to carotid stenting.

Catheter Cardiovasc Interv 2021 Aug 13. Epub 2021 Aug 13.

Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA.

Background: The multicenter prospective CREST-2 Registry (C2R) provides recent experience in performing carotid artery stenting (CAS) for interventionists to ensure safe performance of CAS.

Objective: To determine the periprocedural safety of CAS performed using a transradial approach relative to CAS performed using a transfemoral approach.

Methods: Patients with ≥70% asymptomatic and ≥50% symptomatic carotid stenosis, ≤80 years of age and at standard or high risk for carotid endarterectomy (CEA) are eligible for the C2R. The primary endpoint was a composite of severe access-related complications. Comparisons were made using propensity-score matched logistic regression.

Results: The mean age of the cohort was 67.6 ± 8.2 years and 1906 (35.1%) were female. Indications for CAS included 4063 (74.9%) for primary atherosclerosis. A total of 2868 (52.8%) cases underwent CAS for asymptomatic disease. Transradial access was used in 213 (3.9%) patients. The transradial cohort had lower use of general anesthesia (1.5% vs. 6.3%, p = 0.007) and higher use of distal embolic protection (96.7% vs. 89.4%, p = 0.0004). There were no significant differences between radial and femoral access groups in terms of a composite of major access-related complications (0% vs. 1.1%) or a composite of periprocedural stroke or death (3.3% vs. 2.4%; OR = 1.4 [confidence intervals 0.6, 3.1]; p = 0.42).

Conclusion: We found no significant differences in rates of major access-related complications or periprocedural stroke or death with CAS performed using transradial compared to transfemoral access. Our results support incorporation of the transradial approach to clinical trials comparing CAS to other revascularization techniques.
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http://dx.doi.org/10.1002/ccd.29912DOI Listing
August 2021

Number and timing of ambulatory blood pressure monitoring measurements.

Hypertens Res 2021 Aug 11. Epub 2021 Aug 11.

Department of Medicine, Columbia University Irving Medical Center, New York City, NY, USA.

Ambulatory blood pressure (BP) monitoring (ABPM) may cause sleep disturbances. Some home BP monitoring (HBPM) devices obtain a limited number of BP readings during sleep and may be preferred to ABPM. It is unclear how closely a few BP readings approximate a full night of ABPM. We used data from the Jackson Heart (N = 621) and Coronary Artery Risk Development in Young Adults (N = 458) studies to evaluate 74 sampling approaches to estimate BP during sleep. We sampled two to four BP measurements at specific times from a full night of ABPM and computed chance-corrected agreement (i.e., kappa) of nocturnal hypertension (i.e., mean asleep systolic BP ≥ 120 mmHg or diastolic BP ≥ 70 mmHg) defined using the full night of ABPM and subsets of BP readings. Measuring BP at 2, 3, and 4 h after falling asleep, an approach applied by some HBPM devices obtained a kappa of 0.81 (95% confidence interval [CI]: 0.78, 0.85). The highest kappa was obtained by measuring BP at 1, 2, 4, and 5 h after falling asleep: 0.84 (95% CI: 0.81, 0.87). In conclusion, measuring BP three or four times during sleep may have high agreement with nocturnal hypertension status based on a full night of ABPM.
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http://dx.doi.org/10.1038/s41440-021-00717-yDOI Listing
August 2021

Polypharmacy and mortality association by chronic kidney disease status: The REasons for Geographic And Racial Differences in Stroke Study.

Pharmacol Res Perspect 2021 08;9(4):e00823

Department of Biostatistics, University of Alabama at Birmingham School of Public Health, Birmingham, AL, USA.

Many Americans take multiple medications simultaneously (polypharmacy). Polypharmacy's effects on mortality are uncertain. We endeavored to assess the association between polypharmacy and mortality in a large U.S. cohort and examine potential effect modification by chronic kidney disease (CKD) status. The REasons for Geographic And Racial Differences in Stroke cohort data (n = 29 627, comprised of U.S. black and white adults) were used. During a baseline home visit, pill bottle inspections ascertained medications used in the previous 2 weeks. Polypharmacy status (major [≥8 ingredients], minor [6-7 ingredients], and none [0-5 ingredients]) was determined by counting the total number of generic ingredients. Cox models (time-on-study and age-time-scale methods) assessed the association between polypharmacy and mortality. Alternative models examined confounding by indication and possible effect modification by CKD. Over 4.9 years median follow-up, 2538 deaths were observed. Major polypharmacy was associated with increased mortality in all models, with hazard ratios and 95% confidence intervals ranging from 1.22 (1.07-1.40) to 2.35 (2.15-2.56), with weaker associations in more adjusted models. Minor polypharmacy was associated with mortality in some, but not all, models. The polypharmacy-mortality association did not differ by CKD status. While residual confounding by indication cannot be excluded, in this large American cohort, major polypharmacy was consistently associated with mortality.
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http://dx.doi.org/10.1002/prp2.823DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8328192PMC
August 2021

Higher Serum Urate Levels Are Associated With an Increased Risk for Sudden Cardiac Death.

J Rheumatol 2021 Jun 15. Epub 2021 Jun 15.

This research project is supported by cooperative agreement U01 NS041588 co-funded by the National Institute of Neurological Disorders and Stroke (NINDS) and the National Institute on Aging (NIA), National Institutes of Health, Department of Health and Human Service. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NINDS or the NIA. Representatives of the NINDS were involved in the review of the manuscript but were not directly involved in the collection, management, analysis or interpretation of the data. Additional funding was provided by grants R01 HL080477 and K24 HL111154 from the National Heart, Lung, and Blood Institute (NHLBI) and grant P50AR060772 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). Representatives from the NHLBI or the NIAMS did not have any role in the design and conduct of the study, the collection, management, analysis, and interpretation of the data, or the preparation or approval of the manuscript. L.D. Colantonio, MD, PhD, N.S. Chaudhary, MBBS, MPH, N.D. Armstrong, PhD, P. Muntner, PhD, M.R. Irvin, PhD, Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA; R.J. Reynolds, PhD, K.G. Saag, MD, MSc, Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA; T.R. Merriman, PhD, Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA, and Department of Biochemistry, University of Otago, Dunedin, New Zealand; A. Gaffo, MD, MSPH, Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, and Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA; J.A. Singh, MD, MPH, Department of Epidemiology, University of Alabama at Birmingham, Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, and Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA; T.B. Plante, MD, MHS, Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA; E.Z. Soliman, MD, MSc, MS, Epidemiological Cardiology Research Center (EPICARE), Wake Forest School of Medicine, Winston-Salem, North Carolina, USA; J.R. Curtis, MD, MS, MPH, Department of Epidemiology, University of Alabama at Birmingham, and Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA; S.L. Bridges Jr., MD, PhD, Department of Medicine, Division of Rheumatology, Hospital for Special Surgery, and Joan and Sanford I. Weill Department of Medicine, Division of Rheumatology, Weill Cornell Medicine, New York, New York, USA; L. Lang, PhD, Department of Medicine, University of Colorado Denver, Denver, Colorado, USA; G. Howard, DrPH, Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA; M.M. Safford, MD, Department of Medicine, Weill Cornell Medical College, New York, New York, USA. LDC receives research support from Amgen. AG receives research support from Amgen and honoraria from UpToDate. JAS receives consultant fees from Crealta/Horizon, Medisys, Fidia, UBM LLC, Medscape, WebMD, Clinical Care Options, Clearview Healthcare Partners, Putnam Associates, Spherix, Trio Health, Focus Forward, Navigant Consulting, Practice Point Communications, Simply Speaking, the National Institutes of Health, and the American College of Rheumatology; is a member of the Executive Committee of Outcome Measures in Rheumatology (OMERACT), and is a stockholder of Amarin Pharmaceuticals and Viking Therapeutics. MMS receives research support from Amgen. PM receives research support from Amgen and serves as a consultant for Amgen. KGS receives research support from Horizon, Takeda, Sobi, and Shanton; and serves as a consultant/advisor for Arthrosi, Atom Bioscience, LG Pharma, Mallinkrodt, Sobi, Horizon, and Takeda. The remaining authors have no conflicts of interest relevant to this article. Address correspondence to Dr. L.D. Colantonio, 1720 2nd Ave South, RPHB 527C, Birmingham, AL 35294-0013, USA. Email: Accepted for publication June 2, 2021.

Objective: To determine the association of serum urate (SU) levels with sudden cardiac death and incident coronary heart disease (CHD), separately, among adults without a history of CHD.

Methods: We conducted a case-cohort analysis of Black and White participants aged ≥ 45 years enrolled in the REason for Geographic And Racial Differences in Stroke (REGARDS) study without a history of CHD at baseline between 2003 and 2007. Participants were followed for sudden cardiac death or incident CHD (i.e., myocardial infarction [MI] or death from CHD excluding sudden cardiac death) through December 31, 2013. Baseline SU was measured in a random sample of participants (n = 840) and among participants who experienced sudden cardiac death (n = 235) or incident CHD (n = 851) during follow-up.

Results: Participants with higher SU levels were older and more likely to be male or Black. The crude HR (95% CI) per 1 mg/dL higher SU level was 1.26 (1.14-1.40) for sudden cardiac death and 1.17 (1.09-1.26) for incident CHD. After adjustment for age, sex, race, and cardiovascular risk factors, the HR (95% CI) per 1 mg/dL higher SU level was 1.19 (1.03-1.37) for sudden cardiac death and 1.05 (0.96-1.15) for incident CHD. HRs for sudden cardiac death were numerically higher among participants aged 45-64 vs ≥ 65 years, without vs with diabetes, and among those of White vs Black race, although values for effect modification were all ≥ 0.05.

Conclusion: Higher SU levels were associated with an increased risk for sudden cardiac death but not with incident CHD.
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http://dx.doi.org/10.3899/jrheum.210139DOI Listing
June 2021

Multiple Blood Biomarkers and Stroke Risk in Atrial Fibrillation: The REGARDS Study.

J Am Heart Assoc 2021 08 30;10(15):e020157. Epub 2021 Jul 30.

Departments of Medicine and Pathology & Laboratory Medicine Larner College of Medicine at the University of Vermont Burlington VT.

Background Atrial fibrillation is associated with increased stroke risk; available risk prediction tools have modest accuracy. We hypothesized that circulating stroke risk biomarkers may improve stroke risk prediction in atrial fibrillation. Methods and Results The REGARDS (Reasons for Geographic and Racial Differences in Stroke) study is a prospective cohort study of 30 239 Black and White adults age ≥45 years. A nested study of stroke cases and a random sample of the cohort included 175 participants (63% women, 37% Black adults) with baseline atrial fibrillation and available blood biomarker data. There were 81 ischemic strokes over 5.2 years in these participants. Adjusted for demographics, stroke risk factors, and warfarin use, the following biomarkers were associated with stroke risk (hazard ratio [HR]; 95% CI for upper versus lower tertile): cystatin C (3.16; 1.04-9.58), factor VIII antigen (2.77; 1.03-7.48), interleukin-6 (9.35; 1.95-44.78), and NT-proBNP (N-terminal B-type natriuretic peptide) (4.21; 1.24-14.29). A multimarker risk score based on the number of blood biomarkers in the highest tertile was developed; adjusted HRs of stroke for 1, 2, and 3+ elevated blood biomarkers, compared with none, were 1.75 (0.57-5.40), 4.97 (1.20-20.5), and 9.51 (2.22-40.8), respectively. Incorporating the multimarker risk score to the CHADSVASc score resulted in a net reclassification improvement of 0.34 (95% CI, 0.04-0.65). Conclusions Findings in this biracial cohort suggested the possibility of substantial improvement in stroke risk prediction in atrial fibrillation using blood biomarkers or a multimarker risk score.
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http://dx.doi.org/10.1161/JAHA.120.020157DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8475705PMC
August 2021

Rural/urban differences in the prevalence of stroke risk factors: A cross-sectional analysis from the REGARDS study.

J Rural Health 2021 Jul 16. Epub 2021 Jul 16.

Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA.

Purpose: We previously described the magnitude of rural-urban differences in the prevalence of stroke risk factors and stroke mortality. In this report, we sought to extend the understanding of rural-urban differences in the prevalence of stroke risk factors by using an enhanced definition of rural-urban status and assessing the impact of neighborhood socioeconomic status (nSES) on risk factor differences.

Methods: This analysis included 28,242 participants without a history of stroke from the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort. Participants were categorized into the 6-level ordinal National Center for Health Statistics Urban-Rural Classification Scheme. The prevalence of stroke risk factors (hypertension, diabetes, smoking, atrial fibrillation, left ventricular hypertrophy, and heart disease) was assessed across the rural-urban scale with adjustment for demographic characteristics and further adjustment for nSES score.

Findings: Hypertension, diabetes, and heart disease were more prevalent in rural than urban regions. Higher odds were observed for these risk factors in the most rural compared to the most urban areas (odds ratios [95% CI]: 1.25 [1.11-1.42] for hypertension, 1.15 [0.99-1.33] for diabetes, and 1.19 [1.02-1.39] for heart disease). Adjustment for nSES score partially attenuated the odds of hypertension and heart disease with rurality, completely attenuated the odds of diabetes, and unmasked an association of current smoking.

Conclusions: Some of the higher stroke mortality in rural areas may be due to the higher burden of stroke risk factors in rural areas. Lower nSES contributed most notably to rural-urban differences for diabetes and smoking.
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http://dx.doi.org/10.1111/jrh.12608DOI Listing
July 2021

Rural-urban differences in stroke risk.

Authors:
George Howard

Prev Med 2021 Jun 1:106661. Epub 2021 Jun 1.

Department of Biostatistics, UAB School of Public Health, 1665 University Drive, University of Alabama at Birmingham, Birmingham, AL 35294-0022, United States of America. Electronic address:

Rural-urban health disparities in life expectancy are large and increasing, with the rural-urban disparity stroke mortality serving as a potential contributor. Data from Vital Statistics (referenced through the CDC WONDER system) shows an unexplained temporal pattern in the rural-urban disparity in stroke-specific mortality, with the magnitude of the disparity increasing from 15% to 25% between 1999 and 2010, but subsequently decreasing to 8% by 2019. This recent decrease in the magnitude of the rural-urban disparity in stroke mortality appears to be driven by a previously unreported plateauing of stroke mortality in urban areas and a continued decline of stroke mortality in rural areas. There is also a need to better understand the contributors to the higher stroke mortality in rural areas; however, a general lack of temporal data implies that this can only be examined cross-sectionally. A higher stroke incidence in rural areas appears to be a contributor to the higher rural stroke mortality, and there is clear evidence of a higher prevalence of stroke risk factors in rural areas potentially contributing to this higher incidence. Conversely, studies of rural-urban disparities in stroke case fatality show smaller and inconsistent associations. To the extent that disparities in case fatality do exist, there are many studies showing rural-urban disparities in stroke care could be contributing. While these data offer insights to the overall rural-urban disparities in stroke mortality, additional data are needed to help understand temporal changes in the magnitude of the rural-urban stroke mortality disparity.
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http://dx.doi.org/10.1016/j.ypmed.2021.106661DOI Listing
June 2021

Television viewing, physical activity and venous thromboembolism risk: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study.

J Thromb Haemost 2021 Sep 30;19(9):2199-2205. Epub 2021 Jun 30.

Department of Pathology & Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA.

Introduction: Television (TV) viewing may be associated with increased venous thromboembolism (VTE) risk independent of VTE risk factors including physical activity. This association was assessed in a large biracial US cohort of Black and White adults.

Methods: Between 2003 and 2007 The Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study recruited 30,239 participants aged ≥45 years, who were surveyed for baseline TV viewing and followed for VTE events. TV viewing was categorized as <2 hours (light), 2 to 4 hours (moderate), and ≥4 hours (heavy) per day. Physical activity was classified as poor, intermediate, or ideal based on reported weekly activity. Hazard ratios of TV viewing and physical activity were calculated adjusting for VTE risk factors. Multiple imputation for missingness was used as a sensitivity analysis.

Results: Over 96,813 person-years (median: 5.06 years) of follow-up there were 214 VTE events. Heavy TV viewing was not associated with VTE risk in the unadjusted and fully adjusted model (adjusted hazard ratio [aHR]: 0.92 [95% confidence interval (CI): 0.62, 1.36]). Ideal physical activity trended toward a reduced VTE risk (HR: 0.71 [95%CI: 0.51, 1.01]). There was no evidence of an interaction between TV viewing, physical activity, and risk of VTE.

Conclusions: In this contemporary racially and geographically diverse US cohort, there was no association between TV viewing and VTE risk, before and after accounting for physical activity. The high burden of traditional VTE risk factors in REGARDS may mask any association of TV viewing with VTE, or TV viewing may have only a modest association with VTE risk.
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http://dx.doi.org/10.1111/jth.15408DOI Listing
September 2021

Sex and Race Differences in the Risk of Ischemic Stroke Associated With Fasting Blood Glucose in REGARDS.

Neurology 2021 08 27;97(7):e684-e694. Epub 2021 May 27.

From the Departments of Emergency Medicine (T.E.M.), Neurology (K.L.F.), Epidemiology (S.L.), Medicine (S.L.), and Surgery (S.L.), and Center for Global Cardiometabolic Health, Brown University School of Public Health (S.L.), Alpert Medical School of Brown University, Providence, RI; Departments of Biostatistics (D.L.L., G.H.) and Epidemiology (A.P.C., V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology (D.O.K.), University of Michigan Medical School, Ann Arbor; and Department of Medicine, Division of Preventive Medicine (J.E.M.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA.

Objective: To investigate sex and race differences in the association between fasting blood glucose (FBG) and risk of ischemic stroke (IS).

Methods: This prospective longitudinal cohort study included adults age ≥45 years at baseline in the Reasons for Geographic And Racial Differences in Stroke Study, followed for a median of 11.4 years. The exposure was baseline FBG (mg/dL); suspected IS events were ascertained by phone every 6 months and were physician-adjudicated. Cox proportional hazards were used to assess the adjusted sex/race-specific associations between FBG (by category and as a restricted cubic spline) and incident IS.

Results: Of 20,338 participants, mean age was 64.5 (SD 9.3) years, 38.7% were Black, 55.4% were women, 16.2% were using diabetes medications, and 954 IS events occurred. Compared to FBG <100, FBG ≥150 was associated with 59% higher hazards of IS (95% confidence interval [CI] 1.21-2.08) and 61% higher hazards of IS among those on diabetes medications (95% CI 1.12-2.31). The association between FBG and IS varied by race/sex (hazard ratio, FBG ≥150 vs FBG <100: White women 2.05 [95% CI 1.23-3.42], Black women 1.71 [95% CI 1.10-2.66], Black men 1.24 [95% CI 0.75-2.06], White men 1.46 [95% CI 0.93-2.28], = 0.004). Analyses using FBG splines suggest that sex was the major contributor to differences by race/sex subgroups.

Conclusions: Sex differences in the strength and shape of the association between FBG and IS are likely driving the significant differences in the association between FBG and IS across race/sex subgroups. These findings should be explored further and may inform tailored stroke prevention guidelines.
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http://dx.doi.org/10.1212/WNL.0000000000012296DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8377876PMC
August 2021

Atrial fibrillation and risk of incident heart failure with reduced versus preserved ejection fraction.

Heart 2021 May 24. Epub 2021 May 24.

Epidemiological Cardiology Research Center (EPICARE), Department of Epidemiology, Division of Public Health, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.

Objective: Associations between atrial fibrillation (AF) and heart failure (HF) have been established. We compared the extent to which AF is associated with each primary subtype of HF, with reduced (HFrEF) versus preserved ejection fraction (HFpEF).

Methods: We included 25 787 participants free of baseline HF from the REGARDS (REasons for Geographic And Racial Differences in Stroke) cohort. Baseline AF was ascertained from ECG and self-reported history of physician diagnosis. Incident HF events were determined from physician-adjudicated review of hospitalisation medical records and HF deaths. Based on left ventricular ejection fraction (LVEF) at the time of HF event, HFrEF, HFpEF, and mid-range HF were defined as LVEF <40%, ≥50% and 40%-49%, respectively. Multivariable Cox proportional-hazards models examined the association between AF and HF. The Lunn-McNeil method was used to compare associations of AF with incident HFrEF versus HFpEF.

Results: Over a median of 9 years of follow-up, 1109 HF events occurred (356 HFpEF, 388 HFrEF, 77 mid-range and 288 unclassified). In a model adjusted for sociodemographics, cardiovascular risk factors, and incident coronary heart disease, AF was associated with increased risk of all HF events (HR 1.67, 95% CI 1.38 to 2.01). The associations of AF with HFrEF versus HFpEF events did not differ significantly (HR 1.87 (95% CI 1.38 to 2.54) and HR 1.65 (95% CI 1.20 to 2.28), respectively; p value for difference=0.581). These associations were consistent in sex and race subgroups.

Conclusions: AF is associated with both HFrEF and HFpEF events, with no significant difference in the strength of association among these subtypes.
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http://dx.doi.org/10.1136/heartjnl-2021-319122DOI Listing
May 2021

Coronavirus Disease 2019 and Cold Agglutinin Syndrome: An Interesting Case.

Eur J Case Rep Intern Med 2021 10;8(3):002387. Epub 2021 Mar 10.

William Beaumont Hospital, Department of Hematology and Medical Oncology, Royal Oak, Michigan, USA.

The coronavirus disease 2019 (COVID-19) pandemic has caused significant morbidity and mortality worldwide. While patients with COVID-19 most frequently present with pneumonia, respiratory failure and acute respiratory distress syndrome, increasing cases of immune-mediated disorders such as autoimmune thrombocytopenia, haemolytic anaemia and antiphospholipid syndrome have been reported. In this article we describe a rare case of cold agglutinin syndrome (CAS) in a patient with COVID-19. The patient was a 77-year-old man with a history of glucose-6-phosphate dehydrogenase (G6PD) deficiency who presented with COVID-19 infection and acute respiratory failure. Initially he was started on intravenous steroids, antibiotics and hydroxychloroquine. Laboratory analysis revealed haemolytic anaemia with a positive direct anti-globulin test (DAT) and high titres of cold agglutinins. Hydroxychloroquine was stopped due to suspicion of haemolysis due to G6PD deficiency but the haemolysis persisted. Unfortunately, the respiratory failure progressed and the patient died. In summary, this article describes a rare case of CAS associated with COVID-19. CAS is a heterogenous group of cold autoimmune haemolytic anaemias occurring secondary to infections or malignancies. No definite treatment for CAS in COVID-19 patients has been approved so far.

Learning Points: Autoimmune haemolytic anaemia has been reported in COVID-19 patients.Cold agglutinin syndrome (CAS) can occur in patients with COVID-19.Efforts to determine the optimal management of CAS in COVID-19 patients must continue.
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http://dx.doi.org/10.12890/2021_002387DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8112099PMC
March 2021

Does the Association Between Hemoglobin A and Risk of Cardiovascular Events Vary by Residential Segregation? The REasons for Geographic And Racial Differences in Stroke (REGARDS) Study.

Diabetes Care 2021 05 6;44(5):1151-1158. Epub 2021 May 6.

Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL.

Objective: To examine if the association between higher A1C and risk of cardiovascular disease (CVD) among adults with and without diabetes is modified by racial residential segregation.

Research Design And Methods: The study used a case-cohort design, which included a random sample of 2,136 participants at baseline and 1,248 participants with incident CVD (i.e., stroke, coronary heart disease [CHD], and fatal CHD during 7-year follow-up) selected from 30,239 REasons for Geographic And Racial Differences in Stroke (REGARDS) study participants originally assessed between 2003 and 2007. The relationship of A1C with incident CVD, stratified by baseline diabetes status, was assessed using Cox proportional hazards models adjusting for demographics, CVD risk factors, and socioeconomic status. Effect modification by census tract-level residential segregation indices (dissimilarity, interaction, and isolation) was assessed using interaction terms.

Results: The mean age of participants in the random sample was 64.2 years, with 44% African American, 59% female, and 19% with diabetes. In multivariable models, A1C was not associated with CVD risk among those without diabetes (hazard ratio [HR] per 1% [11 mmol/mol] increase, 0.94 [95% CI 0.76-1.16]). However, A1C was associated with an increased risk of CVD (HR per 1% increase, 1.23 [95% CI 1.08-1.40]) among those with diabetes. This A1C-CVD association was modified by the dissimilarity ( < 0.001) and interaction ( = 0.001) indices. The risk of CVD was increased at A1C levels between 7 and 9% (53-75 mmol/mol) for those in areas with higher residential segregation (i.e., lower interaction index). In race-stratified analyses, there was a more pronounced modifying effect of residential segregation among African American participants with diabetes.

Conclusions: Higher A1C was associated with increased CVD risk among individuals with diabetes, and this relationship was more pronounced at higher levels of residential segregation among African American adults. Additional research on how structural determinants like segregation may modify health effects is needed.
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http://dx.doi.org/10.2337/dc20-1710DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8132333PMC
May 2021

Association Between Intracerebral Hemorrhage and Subsequent Arterial Ischemic Events in Participants From 4 Population-Based Cohort Studies.

JAMA Neurol 2021 Jul;78(7):809-816

Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, New York.

Importance: Intracerebral hemorrhage and arterial ischemic disease share risk factors, to our knowledge, but the association between the 2 conditions remains unknown.

Objective: To evaluate whether intracerebral hemorrhage was associated with an increased risk of incident ischemic stroke and myocardial infarction.

Design, Setting, And Participants: An analysis was conducted of pooled longitudinal participant-level data from 4 population-based cohort studies in the United States: the Atherosclerosis Risk in Communities (ARIC) study, the Cardiovascular Health Study (CHS), the Northern Manhattan Study (NOMAS), and the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. Patients were enrolled from 1987 to 2007, and the last available follow-up was December 31, 2018. Data were analyzed from September 1, 2019, to March 31, 2020.

Exposure: Intracerebral hemorrhage, as assessed by an adjudication committee based on predefined clinical and radiologic criteria.

Main Outcomes And Measures: The primary outcome was an arterial ischemic event, defined as a composite of ischemic stroke or myocardial infarction, centrally adjudicated within each study. Secondary outcomes were ischemic stroke and myocardial infarction. Participants with prevalent intracerebral hemorrhage, ischemic stroke, or myocardial infarction at their baseline study visit were excluded. Cox proportional hazards regression was used to examine the association between intracerebral hemorrhage and subsequent arterial ischemic events after adjustment for baseline age, sex, race/ethnicity, vascular comorbidities, and antithrombotic medications.

Results: Of 55 131 participants, 47 866 (27 639 women [57.7%]; mean [SD] age, 62.2 [10.2] years) were eligible for analysis. During a median follow-up of 12.7 years (interquartile range, 7.7-19.5 years), there were 318 intracerebral hemorrhages and 7648 arterial ischemic events. The incidence of an arterial ischemic event was 3.6 events per 100 person-years (95% CI, 2.7-5.0 events per 100 person-years) after intracerebral hemorrhage vs 1.1 events per 100 person-years (95% CI, 1.1-1.2 events per 100 person-years) among those without intracerebral hemorrhage. In adjusted models, intracerebral hemorrhage was associated with arterial ischemic events (hazard ratio [HR], 2.3; 95% CI, 1.7-3.1), ischemic stroke (HR, 3.1; 95% CI, 2.1-4.5), and myocardial infarction (HR, 1.9; 95% CI, 1.2-2.9). In sensitivity analyses, intracerebral hemorrhage was associated with arterial ischemic events when updating covariates in a time-varying manner (HR, 2.2; 95% CI, 1.6-3.0); when using incidence density matching (odds ratio, 2.3; 95% CI, 1.3-4.2); when including participants with prevalent intracerebral hemorrhage, ischemic stroke, or myocardial infarction (HR, 2.2; 95% CI, 1.6-2.9); and when using death as a competing risk (subdistribution HR, 1.6; 95% CI, 1.1-2.1).

Conclusions And Relevance: This study found that intracerebral hemorrhage was associated with an increased risk of ischemic stroke and myocardial infarction. These findings suggest that intracerebral hemorrhage may be a novel risk marker for arterial ischemic events.
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http://dx.doi.org/10.1001/jamaneurol.2021.0925DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8094038PMC
July 2021

Association of 1-Year Blood Pressure Variability With Long-term Mortality Among Adults With Coronary Artery Disease: A Post Hoc Analysis of a Randomized Clinical Trial.

JAMA Netw Open 2021 04 1;4(4):e218418. Epub 2021 Apr 1.

Center for Integrative Cardiovascular and Metabolic Diseases, University of Florida, Gainesville.

Importance: Accumulating evidence indicates that higher blood pressure (BP) variability from one physician office visit to the next (hereafter referred to as visit-to-visit BP variability) is associated with poor outcomes. Short-term measurement (throughout 1 year) of visit-to-visit BP variability in high-risk older patients may help identify patients at increased risk of death.

Objective: To evaluate whether short-term visit-to-visit BP variability is associated with increased long-term mortality risk.

Design, Setting, And Participants: The US cohort of the International Verapamil SR-Trandolapril Study (INVEST), a randomized clinical trial of 16 688 patients aged 50 years or older with hypertension and coronary artery disease, was conducted between September 2, 1997, and December 15, 2000, with in-trial follow-up through February 14, 2003. The study evaluated a calcium antagonist (sustained-release verapamil plus trandolapril) vs β-blocker (atenolol plus hydrochlorothiazide) treatment strategy. Blood pressure measurement visits were scheduled every 6 weeks for the first 6 months and biannually thereafter. Statistical analysis was performed from September 2, 1997, to May 1, 2014.

Exposures: Visit-to-visit systolic BP (SBP) and diastolic BP variability during the first year of enrollment using 4 different BP variability measures: standard deviation, coefficient of variation, average real variability, and variability independent of the mean.

Main Outcomes And Measures: All-cause death, assessed via the US National Death Index, beginning after the exposure assessment period through May 1, 2014.

Results: For the present post hoc analysis, long-term mortality data were available on 16 688 patients (9001 women [54%]; mean [SD] age, 66.5 [9.9] years; 45% White patients, 16% Black patients, and 37% Hispanic patients). During a mean (SD) follow-up of 10.9 (4.2) years, 5058 patients (30%) died. All 4 variability measures for SBP were significantly associated with long-term mortality after adjustment for baseline demographic characteristics and comorbidities. After comparison of lowest vs highest variability measure quintiles, the magnitude of the association with death remained statistically significant even after adjustment for baseline demographic characteristics and comorbidities (average real variability: adjusted hazard ratio [aHR], 1.18; 95% CI, 1.08-1.30; standard deviation: aHR, 1.14; 95% CI, 1.04-1.24; coefficient of variation: aHR, 1.15; 95% CI, 1.06-1.26; variability independent of the mean: aHR, 1.15; 95% CI, 1.05-1.25). The signal was stronger in women compared with men. Associations of diastolic BP variability measures with death were weaker than for SBP and were not significant after adjustment.

Conclusions And Relevance: This study suggests that, in a large population of older patients with hypertension and coronary artery disease, short-term visit-to-visit SBP variability was associated with excess long-term mortality, especially for women. Efforts to identify and minimize visit-to-visit SBP variability may be important in reducing excess mortality later in life.

Trial Registration: ClinicalTrials.gov Identifier: NCT00133692.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.8418DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8085725PMC
April 2021

Selecting an Optimal Antiplatelet Agent for Secondary Stroke Prevention.

Neurol Clin Pract 2021 Apr;11(2):e121-e128

Departments of Neurology and Pharmacology (KCA), SUNY Upstate Medical University, Syracuse, NY; Department of Epidemiology (VJH), and Department of Biostatistics (GH), School of Public Health, University of Alabama at Birmingham.

Four seminal randomized controlled trials (RCTs) have investigated aspirin, aspirin plus extended-release dipyridamole, and clopidogrel for the prevention of recurrent vascular events. Despite studying over 32,000 patients with stroke in these trials, the decision on which antiplatelet agent to select for secondary stroke prevention remains controversial. Attempts to translate the results of these RCTs into clinical practice are complicated by each trial's selection of participants and choice of primary outcome. Herein, we argue that by examining RCT results with participant selection limited to patients with ischemic stroke or TIA and by focusing on recurrent stroke as our outcome, we can use the standard epidemiology 2 × 2 table to assist in selecting an antiplatelet agent for secondary stroke prevention.
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http://dx.doi.org/10.1212/CPJ.0000000000000842DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8032446PMC
April 2021

Editor's Choice - Risk of Stroke before Revascularisation in Patients with Symptomatic Carotid Stenosis: A Pooled Analysis of Randomised Controlled Trials.

Eur J Vasc Endovasc Surg 2021 06 5;61(6):881-887. Epub 2021 Apr 5.

Department of Neurology and Stroke Centre, Department of Clinical Research, University Hospital, University of Basel, Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, London, UK. Electronic address:

Objective: Current guidelines recommending rapid revascularisation of symptomatic carotid stenosis are largely based on data from clinical trials performed at a time when best medical therapy was potentially less effective than today. The risk of stroke and its predictors among patients with symptomatic carotid stenosis awaiting revascularisation in recent randomised controlled trials (RCTs) and in medical arms of earlier RCTs was assessed.

Methods: The pooled data of individual patients with symptomatic carotid stenosis randomised to stenting (CAS) or endarterectomy (CEA) in four recent RCTs, and of patients randomised to medical therapy in three earlier RCTs comparing CEA vs. medical therapy, were compared. The primary outcome event was any stroke occurring between randomisation and treatment by CAS or CEA, or within 120 days after randomisation.

Results: A total of 4 754 patients from recent trials and 1 227 from earlier trials were included. In recent trials, patients were randomised a median of 18 (IQR 7, 50) days after the qualifying event (QE). Twenty-three suffered a stroke while waiting for revascularisation (cumulative 120 day risk 1.97%, 95% confidence interval [CI] 0.75 - 3.17). Shorter time from QE until randomisation increased stroke risk after randomisation (χ = 6.58, p = .011). Sixty-one patients had a stroke within 120 days of randomisation in the medical arms of earlier trials (cumulative risk 5%, 95% CI 3.8 - 6.2). Stroke risk was lower in recent than earlier trials when adjusted for time between QE and randomisation, age, severity of QE, and degree of carotid stenosis (HR 0.47, 95% CI 0.25 - 0.88, p = .019).

Conclusion: Patients with symptomatic carotid stenosis enrolled in recent large RCTs had a lower risk of stroke after randomisation than historical controls. The added benefit of carotid revascularisation to modern medical care needs to be revisited in future studies. Until then, adhering to current recommendations for early revascularisation of patients with symptomatic carotid stenosis considered to require invasive treatment is advisable.
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http://dx.doi.org/10.1016/j.ejvs.2021.02.024DOI Listing
June 2021

Relation of Atrial Fibrillation to Cognitive Decline (from the REasons for Geographic and Racial Differences in Stroke [REGARDS] Study).

Am J Cardiol 2021 06 6;148:60-68. Epub 2021 Mar 6.

Department of Epidemiology & Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Internal Medicine, Sticht Center for Healthy Aging and Alzheimer's Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina. Electronic address:

The association of atrial fibrillation (AF) with cognitive function remains unclear, especially among racially/geographically diverse populations. This analysis included 25,980 black and white adults, aged 48+, from the national REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort, free from cognitive impairment and stroke at baseline. Baseline AF was identified by self-reported medical history or electrocardiogram (ECG). Cognitive testing was conducted yearly with the Six Item Screener (SIS) to define impairment and at 2-year intervals to assess decline on: animal naming and letter fluency, Montreal Cognitive Assessment (MoCA), Word List Learning (WLL) and Delayed Recall tasks (WLD). Multivariable regression models estimated the relationships between AF and baseline impairment and time to cognitive impairment. Models were adjusted sequentially for age, sex, race, geographic region, and education, then cardiovascular risk factors and finally incident stroke. AF was present in 2,168 (8.3%) participants at baseline. AF was associated with poorer baseline performance on measures of: semantic fluency (p<0.01); global cognitive performance (MoCA, p<0.01); and WLD (p<0.01). During a mean follow-up of 8.06 years, steeper declines in list learning were observed among participants with AF (p<0.03) which remained significant after adjusting for cardiovascular risk factors (p<0.04) and incident stroke (p<0.03). Effect modification by race, sex and incident stroke on AF and cognitive decline were also detected. In conclusion, AF was associated with poorer baseline cognitive performance across multiple domains and incident cognitive impairment in this bi-racial cohort. Additional adjustment for cardiovascular risk factors attenuated these relations with the exception of learning.
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http://dx.doi.org/10.1016/j.amjcard.2021.02.036DOI Listing
June 2021

Stenting the carotid artery from radial access using a Simmons guide catheter.

J Neurointerv Surg 2021 Feb 25. Epub 2021 Feb 25.

Biostatistics, UAB, Birmingham, Alabama, USA.

Background: Carotid artery stenting (CAS) is a procedure for stroke prevention, usually done from femoral artery access. Reports of CAS using radial artery access have adopted techniques similar to those used for transfemoral CAS. Initial experience with a simpler and lower profile technique for transradial carotid stenting is described here.

Methods: Of 55 consecutive elective CAS cases with standard (not bovine) arch anatomy performed during a 15 month time period by the same operator, 20 were selected for transradial treatment using a 6 F Simmons 2 guide catheter. This was a retrospective analysis of those initial 20 patients compared with the 35 patients treated with elective transfemoral CAS. The CAS database was reviewed for clinical indications, technique, procedure and fluoroscopy times, and clinical outcomes.

Results: All procedures were technically successful (no crossovers). No patient had a decline in National Institutes of Health Stroke Scale score or modified Rankin Scale score within 30 days. Mean (95% CI) procedural times for transradial CAS were slightly higher than transfemoral CAS (29.4 (26.0 to 32.7) vs 23.8 (21.2 to 26.4) min, p=0.0098). Mean (95% CI) fluoroscopy times were also higher for transradial CAS compared with transfemoral CAS (9.6 (8.0 to 11.2) vs 6.4 (5.4 to 7.4), p=0.0006). One patient developed a radial artery pseudoaneurysm which required elective surgical repair.

Conclusion: Transradial carotid stenting using the described lower profile technique provides another effective option in the array of surgical procedures for the treatment of carotid artery stenosis. Relative procedural and fluoroscopy times may initially be longer compared with transfemoral carotid stenting for experienced CAS operators, although absolute differences are small.
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http://dx.doi.org/10.1136/neurintsurg-2020-017143DOI Listing
February 2021

Correlates of a southern diet pattern in a national cohort study of blacks and whites: the REasons for Geographic And Racial Differences in Stroke (REGARDS) study.

Br J Nutr 2021 Feb 26:1-7. Epub 2021 Feb 26.

Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA.

The Southern dietary pattern, derived within the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort, is characterised by high consumption of added fats, fried food, organ meats, processed meats and sugar-sweetened beverages and is associated with increased risk of several chronic diseases. The aim of the present study was to identify characteristics of individuals with high adherence to this dietary pattern. We analysed data from REGARDS, a national cohort of 30 239 black and white adults ≥45 years of age living in the USA. Dietary data were collected using the Block 98 FFQ. Multivariable linear regression was used to calculate standardised beta coefficients across all covariates for the entire sample and stratified by race and region. We included 16 781 participants with complete dietary data. Among these, 34·6 % were black, 45·6 % male, 55·2 % resided in stroke belt region and the average age was 65 years. Black race was the factor with the largest magnitude of association with the Southern dietary pattern (Δ = 0·76 sd, P < 0·0001). Large differences in Southern dietary pattern adherence were observed between black participants and white participants in the stroke belt and non-belt (stroke belt Δ = 0·75 sd, non-belt Δ = 0·77 sd). There was a high consumption of the Southern dietary pattern in the US black population, regardless of other factors, underlying our previous findings showing the substantial contribution of this dietary pattern to racial disparities in incident hypertension and stroke.
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http://dx.doi.org/10.1017/S0007114521000696DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8387505PMC
February 2021

Neighborhood Walkability as a Predictor of Incident Hypertension in a National Cohort Study.

Front Public Health 2021 1;9:611895. Epub 2021 Feb 1.

Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, United States.

The built environment (BE) has been associated with health outcomes in prior studies. Few have investigated the association between neighborhood walkability, a component of BE, and hypertension. We examined the association between neighborhood walkability and incident hypertension in the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study. Walkability was measured using Street Smart Walk Score based on participants' residential information at baseline (collected between 2003 and 2007) and was dichotomized as more (score ≥70) and less (score <70) walkable. The primary outcome was incident hypertension defined at the second visit (collected between 2013 and 2017). We derived risk ratios (RR) using modified Poisson regression adjusting for age, race, sex, geographic region, income, alcohol use, smoking, exercise, BMI, dyslipidemia, diabetes, and baseline blood pressure (BP). We further stratified by race, age, and geographic region. Among 6,894 participants, 6.8% lived in more walkable areas and 38% ( = 2,515) had incident hypertension. In adjusted analysis, neighborhood walkability (Walk Score ≥70) was associated with a lower risk of incident hypertension (RR [95%CI]: 0.85[0.74, 0.98], = 0.02), with similar but non-significant trends in race and age strata. In secondary analyses, living in a more walkable neighborhood was protective against being hypertensive at both study visits (OR [95%CI]: 0.70[0.59, 0.84], < 0.001). Neighborhood walkability was associated with incident hypertension in the REGARDS cohort, with the relationship consistent across race groups. The results of this study suggest increased neighborhood walkability may be protective for high blood pressure in black and white adults from the general US population.
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http://dx.doi.org/10.3389/fpubh.2021.611895DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7882902PMC
May 2021

The prevalence of cardiovascular risk factors and cardiovascular disease among primary care patients in Poland: results from the LIPIDOGRAM2015 study.

Atheroscler Suppl 2020 Dec;42:e15-e24

Department of Hypertension, Medical University of Lodz, Rzgowska 281/289, 93-338, Łodz, Poland.

Background And Aim: To estimate the prevalence of cardiovascular (CV) disease and CV risk factors among Polish patients.

Methods: A nationwide cross-sectional study, LIPIDOGRAM2015, was carried out in Poland in the 4th quarter of 2015 and 1st and 2nd quarters of 2016; 438 primary care physicians enrolled 13,724 adult patients that sought medical care in primary health care practices.

Results: Nearly 19% of men and approximately 12% of women had cardiovascular disease (CVD). Over 60% of the recruited patients had hypertension (HTN), >80% had dyslipidaemia and <15% of patients were diagnosed with diabetes (DM). All of these disorders were more frequent in men. In 80% of patients the waist circumference exceed norm for the European population. Less than half of the patients were current smokers or had smoked in the past. Patients with CVD had significantly higher blood pressure and glucose levels but lower low density lipoprotein-cholesterol level.

Conclusions: The prevalence of CVD and CV risk factors among patients in Poland is high. CVD is more common in men than in women. The most common CV risk factors are excess waist circumference, dyslipidaemia and HTN. Family physicians should conduct activities to prevent, diagnose early and treat CVD in the primary health care population.
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http://dx.doi.org/10.1016/j.atherosclerosissup.2021.01.004DOI Listing
December 2020

Extranodal blastoid/pleomorphic variant of mantle cell lymphoma involving the testis and skin.

BMJ Case Rep 2021 Jan 28;14(1). Epub 2021 Jan 28.

Department of Hematology and Oncology, Beaumont Health, Royal Oak, Michigan, USA.

We report a case of extranodal mantle cell lymphoma of the testis in a 72-year-old Caucasian man who presented to his physician's office with rapidly enlarging left testicular mass and skin lesions which were subsequently biopsy-proven to be mantle cell lymphoma. We discuss the clinicopathological features and current management in relapsed and refractory settings of this rare presentation of mantle cell lymphoma.
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http://dx.doi.org/10.1136/bcr-2020-239014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7845674PMC
January 2021

Absence of Consistent Sex Differences in Outcomes From Symptomatic Carotid Endarterectomy and Stenting Randomized Trials.

Stroke 2021 Jan 25;52(2):416-423. Epub 2021 Jan 25.

Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.).

Background And Purpose: CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) reported a higher periprocedural risk for any stroke, death, or myocardial infarction for women randomized to carotid artery stenting (CAS) compared with women randomized to carotid endarterectomy (CEA). No difference in risk by treatment was detected for women relative to men in the 4-year primary outcome. We aimed to conduct a pooled analysis among symptomatic patients in large randomized trials to provide more precise estimates of sex differences in the CAS-to-CEA risk for any stroke or death during the 120-day periprocedural period and ipsilateral stroke thereafter.

Methods: Data from the Carotid Stenosis Trialists' Collaboration included outcomes from symptomatic patients in EVA-3S (Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis), SPACE (Stent-Protected Angioplasty Versus Carotid Endarterectomy in Symptomatic Patients), ICSS (International Carotid Stenting Study), and CREST. The primary outcome was any stroke or death within 120 days after randomization and ipsilateral stroke thereafter. Event rates and relative risks were estimated using Poisson regression; effect modification by sex was assessed with a sex-by-treatment-by-trial interaction term, with significant interaction defined a priori as ≤0.10.

Results: Over a median 2.7 years of follow-up, 433 outcomes occurred in 3317 men and 1437 women. The CAS-to-CEA relative risk of the primary outcome was significantly lower for women compared with men in 1 trial, nominally lower in another, and nominally higher in the other two. The sex-by-treatment-by-trial interaction term was significant (=0.065), indicating heterogeneity among trials. Contributors to this heterogeneity are primarily differences in periprocedural period. When the trials are nevertheless pooled, there were no significant sex differences in risk in any follow-up period.

Conclusions: There were significant differences between trials in the magnitude of sex differences in treatment effect (CAS-to-CEA relative risk), indicating pooling data from these trials to estimate sex differences might not be valid. Whether sex is acting as an effect modifier of the CAS-to-CEA treatment effect in symptomatic patients remains uncertain. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00190398 (EVA-3S) and NCT00004732 (CREST). URL: https://www.isrctn.com; Unique identifier: ISRCTN57874028 (SPACE) and ISRCTN25337470 (ICSS).
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http://dx.doi.org/10.1161/STROKEAHA.120.030184DOI Listing
January 2021
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