Publications by authors named "Jared W Magnani"

162 Publications

Educational Attainment, Race, and Ethnicity as Predictors for Ideal Cardiovascular Health: From the National Health and Nutrition Examination Survey.

J Am Heart Assoc 2022 Jan 5;11(2):e023438. Epub 2022 Jan 5.

Division of Cardiology University of Pittsburgh School of Medicine Pittsburgh PA.

Background Educational attainment is protective for cardiovascular health (CVH), but the benefits of education may not persist across racial and ethnic groups. Our objective was to determine whether the association between educational attainment and ideal CVH differs by race and ethnicity in a nationally representative sample. Methods and Results Using the National Health and Nutrition Examination Survey, we determined the distribution of ideal CVH, measured by Life's Simple 7, across levels of educational attainment. We used multivariable ordinal logistic regression to assess the association between educational attainment (less than high school, high school graduate, some college, college graduate) and Life's Simple 7 category (ideal, intermediate, poor), by race and ethnicity (Asian, Black, Hispanic, White). Covariates were age, sex, history of cardiovascular disease, health insurance, access to health care, and income-poverty ratio. Of 7771 National Health and Nutrition Examination Survey participants with complete data, as level of educational attainment increased, the criteria for ideal health were more often met for most metrics. After adjustment for covariates, effect of education was attenuated but remained significant (<0.01). Those with at least a college degree had 4.12 times the odds of having an ideal Life's Simple 7 compared with less than high school (95% CI, 2.70-5.08). Among all racial and ethnic groups, as level of educational attainment increased, so did Life's Simple 7. The magnitude of the association between education and CVH varied by race and ethnicity (interaction <0.01). Conclusions Our findings demonstrate that educational attainment has distinct associations with ideal CVH that differs by race and ethnicity. This work demonstrates the need to elucidate barriers preventing individuals from racial and ethnic minority groups from achieving equitable CVH.
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http://dx.doi.org/10.1161/JAHA.121.023438DOI Listing
January 2022

Incidence of venous thromboembolism in patients with obstructive sleep apnea: a cohort study.

Chest 2021 Dec 13. Epub 2021 Dec 13.

Center for Sleep and Cardiovascular Outcomes Research, University of Pittsburgh School of Medicine, Pittsburgh, PA.

Background: Previous studies suggesting that obstructive sleep apnea (OSA) may be an independent risk factor for venous thromboembolism (VTE) have been limited by reliance on administrative data and lack of adjustment for clinical variables, including obesity.

Research Question: Does OSA confer an independent risk of incident VTE among a large clinical cohort referred for sleep disordered breathing evaluation?

Study Design And Methods: We analyzed the clinical outcomes of 31,309 patients undergoing overnight polysomnography within a large hospital system. We evaluated the association of OSA severity with incident VTE using Cox proportional hazards modeling accounting for age, sex, body mass index (BMI), and common comorbid conditions.

Results: Patients were of mean age 50.4 years and 50.1% female. There were 1,791 VTE events identified over a mean follow-up of 5.3 years. In age and sex-adjusted analyses, each 10 event/hr increase in the apnea hypopnea index (AHI) was associated with a 4% increase in incident VTE risk (hazard ratio [HR] 1.04, 95% confidence interval [CI] 1.02-1.05). After adjusting for BMI, this association disappeared (HR 1.01, 95% CI 0.99-1.03). In contrast, nocturnal hypoxemia had an independent association with incident VTE. Patients with >50% sleep time spent with oxyhemoglobin saturation <90% are at 48% increased VTE risk compared to those without nocturnal hypoxemia (HR 1.48, 95% CI 1.16-1.69).

Interpretation: In this large cohort, we found that patients with more severe OSA as measured by the AHI are more likely to have incident VTE. Adjusted analyses suggest that this association is explained due to confounding by obesity. However, severe nocturnal hypoxemia may be a mechanism by which OSA heightens VTE risk.
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http://dx.doi.org/10.1016/j.chest.2021.12.630DOI Listing
December 2021

COVID-19 and Anticoagulation for Atrial Fibrillation: An Analysis of US Nationwide Pharmacy Claims Data.

J Am Heart Assoc 2021 12 16;10(24):e023235. Epub 2021 Dec 16.

Division of Cardiology Department of Medicine University of Pittsburgh School of Medicine Pittsburgh PA.

Background Adherence to oral anticoagulation (OAC) is critical for stroke prevention in atrial fibrillation. However, the COVID-19 pandemic may have disrupted access to such therapy. We hypothesized that our analysis of a US nationally representative pharmacy claims database would identify increased incidence of lapses in OAC refills during the COVID-19 pandemic. Methods and Results We identified individuals with atrial fibrillation prescribed OAC in 2018. We used pharmacy dispensing records to determine the incidence of 7-day OAC gaps and 15-day excess supply for each 30-day interval from January 1, 2019 to July 8, 2020. We constructed interrupted time series analyses to test changes in gaps and supply around the pandemic declaration by the World Health Organization (March 11, 2020), and whether such changes differed by medication (warfarin or direct OAC), prescription payment type, or prescriber specialty. We identified 1 301 074 individuals (47.5% women; 54% age ≥75 years). Immediately following the COVID-19 pandemic declaration, we observed a 14% decrease in 7-day OAC gaps and 56% increase in 15-day excess supply (both <0.001). The increase in 15-day excess supply was more marked for direct OAC (69% increase) than warfarin users (35%; <0.001); Medicare beneficiaries (62%) than those with commercial insurance (43%; <0.001); and those prescribed OAC by a cardiologist (64%) rather than a primary care provider (48%; <0.001). Conclusions Our analysis of nationwide claims data demonstrated increased OAC possession after the onset of the COVID-19 pandemic. Our findings may have been driven by waivers of early refill limits and patients' tendency to stockpile medications in the first weeks of the pandemic.
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http://dx.doi.org/10.1161/JAHA.121.023235DOI Listing
December 2021

Disparities in Reporting a History of Cardiovascular Disease Among Adults With Limited English Proficiency and Angina.

JAMA Netw Open 2021 12 1;4(12):e2138780. Epub 2021 Dec 1.

School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.

Importance: Individuals with limited English proficiency (LEP) may be unaware of underlying cardiovascular disease (CVD) owing to a lack of diagnostic testing or poor communication with health care practitioners.

Objective: To evaluate whether participants with anginal symptoms and LEP would be less likely to report a history of CVD compared with those without LEP.

Design, Study, And Participants: This population-based cross-sectional study combined data from 5 National Health and Nutrition Examination Survey (NHANES) cycles conducted from 2007 to 2016. Each cycle includes an interview that collects demographic, dietary, and health-related data as well as a medical examination component in which physiological measurements are taken. All NHANES participants aged 40 years or older who took the Rose questionnaire were included. Data were analyzed from September 2020 to April 2021.

Exposures: LEP was defined as a participant receiving the survey in a non-English language or by interpreter.

Main Outcomes And Measures: The 7-item Rose questionnaire assessed the presence of anginal symptoms. Self-reported CVD was defined as history of heart failure, coronary heart disease, angina pectoris, or myocardial infarction. The association between LEP status and self-reported CVD among those with anginal symptoms was determined in multivariable-adjusted models. All analyses were weighted per NHANES analytic protocols.

Results: Among 19 320 participants (mean [SD] age, 57.8 [11.8] years; 9344 [47.2%] male; 4145 [10.6%] Black; 2743 [6.3%] Mexican American; 2111 [4.6%] other Hispanic; 8386 [71.6%] White; and 1935 [6.9%] other race), 583 (3.0%) reported anginal symptoms. Of these, most were non-LEP (484 [96.1%]), women (344 [62.1%]), White (251 [66.8%]), and did not report having CVD (347 [62.8%]). Among those with angina, 73 of 99 respondents with LEP (79.0%) reported not having a history of CVD, compared with 274 of 484 without LEP (61.4%; P = .002). Participants with LEP had 2.8-fold higher odds of not reporting a history of CVD compared with participants without LEP (odds ratio, 2.77; 95% CI, 1.38-5.55; P = .005).

Conclusions And Relevance: Among NHANES participants reporting anginal symptoms, participants with LEP were more likely not to report having CVD. This discrepancy may be because of higher rates of undiagnosed CVD or lower awareness of such diagnoses among individuals with LEP. Our findings highlight the relevance of communication strategies for individuals with LEP to provide effective intervention and treatment for CVD prevention.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.38780DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8672228PMC
December 2021

Potential Protective Effects of Equol (Soy Isoflavone Metabolite) on Coronary Heart Diseases-From Molecular Mechanisms to Studies in Humans.

Nutrients 2021 Oct 23;13(11). Epub 2021 Oct 23.

Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15213, USA.

Equol, a soy isoflavone-derived metabolite of the gut microbiome, may be the key cardioprotective component of soy isoflavones. Systematic reviews have reported that soy isoflavones have no to very small effects on traditional cardiovascular disease risk factors. However, the potential mechanistic mode of action of equol on non-traditional cardiovascular risk factors has not been systematically reviewed. We searched the PubMed through to July 2021 by using terms for equol and each of the following markers: inflammation, oxidation, endothelial function, vasodilation, atherosclerosis, arterial stiffness, and coronary heart disease. Of the 231 records identified, 69 articles met the inclusion criteria and were summarized. Our review suggests that equol is more lipophilic, bioavailable, and generally more potent compared to soy isoflavones. Cell culture, animal, and human studies show that equol possesses antioxidative, anti-inflammatory, and vasodilatory properties and improves arterial stiffness and atherosclerosis. Many of these actions are mediated through the estrogen receptor β. Overall, equol may have a greater cardioprotective benefit than soy isoflavones. Clinical studies of equol are warranted because equol is available as a dietary supplement.
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http://dx.doi.org/10.3390/nu13113739DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8622975PMC
October 2021

Racial and Urban-Rural Difference in the Frequency of Ischemic Stroke as Initial Manifestation of Atrial Fibrillation.

Front Public Health 2021 5;9:780185. Epub 2021 Nov 5.

Center for Pharmaceutical Prescribing and Policy, University of Pittsburgh, Pittsburgh, PA, United States.

Atrial fibrillation (AF) may remain undiagnosed until the development of complications. We aimed to examine the epidemiology and racial/ethnic and rural/urban differences in the frequency of newly diagnosed AF manifesting as ischemic stroke in a nationally representative sample of Medicare beneficiaries. We used a 5% random sample of Medicare claims to identify patients newly diagnosed with AF in 2016. The primary dependent variable was stroke or transient ischemic attack (TIA) in the 7 days to the first AF diagnosis, i.e., stroke or TIA as the initial manifestation of AF. We constructed a multivariable logistic regression to quantify the association between race/ethnicity, urban/rural residence, and the primary dependent variable. Among 39,409 patients newly diagnosed with AF (mean age 77 ± 10 years; 58% women; 7.2% Black, 87.8% White, 5.1% others), 2,819 (7.2%) had ischemic stroke or TIA in the 7 days to AF diagnosis. Black patients (adjusted OR [95% CI]: 1.21 [1.05, 1.40], vs. White) and urban residents (1.21 [1.08, 1.35], vs. rural) were at increased risk of stroke as the initial manifestation of AF. Racial differences were larger among patients aged ≥75 years, with adjusted ORs of 1.43 (1.19, 1.73) for Black vs. White patients, but non-significant for those aged <75 ( for interaction = 0.03). We observed significant and important differences in the risk of stroke as initial manifestation of AF between White and Black patients and between rural and urban residents. Our results suggest potential disparities in the identification AF across race/ethnicity groups and urban/rural areas.
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http://dx.doi.org/10.3389/fpubh.2021.780185DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8602106PMC
November 2021

Association of Race and Ethnicity and Anticoagulation in Patients with Atrial Fibrillation Dually Enrolled in VA and Medicare: Effects of Medicare Part D on Prescribing Disparities.

Circ Cardiovasc Qual Outcomes 2021 Nov 15. Epub 2021 Nov 15.

Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

Racial and ethnic disparities in anticoagulation exist in atrial fibrillation (AF) management in Medicare and the Veterans Health Administration (VA), but the influence of dual VA and Medicare enrollment is unclear. We compared anticoagulant initiation by race and ethnicity in dually enrolled patients and assessed the role of Medicare Part D enrollment on anticoagulation disparities. We identified patients with incident AF (2014-2018) dually enrolled in VA and Medicare. We assessed any anticoagulant initiation (warfarin or direct-acting oral anticoagulants, DOACs) within 90 days of AF diagnosis and DOAC use among anticoagulant initiators. We modeled anticoagulant initiation, adjusting for patient, provider, and facility factors, including main effects for race and ethnicity and Medicare Part D enrollment and an interaction term for these variables. In 43,789 patients, 8.9% were Black, 3.6% Hispanic, and 87.5% White; 10.9% participated in Medicare Part D. Overall, 29,680 (67.8%) patients initiated any anticoagulant, of which 17,568 (59.2%) initiated DOACs. Lower proportions of Black (65.2%) than Hispanic (67.6%) or White (68.0%) patients initiated any anticoagulant (p= 0.001), and lower proportions of Black (56.3%) and Hispanic (55.9%) than White (59.6%) patients (p=0.001) initiated DOACs. Compared to White patients, Black patients had significantly lower initiation of any anticoagulant, adjusted odds ratio (aOR) 0.89; 95% CI 0.82-0.97. The aORs for DOAC initiation were significantly lower for Black (0.72; 95% CI, 0.65-0.81) and Hispanic (0.84; 95% CI, 0.70-1.00) than White patients.The interaction between race and ethnicity and Medicare Part D enrollment was non-significant for any anticoagulant (p=0.99) and DOAC (p=0.27) therapies. In dually enrolled VA and Medicare patients with AF, Black patients were less likely to initiate any anticoagulant and Black and Hispanic patients were less likely to initiate DOACs. Medicare Part D enrollment did not moderate the associations between race and ethnicity and anticoagulant therapies.
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http://dx.doi.org/10.1161/CIRCOUTCOMES.121.008389DOI Listing
November 2021

Association of income and educational attainment in hospitalization events in atrial fibrillation.

Am J Prev Cardiol 2021 Sep 1;7:100201. Epub 2021 Jun 1.

Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.

Objective: Social determinants contribute to adverse outcomes in cardiovascular and non-cardiovascular conditions. However, their investigation in atrial fibrillation (AF) remains limited. We examined the associations between annual income and educational attainment with risk of hospitalization in individuals with AF receiving care in a regional health care system. We hypothesized that individuals with lower income and lower education would have an increased risk of hospitalization.

Methods: We enrolled a cohort of individuals with prevalent AF from an ambulatory setting. We related annual income (≤$19,999/year; $20,000-49,000/year; $50,000-99,999/year; ≥$100,000/year) and educational attainment (high school/vocational; some college; Bachelor's; graduate) to hospitalization events in multivariable-adjusted Cox proportional hazards models, using the Andersen-Gill model to account for the potential of participants to have multiple events.

Results: In 339 individuals with AF (age 72.3 ± 10.1 years; 43% women) followed for median 2.6 years (range 0-3.4 years), we observed 417 hospitalization events. We identified an association between both income and educational attainment and hospitalization risk. In multivariable-adjusted analyses which included educational attainment individuals in the lowest annual income category (≤19,999/year) had 2.0-fold greater hospitalization risk than those in the highest (≥100,000/year; 95% Confidence Interval [CI] 1.08-4.09;  = 0.03). In multivariable-adjusted analyses without adjustment for income, those in the lowest educational attainment category (high school/vocational) had a 2-fold increased risk of hospitalization relative to the highest (graduate-level; 95% CI 1.12-3.54,  = 0.02). However, this association between education and events was attenuated with further adjustment for income (95% CI 0.97-3.15,  = 0.06).

Conclusions: We identified relationships between income and education and prospective risk of hospitalization risk in AF. Our findings support the consideration of social determinants in evaluating and treating socioeconomically disadvantaged individuals with AF to reduce hospitalization risk.
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http://dx.doi.org/10.1016/j.ajpc.2021.100201DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8387303PMC
September 2021

Sex differences in atrial fibrillation: patient-reported outcomes and the persistent toll on women.

Am J Prev Cardiol 2021 Dec 3;8:100252. Epub 2021 Sep 3.

Department of Medicine, University of Pittsburgh, Pittsburgh, PA, US.

Background: Women have worse patient-reported outcomes in atrial fibrillation (AF) than men, but the reasons remain poorly understood. We investigated how comorbid conditions, treatment, social factors, and their modification by sex would attenuate sex-specific differences in patient-reported outcomes in AF.

Methods: In a cohort with prevalent AF we measured patient-reported outcomes with the Short-Form-12 (SF-12, an 8-domain quality of life measure), and the AF Effect on QualiTy of Life (AFEQT), an instrument specific to AF, both with range 0-100 and higher scores indicating superior outcomes. We examined sex-specific differences in patient-reported outcomes in multivariable-adjusted regression analyses incorporating demographics, comorbid conditions, treatment, social factors, and their sex-based modification.

Results: In 339 individuals (age 72±10, 45% women), women (vs. men) reported worse physical functioning on the SF-12 (49.7±39.0 versus 65.0±34.0), social functioning (69.8±31.8 versus 79.7±25.8), and mental health (67.4±20.2 versus 75.0±18.6). These differences were attenuated with adjustment for comorbid conditions and depression. Women had worse composite AFEQT scores (73.8±18.4 versus 78.5±16.6) and symptoms and treatment scores than men with differences remaining significant after multivariable adjustment. There were not significant interactions by sex and the array of covariates when examining differences in patient-reported outcomes between women and men.

Conclusions: We identified sex-specific differences in patient-reported outcomes assessed with general and AF-specific measures. Compared to men, women with AF reported worse overall health-related quality of life, even after consideration of both relevant covariates and their modification by sex. Our research indicates the importance of consideration of sex-based inequities when evaluating patient-reported outcomes in AF.
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http://dx.doi.org/10.1016/j.ajpc.2021.100252DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8435986PMC
December 2021

The effect of the lone parent household on cardiovascular health (National Health and Nutrition Examination Survey, 2015-2016).

Am Heart J Plus 2021 Mar 27;3. Epub 2021 May 27.

Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, United States of America.

Study Objective: Single parenthood is associated with adverse health outcomes. How cardiovascular risk differs by parenthood status has had limited study. We hypothesized that single parents would have worse cardiovascular risk profiles compared to those in partnered-parent households.

Design: We compared associations of parenthood status and the American Heart Association's Life Simple 7 (LS7), an established metric measuring modifiable components of cardiovascular health (smoking status, body mass index, physical activity, diet, cholesterol, glycohemoglobin, and blood pressure) in multivariable-adjusted models.

Participants: We selected adults (age ≥ 25) from the National Health and Nutrition Examination Survey (NHANES) 2015-16 cycle. We defined single parenthood as reporting a child <18 years residing in the home and marital status other than married or living with partner.

Main Outcome Measures: LS7, continuous (range 0-14) and categorized as poor (0-4), intermediate (5-9), or ideal (10-14).

Results: In total, 2180 NHANES participants identified as parents and 1782 (82%) had complete LS7 scores. Of these, 462 identified as single parents, of whom 356 (74.9%) were women. Single parents were more likely to smoke, have poor physical activity, and have high blood pressure ( < 0.01) than partnered parents. Single parents had 1.3-fold greater likelihood of poor cardiovascular health compared with partnered parents, adjusting for age, sex, race/ethnicity, health insurance, healthcare access, poverty index, educational attainment and number of children (95% confidence interval [CI] 1.01-1.71).

Conclusions: We identified an association between single parenthood and adverse cardiovascular health. Our results demonstrate the importance of considering household composition in risk assessment and cardiovascular disease prevention.
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http://dx.doi.org/10.1016/j.ahjo.2021.100015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8389735PMC
March 2021

Association between human immunodeficiency virus serostatus and the prevalence of atrial fibrillation.

Medicine (Baltimore) 2021 Jul;100(29):e26663

Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD.

Abstract: Atrial fibrillation (AF) leads to increased risk for stroke. Human immunodeficiency virus (HIV) is associated with cardiovascular disease (CVD), although it is unclear if HIV is associated with AF. The purpose of this study was to evaluate the association between HIV serostatus and the prevalence of AF in the Multicenter AIDS Cohort Study.A cross sectional study was conducted among 1674 HIV-infected (HIV+) and uninfected (HIV-) men who completed resting 12-lead electrocardiograms, and/or ambulatory electrocardiogram monitoring. Multivariable logistic regression was used to evaluate the association between AF, defined as the presence of either AF or atrial flutter, and HIV+ serostatus. Associations were adjusted for demographic variables, and then also for CVD risk factors.HIV+ men were younger than HIV- men (median 55.5 vs 61.7 years, P < .001) and were more frequently African-American (30.5% vs 17.8%, P < .001). Most HIV+ men (81%) had undetectable viral load. The age and race adjusted prevalence of AF was 3.0% in HIV+ and 3.3% in HIV- men. There was only 1 case of AF among African-American men. There were no associations between AF and HIV serostatus after adjusting for demographic factors (odds ratio 0.76; 95% CI 0.37 to -1.58; P = .47) or after further adjustment for CVD risk factors (odds ratio 0.84; 95% CI 0.39 to -1.81; P = .66).We found no association between HIV and AF in this cohort in which viral replication among the HIV+ men is generally suppressed. The overall prevalence of AF was low and was rare in African-American men.
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http://dx.doi.org/10.1097/MD.0000000000026663DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8294896PMC
July 2021

Disparities in Anticoagulant Therapy Initiation for Incident Atrial Fibrillation by Race/Ethnicity Among Patients in the Veterans Health Administration System.

JAMA Netw Open 2021 07 1;4(7):e2114234. Epub 2021 Jul 1.

Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.

Importance: Atrial fibrillation is a common cardiac rhythm disturbance causing substantial morbidity and mortality that disproportionately affects racial/ethnic minority groups. Anticoagulation reduces stroke risk in atrial fibrillation, yet studies show it is underprescribed in racial/ethnic minority patients.

Objective: To compare initiation of anticoagulant therapy by race/ethnicity for patients in the Veterans Health Administration (VA) system with atrial fibrillation.

Design, Setting, And Participants: This retrospective cohort study included 111 666 patients within the VA system with incident atrial fibrillation between January 1, 2014, and December 31, 2018. Data were analyzed between December 1, 2019, and March 31, 2020.

Exposures: Any anticoagulation was defined as receipt of warfarin or direct-acting oral anticoagulants, apixaban, dabigatran, edoxaban, or rivaroxaban.

Main Outcomes And Measures: Initiation of any anticoagulation (or direct-acting oral anticoagulant therapy in those who initiated any anticoagulation) was examined within 90 days of an index atrial fibrillation diagnosis.

Results: Our final cohort comprised 111 666 patients (109 386 men [98.0%] and 95 493 White patients [85.5%]; mean [SD] age, 72.9 [10.4] years). A total of 69 590 patients (62.3%) initiated any anticoagulant therapy, varying 10.5 percentage points by race/ethnicity (P < .001); initiation was lowest in Asian (52.2% [n = 676]) and Black (60.3% [n = 6177]) patients and highest in White patients (62.7% [n = 59 881]). Among anticoagulant initiators, 45 381 (65.2%) used direct-acting oral anticoagulants, varying 7.2 percentage points by race/ethnicity (P < .001); initiation was lowest in Hispanic (58.3% [n = 1470]), American Indian/Alaska Native (59.8% [n = 201]), and Black (60.9% [n = 3763]) patients and highest in White patients (66.0% [n = 39 502). Compared with White patients, the odds of initiating any anticoagulant therapy were significantly lower for Asian (adjusted odds ratio [aOR], 0.82; 95% CI, 0.72-0.94) and Black (aOR, 0.90; 95% CI 0.85-0.95) patients. Among initiators, the adjusted odds of direct-acting oral anticoagulant initiation were significantly lower for Hispanic (aOR, 0.79; 95% CI, 0.70-0.89), American Indian/Alaska Native (aOR, 0.75; 95% CI, 0.57-0.99), and Black (aOR, 0.74; 95% CI 0.69-0.80) patients.

Conclusions And Relevance: This cohort study found that in patients with incident atrial fibrillation managed in the VA system, race/ethnicity was independently associated with initiating any anticoagulant therapy and direct-acting oral anticoagulant use among anticoagulant initiators. Understanding the reasons for these treatment disparities is essential to improving equitable atrial fibrillation management and outcomes among racial/ethnic minority patients treated in the VA system.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.14234DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8319757PMC
July 2021

Area Deprivation Index and Cardiac Readmissions: Evaluating Risk-Prediction in an Electronic Health Record.

J Am Heart Assoc 2021 07 2;10(13):e020466. Epub 2021 Jul 2.

Division of Cardiology Department of Medicine UPMC Heart and Vascular Institute University of Pittsburgh PA.

Background Assessment of the social determinants of post-hospital cardiac care is needed. We examined the association and predictive ability of neighborhood-level determinants (area deprivation index, ADI), readmission risk, and mortality for heart failure, myocardial ischemia, and atrial fibrillation. Methods and Results Using a retrospective (January 1, 2011-December 31, 2018) analysis of a large healthcare system, we assess the predictive ability of ADI on 30-day and 1-year readmission and mortality following hospitalization. Cox proportional hazards models analyzed time-to-event. Log rank analyses determined survival. C-statistic and net reclassification index determined the model's discriminative power. Covariates included age, sex, race, comorbidity, number of medications, length of stay, and insurance. The cohort (n=27 694) had a median follow-up of 46.5 months. There were 14 469 (52.2%) men and 25 219 White (91.1%) patients. Patients in the highest ADI quintile (versus lowest) were more likely to be admitted within 1 year of index heart failure admission (hazard ratio [HR], 1.25; 95% CI, 1.03‒1.51). Patients with myocardial ischemia in the highest ADI quintile were twice as likely to be readmitted at 1 year (HR, 2.04; 95% CI, 1.44‒2.91]). Patients with atrial fibrillation living in areas with highest ADI were less likely to be admitted within 1 year (HR, 0.79; 95% CI, 0.65‒0.95). As ADI increased, risk of readmission increased, and risk reclassification was improved with ADI in the models. Patients in the highest ADI quintile were 25% more likely to die within a year (HR, 1.25 1.08‒1.44). Conclusions Residence in socioeconomically disadvantaged communities predicts rehospitalization and mortality. Measuring neighborhood deprivation can identify individuals at risk following cardiac hospitalization.
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http://dx.doi.org/10.1161/JAHA.120.020466DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8403312PMC
July 2021

Rurality and atrial fibrillation: a pathway to virtual engagement and clinical trial recruitment in response to COVID-19.

Am Heart J Plus 2021 03;3

Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA.

Study Objective: To summarize trial adaptation from in-clinic to virtual design in response to the SARS-2 coronavirus-2 (COVID-19).

Design: A clinical trial of a mobile health intervention to improve chronic disease self-management for rural individuals with atrial fibrillation (AF). The trial has a 4-month intervention - accessible regardless of health or digital literacy - to enhance AF medication adherence and patient experience with 8- and 12-month assessments of sustainability.

Setting: Rural, western Pennsylvania.

Participants: Rural individuals with AF receiving oral anticoagulation for stroke prevention.

Interventions: Enrolled participants underwent a telephone-based orientation, provided verbal consent, and were randomized using a digital platform. They received a smartphone with intervention or control applications and a curriculum on usage tailored for study arm. Participants received study assessments by mail with telephone-based administration and contact for the 12-month trial.

Main Outcome Measures: Successful adaptation to virtual engagement and recruitment.

Results: The study enrolled 18 participants during in-clinic recruitment (January-March 2020). From 5/1/2020 to 5/6/2021 the study team enrolled 130 individuals (median age 72.4 years, range 40.8-92.2; 49.2% women, 63.1% without college degree, and 45.4% with limited health literacy. Retention of participants enrolled using virtual methods during the 4-month intervention phase is 92%.

Conclusions: We report a virtual trial of a mobile health intervention for rural individuals with AF. Our successful implementation suggests promise for engaging geographically isolated rural individuals, potential to enhance digital health access, and advance rural health equity.
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http://dx.doi.org/10.1016/j.ahjo.2021.100017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8211123PMC
March 2021

Association of patient-reported outcomes with hospitalization risk in atrial fibrillation.

Am Heart J Plus 2021 Feb 26;2. Epub 2021 Mar 26.

Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.

Background: Patient-reported outcomes in atrial fibrillation (AF) are increasingly used to evaluate treatment efficacy and as endpoints in clinical trials. Few studies have related patient-reported outcomes in AF to clinical events and outcomes. We examined the association between patient-reported outcomes and hospitalization risk in individuals with AF receiving care at a regional healthcare system.

Methods And Results: We related the AF Effect on QualiTy of Life (AFEQT), a validated measure (range 0-100) with higher scores indicating superior AF-specific patient-reported outcomes, to hospitalization events in a cohort with prevalent AF. We determined incidence rates for hospitalization events (all-cause, cardiac-, or AF-related) across quartiles of AFEQT scores. We used the Andersen-Gill method to account for multiple hospitalization events per individual and compared the risks of hospitalization across AFEQT quartiles in multivariable-adjusted models. In 339 individuals with AF (age 72.3 ± 10.1 years; 43% women) followed for median 2.6 years (range 0-3.4 years), we observed 417 total hospitalization events. We identified increased incidence rates of hospitalization with progressively decreased AFEQT quartile. Relative to those in the highest AFEQT quartile, individuals in the lowest AFEQT quartile had 3-fold greater risk of all-cause hospitalization (95% Confidence Interval [CI] 1.67-6.57, < 0.001) and 5-fold greater risk of cardiac hospitalization (95% CI 1.66-13.80, = 0.004).

Conclusions: We identified a progressive association between patient-reported outcomes in AF and risk of hospitalization events. Our results underscore the relevance of patient-reported outcomes to clinical adversity and prognosis in AF.
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http://dx.doi.org/10.1016/j.ahjo.2021.100007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8211119PMC
February 2021

Social determinants of atrial fibrillation.

Nat Rev Cardiol 2021 11 2;18(11):763-773. Epub 2021 Jun 2.

Division of Cardiology, Heart and Vascular Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.

Atrial fibrillation affects almost 60 million adults worldwide. Atrial fibrillation is associated with a high risk of cardiovascular morbidity and death as well as with social, psychological and economic burdens on patients and their families. Social determinants - such as race and ethnicity, financial resources, social support, access to health care, rurality and residential environment, local language proficiency and health literacy - have prominent roles in the evaluation, treatment and management of atrial fibrillation. Addressing the social determinants of health provides a crucial opportunity to reduce the substantial clinical and non-clinical complications associated with atrial fibrillation. In this Review, we summarize the contributions of social determinants to the patient experience and outcomes associated with this common condition. We emphasize the relevance of social determinants and their important intersection with atrial fibrillation treatment and outcomes. In closing, we identify gaps in the literature and propose future directions for the investigation of social determinants and atrial fibrillation.
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http://dx.doi.org/10.1038/s41569-021-00561-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8516747PMC
November 2021

P-wave signal-averaged electrocardiography: Reference values, clinical correlates, and heritability in the Framingham Heart Study.

Heart Rhythm 2021 09 11;18(9):1500-1507. Epub 2021 May 11.

National Heart, Lung, and Blood Institute and Boston University's Framingham Heart Study, Framingham, Massachusetts; Section of Computational Biomedicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts.

Background: P-wave signal-averaged electrocardiography (P-SAECG) quantifies atrial electrical activity. P-SAECG measures and their clinical correlates and heritability have had limited characterization in community-based cohorts.

Objective: The purpose of this study was to (1) establish reference values; (2) identify clinical risk factors associated with P-SAECG; and (3) estimate genetic heritability for P-SAECG traits.

Methods: We performed P-SAECG in 2 generations of Framingham Heart Study participants. We performed backward elimination regression models to assess associations of clinical factors with each SAECG trait (P-wave [PW] duration, root mean square voltage in terminal 40 ms [RMS40], terminal 30 ms RMS30, terminal 20 ms RMS20, RMS PW, and PW integral). We estimated the adjusted genetic heritability of P-SAECG measures using the Sequential Oligogenic Linkage Analysis Routines (SOLAR) program.

Results: We included 4307 participants (age 55 ± 14 years; 56% female). The reference values were derived from 1752 participants without cardiovascular risk factors. Median (2.5th percentile; 97.5th percentile) total PW duration was 118 ms (93; 146) in women and 128 ms (104; 158) in men in the reference sample, and 121 ms (94; 151) in women and 129 ms (103; 159) in the entire study cohort (broad sample). In the broad sample, after adjusting for age and sex, total PW duration was positively associated with height, weight, prevalent heart failure, history of atrial fibrillation (AF), and atrioventricular node blockers, and negatively associated with smoking, waist circumference, heart rate, and diabetes. The estimated heritability of P-SAECG traits was moderate, ranging from 11.9% for RMS30 to 24.9% for PW integral.

Conclusion: P-SAECG traits are associated with multiple AF-related risk factors and are moderately heritable.
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http://dx.doi.org/10.1016/j.hrthm.2021.05.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8419007PMC
September 2021

Impact of the COVID-19 Pandemic on Global Anticoagulant Sales: A Cross-Sectional Analysis Across 39 Countries.

Am J Cardiovasc Drugs 2021 09 26;21(5):581-583. Epub 2021 Mar 26.

Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.

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http://dx.doi.org/10.1007/s40256-021-00475-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7994109PMC
September 2021

Area Deprivation Index and Cardiovascular Events: CAN CARDIAC REHABILITATION MITIGATE THE EFFECTS?

J Cardiopulm Rehabil Prev 2021 09;41(5):315-321

Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Drs Guhl, Zhu, Johnson, Mulukutla, and Magnani and Mr Thoma); Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (Drs Essien and Magnani); and Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (Dr Essien).

Introduction: Neighborhood socioeconomic status is associated with health outcomes. Cardiac rehabilitation (CR) provides a cost-effective, multidisciplinary approach to improve outcomes in cardiovascular disease. We aimed to evaluate the association of the Area Deprivation Index (ADI), a marker of neighborhood social composition, with risk of recurrent cardiovascular outcomes and assessed the modifying effect of CR.

Methods: We identified patients with a primary diagnosis of (1) myocardial infarction or (2) incident heart failure (HF) admitted to a large-sized regional health center during 2010-2018. We derived the ADI from home addresses and categorized it into quartiles (higher quartiles indicating increased deprivation). We obtained number of CR visits and covariates from the health record. We compared rehospitalization (cardiovascular, acute coronary syndrome [ACS], and HF) and mortality rates across ADI quartiles.

Results: We included 6957 patients (age 69.2 ± 13.4 yr, 38% women, 89% White race). After covariate adjustment, the ADI was significantly associated with higher incidence rates (IRs)/100 person-yr of cardiovascular rehospitalization (quartile 1, IR 34.6 [95% CI, 31.2-38.2]; quartile 4, 41.5 [95% CI, 39.1-44.1], P < .001). In addition, the ADI was significantly associated with higher rates of rehospitalization for HF (P < .001), ACS (P < .012), and all-cause mortality (P < .04). These differences in rehospitalization and mortality rates by the ADI were no longer significant in those who attended CR.

Conclusions: We found the increased ADI was adversely associated with rehospitalizations and mortality. However, in individuals with CR, outcomes were significantly improved compared with those with no CR. Our findings suggest that CR participation has the potential to improve outcomes in disadvantaged neighborhoods.
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http://dx.doi.org/10.1097/HCR.0000000000000591DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8410614PMC
September 2021

Associations Between HIV Serostatus and Cardiac Structure and Function Evaluated by 2-Dimensional Echocardiography in the Multicenter AIDS Cohort Study.

J Am Heart Assoc 2021 04 20;10(7):e019709. Epub 2021 Mar 20.

Johns Hopkins University School of Medicine Baltimore MD.

Background We aimed to investigate whether there are differences in cardiac structure and systolic and diastolic function evaluated by 2-dimensional echocardiography among men living with versus without HIV in the era of combination antiretroviral therapy. Methods and Results We performed a cross-sectional analysis of 1195 men from MACS (Multicenter AIDS Cohort Study) who completed a transthoracic echocardiogram examination between 2017 and 2019. Associations between HIV serostatus and echocardiographic indices were assessed by multivariable regression analyses, adjusting for demographics and cardiovascular risk factors. Among men who are HIV+, associations between HIV disease severity markers and echocardiographic parameters were also investigated. Average age was 57.1±11.9 years; 29% of the participants were Black, and 55% were HIV+. Most men who were HIV+ (77%) were virally suppressed; 92% received combination antiretroviral therapy. Prevalent left ventricular (LV) systolic dysfunction (ejection fraction <50%) was low and HIV serostatus was not associated with left ventricular ejection fraction. Multivariable adjustment models showed that men who were HIV+ versus those who were HIV- had greater LV mass index and larger left atrial diameter and right ventricular (RV) end-diastolic area; lower RV function; and higher prevalence of diastolic dysfunction. Higher current CD4+ T cell count ≥400 cell/mm versus <400 was associated with smaller LV diastolic volume and RV area. Virally suppressed men who were HIV+ versus those who were HIV- had higher indexed LV mass and left atrial areas and greater diastolic dysfunction. Conclusions HIV seropositivity was independently associated with greater LV mass index, left atrial and RV sizes, lower RV function and diastolic abnormalities, but not left ventricular ejection fraction, which may herald a future predisposition to heart failure with preserved ejection fraction among men living with HIV.
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http://dx.doi.org/10.1161/JAHA.120.019709DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8174316PMC
April 2021

Separate and Unequal: The Cost of Coronavirus Disease 2019 on Childhood Health and Well-Being.

Health Equity 2021 25;5(1):72-75. Epub 2021 Feb 25.

Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.

The coronavirus disease 2019 has and will have an untoward effect on children. In this perspective we summarize the short- and long-term impact of the pandemic on childhood social and physical health. School closure has resulted in an absence of educational opportunity, alongside deprivations of social structure, essential food, and adult guidance, as well as augmented deprivation for the neediest students. The loss of educational attainment will have long-term effects on social mobility, employment and income, and health outcomes. We advocate for transdisciplinary approaches and outline priorities to address the pandemic's impact on schools, literacy, and childhood welfare.
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http://dx.doi.org/10.1089/heq.2020.0080DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7929920PMC
February 2021

Subclinical myocardial injury and cardiovascular mortality: Racial differences in prevalence and risk (from the third National Health and Nutrition Examination survey).

Ann Noninvasive Electrocardiol 2021 07 6;26(4):e12827. Epub 2021 Mar 6.

Department of Internal Medicine, Division of Cardiology, University of Pittsburgh School of Medicine and Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

Background: Subclinical myocardial injury (SCMI) determined from the Electrocardiographic Cardiac Infarction/Injury Score (CIIS) is associated with increased risk of cardiovascular disease and mortality. We hypothesized that SCMI prevalence and association with mortality would differ by race, categorized as non-Hispanic White (White), non-Hispanic Black (Black), and Mexican American.

Methods: Our analysis included 5,852 participants (age 58.5 ± 13.2 years; 54% women, 52% Whites, 23% Blacks, and 25% Mexican American participants) from the National Health and Nutrition Examination Survey (NHANES III, 1988-94) who were free of cardiovascular disease at the time of enrollment. SCMI was defined as the presence of CIIS ≥ 10 score points on the 12-lead ECG. Prevalence of SCMI and its association with cardiovascular mortality were examined in each race/ethnic group in models adjusted for sociodemographics and common cardiovascular risk factors.

Results: SCMI prevalence was 23.4% in Whites, 21.8% in Blacks, and 18.0% in Mexican Americans. Compared to Whites, Blacks were as likely to have SCMI (odds ratio [OR] 0.95, 95% confidence interval [CI] 0.80-1.13), while Mexican Americans were less likely (OR 0.74, 95% CI 0.62-0.88). SCMI was not associated with increased risk of cardiovascular mortality in either Whites (hazard ratio [HR] 1.18, 95% CI 0.95-1.48) or Blacks (HR 1.19, 95% CI 0.79-1.80). In contrast, SCMI in Mexican Americans was associated with increased risk of cardiovascular mortality (HR 1.74, 95% CI 1.13-2.67, p < .05).

Conclusion: Mexican Americans had a lower prevalence of SCMI, but increased risk of cardiovascular mortality. Screening for SCMI may identify individuals at increased risk and improve targeted prevention efforts.
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http://dx.doi.org/10.1111/anec.12827DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8293602PMC
July 2021

Abdominal visceral adipose tissue over the menopause transition and carotid atherosclerosis: the SWAN heart study.

Menopause 2021 03 1;28(6):626-633. Epub 2021 Mar 1.

Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA.

Objectives: To characterize abdominal visceral adipose tissue (VAT) trajectory relative to the final menstrual period (FMP), and to test whether menopause-related VAT accumulation is associated with greater average, common carotid artery intima-media thickness (cIMT) and/or internal carotid artery intima-media thickness (ICA-IMT).

Methods: Participants were 362 women (at baseline: age was (mean ± SD) 51.1 ± 2.8 y; 61% White, 39% Black) with no cardiovascular disease from the Study of Women's Health Across the Nation Heart study. Women had up to two measurements of VAT and cIMT over time. Splines revealed a nonlinear trajectory of VAT with two inflection points demarcating three time segments: segment 1: >2 years before FMP; segment 2: 2 years before FMP to FMP; and segment 3: after FMP. Piecewise-linear random-effects models estimated changes in VAT. Random-effects models tested associations of menopause-related VAT with each cIMT measure separately. Estimates were adjusted for age at FMP, body mass index, and sociodemographic, lifestyle, and cardiovascular disease risk factors.

Results: VAT increased significantly by 8.2% (95% CI: 4.1%-12.5%) and 5.8% (3.7%-7.9%) per year in segments 2 and 3, respectively, with no significant change in VAT within segment 1. VAT predicted greater ICA-IMT in segment 2, such that a 20% greater VAT was associated with a 2.0% (0.8%-3.1%) greater ICA-IMT. VAT was not an independent predictor of ICA-IMT in the other segments or of the other cIMT measures after adjusting for covariates.

Conclusions: Women experience an accelerated increase in VAT starting 2 years before menopause. This menopause-related increase in VAT is associated with greater risk of subclinical atherosclerosis in the internal carotid artery.
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http://dx.doi.org/10.1097/GME.0000000000001755DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8141004PMC
March 2021

Atrial fibrillation: global burdens and global opportunities.

Heart 2021 Jan 28. Epub 2021 Jan 28.

Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.

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http://dx.doi.org/10.1136/heartjnl-2020-318480DOI Listing
January 2021

Periodontal Disease, Atrial Fibrillation and Stroke.

Am Heart J 2021 05 24;235:36-43. Epub 2021 Jan 24.

Department of Periodontology, University of North Carolina, Chapel Hill, NC.

Background: We recently described the association between periodontal disease (PD) and stroke risk.

Purpose: The purpose of this study was to test the association between PD, dental care utilization and incident atrial fibrillation (AF), as well as AF as a mediator to PD- stroke association.

Methods: In dental cohort of the Atherosclerosis Risk in Communities Study (ARIC), participants without prior AF underwent full-mouth periodontal measurements. PD was defined on an ordinal scale as healthy (referent), mild, moderate and severe. In ARIC main cohort, participants were classified as regular or episodic dental care users. These patients were followed for AF, over 17 years. Cox proportional hazards models adjusted for AF risk factors were used to study relationships between PD severity, dental care utilization and AF. Mediation analysis was used to test if AF mediated the PD- stroke association.

Results: In dental ARIC cohort, 5,958 were assessed without prior AF, 754 were found to have AF. Severe PD was associated with AF on both univariable (crude HR, 1.54; 95% CI, 1.26-1.87) and multivariable (adjusted HR, 1.31, 95% CI, 1.06-1.62) analyses. Mediation analysis suggested AF mediates the association between PD and stroke. In the main ARIC cohort, 9,666 participants without prior AF were assessed for dental care use, 1558 were found to have AF. Compared with episodic users, regular users had a lower risk for AF on univariable (crude HR, 0.82, 95% CI, 0.74-0.90) and multivariable (adjusted HR, 0.88, 95% CI, 0.78-0.99) analyses.

Conclusions: PD is associated with AF. The association may explain the PD-stroke risk. Regular users had a lower risk of incident AF compared with episodic users.
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http://dx.doi.org/10.1016/j.ahj.2021.01.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8084947PMC
May 2021

Correction to: Health Literacy Within a Diverse Community-Based Cohort: The Multi-Ethnic Study of Atherosclerosis.

J Immigr Minor Health 2021 Aug;23(4):668

Division of Epidemiology and Community Health, University of Minnesota, 1300 S 2nd St, Suite 300, Minneapolis, MN, 55455, USA.

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http://dx.doi.org/10.1007/s10903-020-01137-9DOI Listing
August 2021

Social Role Stress, Reward, and the American Heart Association Life's Simple 7 in Midlife Women: The Study of Women's Health Across the Nation.

J Am Heart Assoc 2020 12 11;9(24):e017489. Epub 2020 Dec 11.

Department of Epidemiology University of Pittsburgh Graduate School of Public Health Pittsburgh PA.

Background Most women occupy multiple social roles during midlife. Perceived stress and rewards from these roles may influence health behaviors and risk factors. This study examined whether social role stress and reward were associated with the American Heart Association Life's Simple 7 in a cohort of midlife women in the United States. Methods and Results Women (n=2764) rated how stressful and rewarding they perceived their social roles during cohort follow-up (age range, 42-61 years). Body mass index, blood pressure, glucose, cholesterol, physical activity, diet, and smoking were assessed multiple times. All components were collected at the fifth study visit for 1694 women (mean age, 51 years). Adjusted linear and logistic regression models were used in analyses of the number of ideal components and the odds of achieving the ideal level of each component, respectively. Longitudinal analyses using all available data from follow-up visits were conducted. At the fifth visit, more stressful and less rewarding social roles were associated with fewer ideal cardiovascular factors. Higher average stress was associated with lower odds of any component of a healthy diet and an ideal blood pressure. Higher rewards were associated with greater odds of ideal physical activity and nonsmoking. Longitudinal analyses produced consistent results; moreover, there was a significant relationship between greater stress and lower odds of ideal glucose and body mass index. Conclusions Perceived stress and rewards from social roles may influence cardiovascular risk factors in midlife women. Considering social role qualities may be important for improving health behaviors and risk factors in midlife women.
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http://dx.doi.org/10.1161/JAHA.120.017489DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955397PMC
December 2020
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