Publications by authors named "Sebhat Erqou"

74 Publications

Long-term Cardiovascular Manifestations and Complications of COVID-19: Spectrum and Approach to Diagnosis and Management.

R I Med J (2013) 2022 Sep 1;105(7):16-22. Epub 2022 Sep 1.

Department of Medicine, Brown University, Providence, RI; Department of Medicine, Providence VA Medical Center, Providence, RI; Innovation in Long Term Services and Supports, Providence VA Medical Center, Providence, RI.

Survivors of coronavirus disease 2019 (COVID-19) may experience persistent symptoms, abnormal diagnostic test findings, incident disease in specific organ systems, or progression of existing disease. Post-acute COVID-19 syndrome (PACS) is defined by persistent, recurrent, or new symptoms, findings, or diagnoses beyond four weeks after the initial infection. PACS has been characterized as a multi-organ syndrome, often with cardiopulmonary symptoms that include fatigue, dyspnea, chest pain, and palpitations. Cardiovascular pathologies in PACS include new-onset arrhythmia, myocarditis, unmasked coronary artery disease, and diastolic dysfunction as well as abnormal findings on electrocardiogram, troponin testing, and cardiac magnetic resonance imaging. In this review, we discuss the cardiovascular symptoms, pathophysiology, clinical investigation, and management strategies for cardiopulmonary symptoms of PACS. We offer a treatment algorithm for primary care clinicians encountering patients with cardiopulmonary PACS and discuss ongoing research on this topic.
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September 2022

Associations between cumulative social risk, psychosocial risk, and ideal cardiovascular health: Insights from the HeartSCORE study.

Am J Prev Cardiol 2022 Sep 17;11:100367. Epub 2022 Jul 17.

Department of Medicine, the Warren Alpert Medical School of Brown University, Providence, RI, United States.

Background: Limited studies have assessed the effects of psychosocial risk factors on achievement of ideal cardiovascular health .

Methods: Using the Heart Strategies Concentrating on Risk Evaluation (HeartSCORE) cohort, we examined the cross-sectional associations of cumulative social risk (CSR) and three psychosocial factors (depression, stress, perceived discrimination) with . CSR was calculated by assigning one point for each of: low family income, low education level, minority race (Black), and single-living status. was calculated by assigning one point for ideal levels of each factor in American Heart Association's Life's Simple 7. was dichotomized into fewer versus higher by combining participants achieving <3 versus ≥3 factors. Logistic regression models were used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) of having fewer factors. Psychosocial factors were assessed as mediators of the association between CSR and .

Results: We included 2000 participants (mean age 59.1 [7.5] years, 34.6% male, 42.7% Black, and 29.1% with low income), among whom 60.6% had <3 ideal CVH factors. The odds of having fewer factors increased significantly with increasing CSR scores from 1 to 2, to ≥3 compared to individuals with CSR score of zero, after adjusting for age and sex (OR [95% CIs]: 1.77 [1.41 - 2.22]; 2.09 [1.62 - 2.69] 2.67 [1.97 - 3.62], respectively). Taking the components of ideal CVH separately, higher CSR was directly associated with odds of being in 'non-ideal' category for six of the seven factors, but was inversely associated with probability of being in 'non-ideal' category for cholesterol. The association was modestly attenuated after adjusting for depression, stress, and perceived discrimination (corresponding OR [95% CI]: 1.69 [1.34 - 2.12], 1.96 [1.51 - 2.55], 2.34 [1.71 - 3.20]). The psychosocial factors appeared to mediate between 10% and 20% of relationship between CSR and .

Conclusions: Increased CSR was associated with lower probability of achieving factors. A modest amount of the effect of CSR on appeared to be mediated by depression, stress and perceived discrimination. Public health strategies aimed at improving ideal cardiovascular health may benefit from including interventions targeting social and psychosocial risk factors.
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http://dx.doi.org/10.1016/j.ajpc.2022.100367DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9340530PMC
September 2022

Utilization of palliative care in veterans admitted with heart failure experiencing homelessness.

J Pain Symptom Manage 2022 Jul 25. Epub 2022 Jul 25.

Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, RI; Center of Innovation in Long Term Services and Supports, Providence VA Medical Center, Providence, RI. Electronic address:

Context: Patients experiencing housing insecurity have numerous barriers affecting their utilization of medical care.

Objectives: Determine if housing insecurity is associated with PC encounters and hospice services in patients with heart failure who receive care in United States Veterans Affairs (VA) medical centers.

Methods: This retrospective study included inpatients in VA hospitals with a primary diagnosis of congestive heart failure from 2010 to 2020. Housing stability was collected from coding and separated into three cohorts: at risk for homelessness, experiencing homelessness and stably housed. The primary outcome was a PC encounter during admission and the stably housed cohort was used as the analytic reference. Inverse-probability-weighting (IPTW) was calculated to adjust the likelihood of receiving PC during the index admission.

Results: 70,849 veterans were identified. Veterans were identified as at risk for homelessness (n=4,039, 5.7%), experiencing homelessness (n=1,967, 2.8%) and stably housed (n=64,843, 91.5%). PC was delivered to veterans at risk for homelessness (n=484, 12.0%), veterans experiencing homelessness, (n=161, 8.2%) and patients with stable housing (n=6249, 9.6%). Relative to the stably housed and adjusted for IPTW, those at risk for homelessness received PC services similarly (adjusted OR=1.06, 95% CI 0.94,1.19) and those experiencing homelessness were at lower odds of receiving PC services (adjusted OR=0.62, 95% CI 0.52,0.75).

Conclusion: Housing stability may be a factor in Veterans receiving PC during hospitalization for heart failure. While the logistical challenges of delivering palliative care and hospice to people experiencing homelessness are daunting, advocating for these services shows commitment to reducing suffering in life-limiting Illness.
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http://dx.doi.org/10.1016/j.jpainsymman.2022.07.010DOI Listing
July 2022

Insulin resistance and incident heart failure: a meta-analysis.

Eur J Heart Fail 2022 Jun 16;24(6):1139-1141. Epub 2022 May 16.

Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA.

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http://dx.doi.org/10.1002/ejhf.2531DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9262840PMC
June 2022

Insulin resistance and incident heart failure: a meta-analysis.

Eur J Heart Fail 2022 Jun 16;24(6):1139-1141. Epub 2022 May 16.

Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA.

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http://dx.doi.org/10.1002/ejhf.2531DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9262840PMC
June 2022

Severe Hypoglycemia and Incidence of QT Interval Prolongation Among Adults With Type 2 Diabetes.

J Clin Endocrinol Metab 2022 06;107(7):e2743-e2750

Division of Endocrinology Diabetes & Metabolism, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21224, USA.

Context: There is a paucity of large-scale epidemiological studies on the link between severe hypoglycemia (SH) and corrected QT (QTc) interval prolongation in type 2 diabetes (T2DM).

Objective: To evaluate the association of SH with QTc prolongation in adults with T2DM.

Methods: Prospective cohort analysis of participants enrolled in the ACCORD (Action to Control Cardiovascular Risk in Diabetes) study without QTc prolongation at baseline. SH was assessed over a 24-month period. Incident QTc prolongation was ascertained using follow-up electrocardiograms. Modified Poisson regression was used to generate the risk ratio (RR) and 95% CI for QTc prolongation.

Results: Among 8277 participants (mean age 62.6 years [SD 6.5], 38.7% women, 62.8% White), 324 had ≥1 SH episode (3.9%). Over a median of 5 years, 517 individuals developed QTc prolongation (6.3%). Participants with SH had a 66% higher risk of QTc prolongation (RR 1.66, 95% CI 1.16-2.38). The incidence of QTc prolongation was 10.3% (27/261) and 14.3% (9/63) for participants with 1 and ≥2 SH, respectively. Compared with no SH, RRs for patients with 1 and ≥2 SH episodes were 1.57 (95% CI 1.04-2.39) and 2.01 (95% CI 1.07-3.78), respectively. Age modified the association of SH with QTc prolongation (PInteraction = .008). The association remained significant among younger participants (<61.9 years [median age]: RR 2.63, 95% CI 1.49-4.64), but was nonsignificant among older participants (≥61.9 years: RR 1.37, 95% CI 0.87-2.17).

Conclusion: In a large population with T2DM, SH was associated with an increased risk of QTc prolongation independently of other risk factors such as cardiac autonomic neuropathy. The association was strongest among younger participants.
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http://dx.doi.org/10.1210/clinem/dgac195DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9202715PMC
June 2022

Variation in statin prescription among veterans with HIV and known atherosclerotic cardiovascular disease.

Am Heart J 2022 07 19;249:12-22. Epub 2022 Mar 19.

Department of Medicine, Providence VA Medical Center, Providence, RI; Center of Innovation in Long Term Services & Supports, Providence VA Medical Center, Providence, RI; Department of Medicine, Brown University, Providence, RI; Brown University School of Public Health, Center for Gerontology & Healthcare Research, Providence, RI.

Background: People with HIV have increased atherosclerotic cardiovascular disease (ASCVD) risk, worse outcomes following incident ASCVD, and experience gaps in cardiovascular care, highlighting the need to improve delivery of preventive therapies in this population.

Objective: Assess patient-level correlates and inter-facility variations in statin prescription among Veterans with HIV and known ASCVD.

Methods: We studied Veterans with HIV and existing ASCVD, ie, coronary artery disease (CAD), ischemic cerebrovascular disease (ICVD), and peripheral arterial disease (PAD), who received care across 130 VA medical centers for the years 2018-2019. We assessed correlates of statin prescription using two-level hierarchical multivariable logistic regression. Median odds ratios (MORs) were used to quantify inter-facility variation in statin prescription.

Results: Nine thousand six hundred eight Veterans with HIV and known ASCVD (mean age 64.3 ± 8.9 years, 97% male, 48% Black) were included. Only 68% of the participants were prescribed any-statin. Substantially higher statin prescription was observed for those with diabetes (adjusted odds ratio [OR] = 2.3, 95% confidence interval [CI], 2.0-2.6), history of coronary revascularization (OR = 4.0, CI, 3.2-5.0), and receiving antiretroviral therapy (OR = 3.0, CI, 2.7-3.4). Blacks (OR = 0.7, CI, 0.6-0.9), those with non-coronary ASCVD, ie, ICVD and/or PAD only, (OR 0.53, 95% CI: 0.48-0.57), and those with history of illicit substance use (OR=0.7, CI, 0.6-0.9) were less likely to be prescribed statins. There was significant variation in statin prescription across VA facilities (10th, 90th centile: 55%, 78%), with an estimated 20% higher likelihood of difference in statin prescription practice for two clinically similar individuals treated at two comparable facilities (adjusted MOR = 1.21, CI, 1.18-1.24), and a greater variation observed for Blacks or those with non-coronary ASCVD or history of illicit drug use.

Conclusion: In an analysis of large-scale VA data, we found suboptimal statin prescription and significant interfacility variation in statin prescription among Veterans with HIV and known ASCVD, particularly among Blacks and those with a history of non-coronary ASCVD.
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http://dx.doi.org/10.1016/j.ahj.2022.03.006DOI Listing
July 2022

Outcomes in heart failure patients discharged to skilled nursing facilities with delirium.

ESC Heart Fail 2022 06 15;9(3):1891-1900. Epub 2022 Mar 15.

Providence VA Medical Center, Center of Innovation in Long Term Services and Supports, 830 Chalkstone Avenue, Providence, RI, 02908, USA.

Aim: Heart failure (HF) outcomes are disproportionately worse in patients discharged to skilled nursing facilities (SNF) as opposed to home. We hypothesized that dementia and delirium were key factors influencing these differences. Our aim was to explore the associations of dementia and delirium with risk of hospital readmission and mortality in HF patients discharged to SNF.

Methods And Results: The study population included Veterans hospitalized for a primary diagnosis of HF and discharged to SNFs between 2010 and 2015. Pre-existing dementia was identified based on International Classification of Diseases-9 codes. Delirium was determined using the Minimum Data Set 3.0 Confusion Assessment Method algorithm. Proportional hazard regression analyses were used to model outcomes and were adjusted for covariates of interest. Patients (n = 21 655) were older (77.0 ± 10.5 years) and predominantly male (96.9%). Four groups were created according to presence (+) or absence (-) of dementia and delirium. Relative to the dementia-/delirium- group, the dementia-/delirium+ group was associated with increased 30 day mortality [adjusted hazard ratio (HR) = 2.2, 95% confidence interval (CI) = 1.7, 3.0] and 365 day mortality (adjusted HR = 1.5, 95% CI = 1.3, 1.7). Readmission was highest in the dementia-/delirium+ group after 30 days (HR = 1.2, 95% CI = 1.0, 1.5). In the group with dementia (delirium-/dementia+), 30 day mortality (12.8%; HR = 0.7, 95% CI = 0.7, 0.8) and readmissions (5.3%; HR = 1.0, 95% CI = 0.8, 1.1) were not different relative to the reference group.

Conclusions: Delirium, independent of pre-existing dementia, confers increased risk of hospital readmission and mortality in HF patients discharged to SNFs. Managing HF after hospitalization is a complex cognitive task and an increased focus on mental status in the acute care setting prior to discharge is needed to improve HF management and transitional care, mitigate adverse outcomes, and reduce healthcare costs.
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http://dx.doi.org/10.1002/ehf2.13895DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9065834PMC
June 2022

Racial Differences in Burdensome Transitions in Heart Failure Patients with Palliative Care: A Propensity-Matched Analysis.

J Palliat Med 2022 Jul 11;25(7):1122-1126. Epub 2022 Mar 11.

Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.

Examining racial disparities in the treatment of heart failure (HF) patients and the effects of palliative care (PC) consultation is important to developing culturally competent clinical behaviors. To compare burdensome transitions for Black and White Veterans hospitalized with HF after PC consultation. This retrospective study evaluated Veterans admitted for HF to Veterans Administration hospitals who received PC consultation from October 2010 through August 2017. We propensity-matched Black to White Veterans using demographic, comorbidity, clinical, hospital, and survival time data. Propensity matching of our cohort ( = 5638) yielded 796 Black and White Veterans (total  = 1592) who were well-matched on observed variables (standard mean difference <0.15 for all variables). Matched Black Veterans had more burdensome transitions than White Veterans ( = 218, 27.4% vs.  = 174, 21.9%;  = 0.011) over the six-month follow-up period. This propensity-matched cohort found racial differences in burdensome transitions among admitted HF patients after PC consultation.
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http://dx.doi.org/10.1089/jpm.2021.0317DOI Listing
July 2022

Body Weight Variability and Risk of Cardiovascular Outcomes and Death in the Context of Weight Loss Intervention Among Patients With Type 2 Diabetes.

JAMA Netw Open 2022 02 1;5(2):e220055. Epub 2022 Feb 1.

Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.

Importance: Body weight fluctuation is associated with greater risks of adverse health outcomes. Whether intensive weight loss interventions affect the association of variability in adiposity measures with adverse health outcomes in individuals with type 2 diabetes has not been studied previously.

Objective: To evaluate the associations of long-term variability in adiposity indices with cardiovascular disease (CVD) outcomes and whether these associations are affected by an intensive lifestyle intervention among adults with type 2 diabetes.

Design, Setting, And Participants: This prospective cohort study included participants in the Action for Health in Diabetes (Look AHEAD) trial without CVD at baseline (August 2001 to April 2004). The Look AHEAD study included 16 centers in the United States. Data analysis was performed from December 2020 to June 2021.

Exposures: Variability of body mass index (BMI) and waist circumference (WC) across 4 annual visits, assessed using the coefficient of variation (CV), variability independent of the mean (VIM), and standard deviation (SD).

Main Outcomes And Measures: Main outcomes were (1) all-cause mortality, (2) cardiovascular deaths (deaths from myocardial infarction [MI] or stroke), and (3) CVD events (MI, stroke, and/or death from cardiovascular causes).

Results: Among 3604 study participants (mean [SD] age, 58.4 [6.6] years; 2240 [62.3%] women; 1364 [37.7%] Black participants; 2404 [66%] White participants), there were 216 CVD events, 33 CVD deaths, and 166 deaths over a median of 6.7 years. In the control group, the hazard ratios (HRs) for the highest quartile (quartile 4) compared with the lowest quartile (quartile 1) of CV of BMI were 4.06 (95% CI, 2.17-7.57), 15.28 (95% CI, 2.89-80.90), and 2.16 (95% CI, 1.21-3.87) for all-cause mortality, CVD mortality, and cardiovascular events, respectively. In the intervention group, the corresponding HRs were 0.99 (95% CI, 0.45-2.16), 1.14 (95% CI, 0.12-10.53), and 0.77 (95% CI, 0.40-1.49) for quartile 4 vs quartile 1. Regarding WC, in the control group, HRs for quartile 4 vs quartile 1 were 1.84 (95% CI, 1.01-3.35), 6.46 (95% CI, 1.16-36.01), and 1.28 (95% CI, 0.72-2.29). In the intervention group, HRs were 1.23 (95% CI, 0.61-2.46), 0.55 (95% CI, 0.15-2.11), and 0.70 (95% CI, 0.39-1.25) for quartile 4 vs quartile 1.

Conclusions And Relevance: In this cohort study of individuals with type 2 diabetes, higher variability of adiposity indices was associated with significantly increased risk of CVD outcomes and death in the control group but not in the intensive lifestyle intervention group.
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http://dx.doi.org/10.1001/jamanetworkopen.2022.0055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8857684PMC
February 2022

Anticipating and Addressing Challenges During Implementation of Clinical Decision Support Systems.

JAMA Netw Open 2022 02 1;5(2):e2146528. Epub 2022 Feb 1.

Division of Cardiology, Department of Medicine, Brown University Alpert Medical School, Providence, Rhode Island.

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http://dx.doi.org/10.1001/jamanetworkopen.2021.46528DOI Listing
February 2022

Variability of adiposity indices and incident heart failure among adults with type 2 diabetes.

Cardiovasc Diabetol 2022 02 1;21(1):16. Epub 2022 Feb 1.

Department of Medicine, Division of Endocrinology, Diabetes & Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, 21224, USA.

Background: It remains unclear how the variability of adiposity indices relates to incident HF. This study evaluated the associations of the variability in several adiposity indices with incident heart failure (HF) in individuals with type 2 diabetes (T2DM).

Methods: We included 4073 participants from the Look AHEAD (Action for Health in Diabetes) study. We assessed variability of body mass index (BMI), waist circumference (WC), and body weight across four annual visits using three variability metrics, the variability independent of the mean (VIM), coefficient of variation (CV), and intraindividual standard deviation (SD). Multivariable Cox regression models were used to generate adjusted hazard ratios (aHR) and 95% confidence intervals (CI) for incident HF.

Results: Over a median of 6.7 years, 120 participants developed incident HF. After adjusting for relevant confounders including baseline adiposity levels, the aHR for the highest (Q4) versus lowest quartile (Q1) of VIM of BMI was 3.61 (95% CI 1.91-6.80). The corresponding aHRs for CV and SD of BMI were 2.48 (95% CI 1.36-4.53) and 2.88 (1.52-5.46), respectively. Regarding WC variability, the equivalent aHRs were 1.90 (95% CI 1.11-3.26), 1.79 (95% CI 1.07-3.01), and 1.73 (1.01-2.95) for Q4 versus Q1 of VIM, CV and SD of WC, respectively.

Conclusions: In a large sample of adults with T2DM, a greater variability of adiposity indices was associated with higher risks of incident HF, independently of traditional risk factors and baseline adiposity levels. Registration-URL: https://clinicaltrials.gov/ct2/show/NCT00000620 .
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http://dx.doi.org/10.1186/s12933-021-01440-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8805255PMC
February 2022

Cardiac autonomic neuropathy and risk of incident heart failure among adults with type 2 diabetes.

Eur J Heart Fail 2022 Apr 31;24(4):634-641. Epub 2022 Jan 31.

Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins School of Medicine, Baltimore, MD, USA.

Aims: Community-based data on the association between cardiac autonomic neuropathy (CAN) and incident heart failure (HF) in type 2 diabetes are limited. We evaluated the association of CAN with incident HF in adults with type 2 diabetes.

Methods And Results: This analysis included participants from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study without HF at baseline. CAN was assessed by electrocardiogram-based measures of heart rate variability (HRV) and QT interval index (QTI). HRV was measured using standard deviation of all normal-to-normal intervals (SDNN) and root mean square of successive differences between normal-to-normal intervals (rMSSD). CAN was defined using composite measures of the lowest quartile of SDNN and highest quartiles of QTI and heart rate. Multivariable Cox regression models were used to generate adjusted hazard ratios (aHR) for HF in relation to various CAN measures. A total of 7160 participants (mean age 62.3 [standard deviation 6.4] years, 40.8% women, 61.9% white) were included. Over a median follow-up of 4.9 years (interquartile range 4.0-5.7), 222 participants developed incident HF. After multivariable adjustment for relevant confounders, lower HRV as assessed by SDNN was associated with a higher risk of HF (aHR for the lowest vs highest quartile of SDNN: 1.70, 95% confidence interval [CI] 1.14-2.54). Participants with CAN (defined as lowest quartile of SDNN and highest quartiles of QTI and heart rate) had a 2.7-fold greater risk of HF (aHR 2.65, 95% CI 1.57-4.48).

Conclusions: In a large cohort of adults with type 2 diabetes, CAN was independently associated with higher risk of incident HF.
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http://dx.doi.org/10.1002/ejhf.2432DOI Listing
April 2022

Correlates of cardiorespiratory fitness among overweight or obese individuals with type 2 diabetes.

BMJ Open Diabetes Res Care 2022 01;10(1)

Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA

Introduction: Mechanistic studies suggest that type 2 diabetes is independently associated with low cardiorespiratory fitness (CRF). Little is known about the CRF profile in type 2 diabetes; we assessed the correlates of low CRF among overweight/obese adults with type 2 diabetes.

Research Design And Methods: A total of 4215 participants with type 2 diabetes and without cardiovascular disease underwent maximal exercise testing in the Look AHEAD (Action for Health in Diabetes) study. Low CRF was defined based on the Aerobics Center Longitudinal Study reference standards. Calorie intake and physical activity were assessed using questionnaires. Body fat composition was assessed using dual-energy X-ray absorptiometry.

Results: Waist circumference, systolic blood pressure, glycemic measures, whole body fat, caloric intake, and fat-free mass were inversely associated with fitness across sex (all p<0.001). Comparing with moderate or high CRF groups, the low CRF group was associated with higher adjusted odds of obesity (OR 3.19 (95% CI 1.95 to 5.20) in men, 3.86 (95% CI 2.55 to 5.84)) in women), abdominal obesity (OR 3.99 (95% CI 2.00 to 7.96) in men, 2.28 (95% CI 1.08 to 4.79) in women), hypertension (OR 1.74 (95% CI 1.09 to 2.77) in men, 1.44 (95% CI 1.02 to 2.05) in women), metabolic syndrome (OR 5.52 (95% CI 2.51 to 12.14) in men, 2.25 (95% CI 1.35 to 3.76) in women), use of beta-blocker (1.22 (95% CI 0.86 to 1.73) in men, 1.33 (95% CI 1.03 to 1.73) in women), and ACE inhibitor/angiotensin-receptor blocker (1.86 (95% CI 1.39 to 2.50) in men, 1.07 (95% CI 0.86 to 1.32) in women). Women with low CRF had higher odds of current smoking (2.02 (95% CI 1.25 to 3.28)).

Conclusions: Low CRF was associated with increased odds of cardiometabolic correlates in a large cohort of adults with type 2 diabetes.
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http://dx.doi.org/10.1136/bmjdrc-2021-002446DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8734012PMC
January 2022

New Antipsychotic Prescribing Continued into Skilled Nursing Facilities Following a Heart Failure Hospitalization: a Retrospective Cohort Study.

J Gen Intern Med 2022 Jan 3. Epub 2022 Jan 3.

Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.

Background: Multimorbidity and polypharmacy are common among individuals hospitalized for heart failure (HF). Initiating high-risk medications such as antipsychotics may increase the risk of poor clinical outcomes, especially if these medications are continued unnecessarily into skilled nursing facilities (SNFs) after hospital discharge.

Objective: Examine how often older adults hospitalized with HF were initiated on antipsychotics and characteristics associated with antipsychotic continuation into SNFs after hospital discharge.

Design: Retrospective cohort.

Participants: Veterans without prior outpatient antipsychotic use, who were hospitalized with HF between October 1, 2010, and September 30, 2015, and were subsequently discharged to a SNF.

Main Measures: Demographics, clinical conditions, prior healthcare utilization, and antipsychotic use data were ascertained from Veterans Administration records, Minimum Data Set assessments, and Medicare claims. The outcome of interest was continuation of antipsychotics into SNFs after hospital discharge.

Key Results: Among 18,008 Veterans, antipsychotics were newly prescribed for 1931 (10.7%) Veterans during the index hospitalization. Among new antipsychotic users, 415 (21.5%) continued antipsychotics in skilled nursing facilities after discharge. Dementia (adjusted OR (aOR) 1.48, 95% CI 1.11-1.98), psychosis (aOR 1.62, 95% CI 1.11-2.38), proportion of inpatient days with antipsychotic use (aOR 1.08, 95% CI 1.07-1.09, per 10% increase), inpatient use of only typical (aOR 0.47, 95% CI 0.30-0.72) or parenteral antipsychotics (aOR 0.39, 95% CI 0.20-0.78), and the day of hospital admission that antipsychotics were started (day 0-4 aOR 0.36, 95% CI 0.23-0.56; day 5-7 aOR 0.54, 95% CI 0.35-0.84 (reference: day > 7 of hospital admission)) were significant predictors of continuing antipsychotics into SNFs after hospital discharge.

Conclusions: Antipsychotics are initiated fairly often during HF admissions and are commonly continued into SNFs after discharge. Hospital providers should review antipsychotic indications and doses throughout admission and communicate a clear plan to SNFs if antipsychotics are continued after discharge.
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http://dx.doi.org/10.1007/s11606-021-07233-2DOI Listing
January 2022

Coronary Artery Calcification and Plaque Characteristics in People Living With HIV: A Systematic Review and Meta-Analysis.

J Am Heart Assoc 2021 10 29;10(19):e019291. Epub 2021 Sep 29.

Division of Cardiology VA Providence Medical Center Providence RI.

Background Studies have reported that people living with HIV have higher burden of subclinical cardiovascular disease, but the data are not adequately synthesized. We performed meta-analyses of studies of coronary artery calcium and coronary plaque in people living with HIV. Methods and Results We performed systematic search in electronic databases, and data were abstracted in standardized forms. Study-specific estimates were pooled using meta-analysis. 43 reports representing 27 unique studies and involving 10 867 participants (6699 HIV positive, 4168 HIV negative, mean age 52 years, 86% men, 32% Black) were included. The HIV-positive participants were younger (mean age 49 versus 57 years) and had lower Framingham Risk Score (mean score 6 versus 18) compared with the HIV-negative participants. The pooled estimate of percentage with coronary artery calcium >0 was 45% (95% CI, 43%-47%) for HIV-positive participants, and 52% (50%-53%) for HIV-negative participants. This difference was no longer significant after adjusting for difference in Framingham Risk Score between the 2 groups. The odds ratio of coronary artery calcium progression for HIV-positive versus -negative participants was 1.64 (95% CI, 0.91-2.37). The pooled estimate for prevalence of noncalcified plaque was 49% (95% CI, 47%-52%) versus 20% (95% CI, 17%-23%) for HIV-positive versus HIV-negative participants, respectively. Odds ratio for noncalcified plaque for HIV-positive versus -negative participants was 1.23 (95% CI, 1.08-1.38). There was significant heterogeneity that was only partially explained by available study-level characteristics. Conclusions People living with HIV have higher prevalence of noncalcified coronary plaques and similar prevalence of coronary artery calcium, compared with HIV-negative individuals. Future studies on coronary artery calcium and plaque progression can further elucidate subclinical atherosclerosis in people living with HIV.
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http://dx.doi.org/10.1161/JAHA.120.019291DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8649136PMC
October 2021

Microvascular Disease and Incident Heart Failure Among Individuals With Type 2 Diabetes Mellitus.

J Am Heart Assoc 2021 06 10;10(12):e018998. Epub 2021 Jun 10.

Division of Endocrinology, Diabetes & Metabolism Johns Hopkins School of Medicine Baltimore MD.

Background Microvascular disease (MVD) is a potential contributor to the pathogenesis of diabetes mellitus-related cardiac dysfunction. However, there is a paucity of data on the link between MVD and incident heart failure (HF) in type 2 diabetes mellitus. We examined the association of MVD with incident HF in adults with type 2 diabetes mellitus. Methods and Results A total of 4095 participants with type 2 diabetes mellitus and free of HF were assessed for diabetes mellitus-related MVD including nephropathy, retinopathy, or neuropathy at baseline in the Look AHEAD (Action for Health in Diabetes) study. Incident HF events were prospectively assessed and adjudicated using hospital and death records. Cox models were used to generate hazard ratios and 95% CIs for HF. Of 4095 participants, 34.8% (n=1424) had MVD, defined as the presence of ≥1 of nephropathy, retinopathy, or neuropathy at baseline. Over a median of 9.7 years, there were 117 HF events. After adjusting for relevant confounders, participants with MVD had a 2.5-fold higher risk of incident HF than those without MVD (hazard ratio, 2.54; 95% CI, 1.73-3.75). This association remained significant after additional adjustment for interval development of coronary artery disease (hazard ratio, 2.42; 95% CI, 1.64-3.57). The hazard ratios for HF by type of MVD were 2.22 (95% CI, 1.51-3.27), 1.30 (95% CI, 0.72-2.36), and 1.33 (95% CI, 0.86-2.07) for nephropathy, retinopathy, and neuropathy, respectively. CONCLUSIONS MVD is associated with an excess HF risk in individuals with type 2 diabetes mellitus after adjusting for other known risk factors. Our findings underscore the contribution of MVD to the development of diabetes mellitus-related HF. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00017953.
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http://dx.doi.org/10.1161/JAHA.120.018998DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8477890PMC
June 2021

Long-term variability of blood pressure and incidence of heart failure among individuals with Type 2 diabetes.

ESC Heart Fail 2021 08 25;8(4):2959-2967. Epub 2021 May 25.

Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins School of Medicine, Baltimore, MD, 21224, USA.

Aims: Data on the association of long-term variability of blood pressure (BP) with incident heart failure (HF) in individuals with Type 2 diabetes are scarce. We evaluated this association in a large community-based sample of adults with Type 2 diabetes.

Methods And Results: A total of 4200 participants with Type 2 diabetes who had available BP measurements at four visits (baseline and 12, 24, and 36 months) in the Look AHEAD (Action for Health in Diabetes) study were included. Variability of systolic BP (SBP) and diastolic BP (DBP) across the four visits was assessed using four metrics. Participants free of HF during the first 36 months were followed for HF events. Cox regression was used to generate hazard ratios (HRs) and 95% confidence intervals (CIs) for HF. Of the 4200 participants, the average age was 59 years [standard deviation (SD): 6.8]; 58.5% were women. Over a median follow-up of 6.7 years, 129 developed HF events. After adjusting for relevant confounders, the HR of incident HF for the highest vs. lowest quartile of SD of SBP was 1.77 (95% CI 1.01-3.09); the HR for the highest (vs. lowest) quartile of variability independent of the mean of SBP was 1.29 (95% CI 0.78-2.14). The adjusted HR for participants in the highest (compared with the lowest) quartile of SD of DBP was 1.61 (95% CI 1.01-2.59), and the adjusted HR for variability independent of the mean of DBP was 1.65 (95% CI 1.03-2.65).

Conclusions: A greater variability in SBP and DBP is independently associated with greater risk of incident HF in individuals with Type 2 diabetes.
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http://dx.doi.org/10.1002/ehf2.13385DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8318432PMC
August 2021

Age at Diagnosis of Heart Failure in United States Veterans With and Without HIV Infection.

J Am Heart Assoc 2021 06 15;10(11):e018983. Epub 2021 May 15.

Department of Medicine Providence VA Medical Center Providence RI.

Background Although HIV is associated with increased risk of heart failure (HF), it is not known if people living with HIV develop HF at a younger age compared with individuals without HIV. Crude comparisons of age at diagnosis of HF between individuals with and without HIV does not account for differences in underlying age structures between the populations. Methods and Results We used Veterans Health Administration data to compare the age at HF diagnosis between veterans with and without HIV, with adjustment for difference in population age structure. Statistical weights, calculated for each 1-year strata of veterans with HIV in each calendar year from 2000 to 2018, were applied to the veterans without HIV to standardize the age structure. We identified 5093 veterans with HIV (98% men, 34% White) with first HF episode recorded after HIV diagnosis (median age at incidence of HF, 58 years), and 1 425 987 veterans without HIV (98% men, 78% White) with HF (corresponding age, 72 years), with an absolute difference of 14 years. After accounting for difference in age structure, the adjusted median age at HF diagnosis for veterans without HIV was 63 years, 5 years difference with veterans with HIV (<0.001). The age differences were consistent across important subgroups such as preserved versus reduced ejection fraction and inpatient versus outpatient index HF. Conclusions Veterans with HIV are diagnosed with HF at a significantly younger age compared with veterans without HIV. These findings may have implications for HF prevention in individuals with HIV. Future studies are needed to make the findings more generalizable.
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http://dx.doi.org/10.1161/JAHA.120.018983DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8483515PMC
June 2021

Microvascular disease and cardiovascular outcomes among individuals with type 2 diabetes.

Diabetes Res Clin Pract 2021 Jun 12;176:108859. Epub 2021 May 12.

Department of Medicine, University of Maryland Medical Center, Baltimore, MD, USA. Electronic address:

Aim: To evaluate the associations of microvascular disease (MVD) with incident cardiovascular disease (CVD) in individuals with type 2 diabetes.

Methods: A total of 4098 participants with type 2 diabetes and without CVD were assessed for MVD (diabetic kidney disease, retinopathy or neuropathy) in the Look AHEAD (Action for Health in Diabetes) study. Cox models were used to generate hazard ratios (HRs) for: (1) CVD composite (myocardial infarction, stroke, hospitalization for angina and/or death from cardiovascular causes), (2) coronary artery disease (CAD), (3) stroke, and (4) CVD-related deaths.

Results: Of 4098 participants, 34.7% (n = 1424) had MVD at baseline. Over a median of 9.5 years, 487 developed the CVD composite, 410 CAD events, 100  stroke, and 54 CVD-related deaths. After adjusting for relevant confounders, MVD was associated with increased risks of CVD composite (HR 1.34, 95% CI 1.11-1.61), CAD (HR 1.24, 95% CI 1.01-1.52), stroke (HR 1.55, 95% CI 1.03-2.33), and cardiovascular mortality (HR 1.26, 95% CI 0.72-2.22). HRs for CVD composite by type of MVD were 1.11 (95% CI 0.89-1.38), 1.63 (95% CI 1.22-2.17) and 1.16 (95% CI 0.92-1.46) for diabetic kidney disease, retinopathy, and neuropathy, respectively.

Conclusions: Our findings underscore the relevance of MVD in CVD risk assessment in type 2 diabetes.
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http://dx.doi.org/10.1016/j.diabres.2021.108859DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8627586PMC
June 2021

The Intersection of Physical and Social Frailty in Older Adults.

R I Med J (2013) 2021 May 3;104(4):16-19. Epub 2021 May 3.

VA Center of Innovation in Long Term Services, Providence VA Medical Center, Providence, RI; Division of Geriatrics and Palliative Medicine, Warren Alpert Medical School of Brown University, Providence, RI; Center for Gerontology and Health Services Research, Brown University School of Public Health, Providence RI.

Frailty, a vulnerability to stressors, has been increasingly woven into the clinical understanding of older people who are unable to respond to the impact of diseases, disability, and age-related decline. While the literature has focused on physical frailty, social frailty has been conceptualized within the domains of social needs (social and emotional support, loneliness), resources (income, food, housing, medical care, etc), social fulfillment (engagement in work and activities), and self-management (cognitive function, mental health, advance planning). This review outlines the assessment of the four domains of social frailty within the structure of clinical visits, particularly annual wellness and advance care planning. Increasing connectivity with the community, health system, and government support is the primary recommended intervention. On a policy level, expanding opportunities to connect socially frail people with resources may help mitigate the vulnerability of physical frailty.
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May 2021

Long-Term Variability of Blood Pressure, Cardiovascular Outcomes, and Mortality: The Look AHEAD Study.

Am J Hypertens 2021 08;34(7):689-697

Department of Medicine, Division of Endocrinology, Diabetes & Metabolism, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.

Background: We evaluated the associations of visit-to-visit blood pressure (BP) variability with incident cardiovascular disease (CVD) and deaths in adults with type 2 diabetes.

Methods: We analyzed 4,152 participants in Look AHEAD (Action for Health in Diabetes) free of CVD events and deaths during the first 36 months of follow-up. Variability of systolic BP (SBP) and diastolic BP (DBP) across 4 annual visits was assessed using the intraindividual SD, variation independent of the mean, and coefficient of variation. Cox regression was used to generate the adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for CVD (myocardial infarction [MI], stroke, or CVD-related deaths) and mortality.

Results: Over a median of 6.6 years, there were 220 MIs, 105 stroke cases, 62 CVD-related deaths, and 236 deaths. After adjustment for confounders including average BP, the aHRs for the highest (vs. lowest) tertile of SD of SBP were 1.98 (95% CI 1.01-3.92), 1.25 (95% CI 0.90-1.72), 1.26 (95% CI 0.96-1.64), 1.05 (95% CI 0.75-1.46), and 1.64 (95% CI 0.99-2.72) for CVD mortality, all-cause mortality, CVD, MI, and stroke, respectively. The equivalent aHRs for SD of DBP were 1.84 (95% CI 0.98-3.48), 1.43 (95% CI 1.03-1.98), 1.19 (95% CI 0.91-1.56), 1.14 (95% CI 0.82-1.58), and 0.97 (95% CI 0.58-1.60), respectively.

Conclusions: In a large sample of individuals with type 2 diabetes, a greater variability in SBP was associated with higher cardiovascular mortality and CVD events; a higher variability in DBP was linked to increased overall and cardiovascular mortality.
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http://dx.doi.org/10.1093/ajh/hpaa210DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8351510PMC
August 2021

Outcomes of coronavirus disease-2019 among veterans with pre-existing diagnosis of heart failure.

ESC Heart Fail 2021 06 16;8(3):2338-2344. Epub 2021 Mar 16.

Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA.

Aims: Pre-existing cardiovascular disease in general and related risk factors have been associated with poor coronavirus disease-2019 (COVID-19) outcomes. However, data on outcomes of COVID-19 among people with pre-existing diagnosis of heart failure (HF) have not been studied in sufficient detail. We aimed to perform detailed characterization of the association of pre-existing HF with COVID-19 outcomes.

Methods And Results: A retrospective cohort study based on Veterans Health Administration (VHA) data comparing 30 day mortality and hospital admission rates after COVID-19 diagnosis among Veterans with and without pre-existing diagnosis of HF. Cox-regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (95% CIs) with adjustment for covariates. Among 31 051 veterans (97% male) with COVID-19, 6148 had pre-existing diagnosis of HF. The mean (SD) age of patients with HF was 70 (13) whereas the mean (SD) age of patients without HF was 57 (17). Within the HF group with available data on left ventricular ejection fraction (EF), 1844 patients (63.4%) had an EF of >45%, and 1063 patients (36.6%) had an EF of ≤45%. Patients in the HF cohort had higher 30 day mortality (5.4% vs. 1.5%) and admission (18.5% vs. 8.4%) rates after diagnosis of COVID-19. After adjustment for age, sex, and race, HRs (95% CIs) for 30 day mortality and for 30 day hospital admissions were 1.87 (1.61-2.17) and 1.79 (1.66-1.93), respectively. After additional adjustment for medical comorbidities, HRs for 30 day mortality and for 30 day hospital admissions were 1.37 (1.15-1.64) and 1.27 (1.16-1.38), respectively. The findings were similar among HF patients with preserved vs. reduced EF, among those taking vs. not taking angiotensin-converting enzyme inhibitors, angiotensin receptor blockers or angiotensin receptor neprilysin inhibitors, and among those taking vs. not taking anticoagulants.

Conclusions: Patients with COVID-19 and pre-existing diagnosis of HF had a higher risk of 30 day mortality and hospital admissions compared to those without history of HF. The findings were similar by EF categories and by angiotensin-converting enzyme inhibitors/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitors or anticoagulant use.
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http://dx.doi.org/10.1002/ehf2.13291DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8120381PMC
June 2021

Delirium and Functional Recovery in Patients Discharged to Skilled Nursing Facilities After Hospitalization for Heart Failure.

JAMA Netw Open 2021 03 1;4(3):e2037968. Epub 2021 Mar 1.

Providence VA Medical Center, Center of Innovation in Long Term Services and Supports, Providence, Rhode Island.

Importance: A substantial number of patients discharged to skilled nursing facilities (SNFs) after heart failure (HF) hospitalization experience regression in function or do not improve. Delirium is one of few modifiable risk factors in this patient population. Therefore, understanding the role of delirium in functional recovery may be useful for improving outcomes.

Objective: To assess the association of delirium with 30-day functional improvement in patients discharged to SNFs after HF hospitalization.

Design, Setting, And Participants: This retrospective cohort study included patients hospitalized for HF in 129 US Department of Veterans Affairs hospitals who were discharged to SNFs from October 1, 2010, to September 30, 2015. Data were analyzed from June 14 to December 18, 2020.

Exposures: Delirium, as determined by the Minimum Data Set (MDS) 3.0 Confusion Assessment Method, with dementia as a covariate, determined via International Classification of Diseases, Ninth Revision (ICD-9) coding.

Main Outcomes And Measures: The difference between admission and 30-day MDS 3.0 Activities of Daily Living (ADL) scores.

Results: A total of 20 495 patients (mean [SD] age, 78 [10.3] years; 78.9% White; and 97% male) were included in the analysis. Of the total sample, 882 patients (4.3%) had delirium on an SNF admission. The mean (SD) baseline ADL score on admission to SNF was significantly worse among patients with delirium than without (18.3 [4.7] vs 16.1 [5.2]; P < .001; d = 0.44.). On the 30-day repeated assessment, mean (SD) function (ADL scores) improved for both patients with delirium (0.6 [2.9]) and without delirium (1.8 [3.6]) (P < .001; d = -0.38). In the multivariate adjusted model, delirium was associated with statistically significant lower ADL improvement (difference in ADL score, -1.07; 95% CI, -1.31 to -0.83; P < .001).

Conclusions And Relevance: In this retrospective cohort study, patients with HF discharged to SNFs with delirium were less likely to show improvement in function compared with patients without delirium. Findings suggest a potential need to reexamine how and when health care professionals assess delirium in HF patients throughout their hospitalization and SNF course. Identifying and treating delirium for HF patients earlier in their care trajectory may play an important role in improving care and long-term functional outcomes in this population. Future research is warranted to further investigate the association between delirium and functional recovery for HF and other patient populations.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.37968DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7967078PMC
March 2021

Cardiorespiratory Fitness and Atherosclerotic Cardiovascular Outcomes by Levels of Baseline-Predicted Cardiovascular Risk: The Look AHEAD Study.

Am J Med 2021 06 17;134(6):769-776.e1. Epub 2021 Feb 17.

Department of Medicine, Division of Endocrinology, Diabetes & Metabolism, Johns Hopkins School of Medicine, Baltimore, Md. Electronic address:

Background: We evaluated the associations of cardiorespiratory fitness with atherosclerotic cardiovascular disease (ASCVD) by levels of baseline-predicted ASCVD risk among adults with type 2 diabetes.

Methods: We analyzed data from 4203 adults with type 2 diabetes in the Look AHEAD (Action for Health in Diabetes) study. Cardiorespiratory fitness was assessed using maximal exercise testing and categorized into low, moderate, and high; baseline-predicted. ASCVD risk was calculated using the American College of Cardiology/American Heart Association Pooled Cohort Equation. We used Cox regression models to estimate hazard ratios (HR) and 95% confidence intervals (CI) for ASCVD events (fatal and nonfatal myocardial infarction and stroke).

Results: Over a median of 9.6 years, there were 295 ASCVD events. The effect of fitness on outcomes was different across levels of 10-year predicted ASCVD risk (P for interaction < .001). Among participants with a baseline-predicted risk of 7.5% to 20%, the HR of low (vs high) fitness group was 1.94 (95% CI, 1.12-3.35) for ASCVD events. Fitness was not significantly associated with ASCVD events in the groups with baseline-predicted risk <7.5% (HR 1.53; 95% CI, 0.49-4.76) or ≥20% (HR 1.40; 95% CI, 0.88-2.24). A similar pattern was observed for myocardial infarction and stroke separately.

Conclusions: In a large sample of type 2 diabetes individuals, the association of low fitness with incident ASCVD was modified by the baseline-predicted 10-year ASCVD risk. Our findings suggest the utility of assessing fitness in ASCVD risk stratification in type 2 diabetes, especially among those with intermediate predicted 10-year risk of ASCVD.
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http://dx.doi.org/10.1016/j.amjmed.2021.01.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8176653PMC
June 2021

Risk of ventricular arrhythmia in cardiac resynchronization therapy responders and super-responders: a systematic review and meta-analysis.

Europace 2021 08;23(8):1262-1274

Department of Medicine, Harvard Medical School, Boston, MA, USA.

Aims: Response to cardiac resynchronization therapy (CRT) is associated with improved survival, and reduction in heart failure hospitalization, and ventricular arrhythmia (VA) risk. However, the impact of CRT super-response [CRT-SR, increase in left ventricular ejection fraction (LVEF) to ≥ 50%] on VA remains unclear.

Methods And Results: We undertook a meta-analysis aimed at determining the impact of CRT response and CRT-SR on risk of VA and all-cause mortality. Systematic search of PubMed, EMBASE, and Cochrane databases, identifying all relevant English articles published until 31 December 2019. A total of 34 studies (7605 patients for VA and 5874 patients for all-cause mortality) were retained for the meta-analysis. The pooled cumulative incidence of appropriate implantable cardioverter-defibrillator therapy for VA was significantly lower at 13.0% (4.5% per annum) in CRT-responders, vs. 29.0% (annualized rate of 10.0%) in CRT non-responders, relative risk (RR) 0.47 [95% confidence interval (CI) 0.39-0.56, P < 0.0001]; all-cause mortality 3.5% vs. 9.1% per annum, RR of 0.38 (95% CI 0.30-0.49, P < 0.0001). The pooled incidence of VA was significantly lower in CRT-SR compared with CRT non-super-responders (non-responders + responders) at 0.9% vs. 3.8% per annum, respectively, RR 0.22 (95% CI 0.12-0.40, P < 0.0001); as well as all-cause mortality at 2.0% vs. 4.3%, respectively, RR 0.47 (95% CI 0.33-0.66, P < 0.0001).

Conclusions: Cardiac resynchronization therapy super-responders have low absolute risk of VA and all-cause mortality. However, there remains a non-trivial residual absolute risk of these adverse outcomes in CRT responders. These findings suggest that among CRT responders, there may be a continued clinical benefit of defibrillators.
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http://dx.doi.org/10.1093/europace/euaa414DOI Listing
August 2021

Long-term variability of glycemic markers and risk of all-cause mortality in type 2 diabetes: the Look AHEAD study.

BMJ Open Diabetes Res Care 2020 11;8(2)

Department of Medicine, Division of Endocrinology, Diabetes & Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA

Introduction: Glycemic variability may predict poor outcomes in type 2 diabetes. We evaluated the associations of long-term variability in glycosylated hemoglobin (HbA) and fasting plasma glucose (FPG) with cardiovascular disease (CVD) and death among individuals with type 2 diabetes.

Research Design And Methods: We conducted a secondary, prospective cohort analysis of the Look AHEAD (Action for Health in Diabetes) data, including 3560 participants who attended four visits (baseline, 12 months, 24 months, and 36 months) at the outset. Variability of HbA and FPG was assessed using four indices across measurements from four study visits. Participants without CVD during the first 36 months were followed for incident outcomes including a CVD composite (myocardial infarction, stroke, hospitalization for angina, and CVD-related deaths), heart failure (HF), and deaths.

Results: Over a median follow-up of 6.8 years, there were 164 deaths from any cause, 33 CVD-related deaths, 91 HF events, and 340 participants experienced the CVD composite. Adjusted HRs comparing the highest to lowest quartile of SD of HbA were 2.10 (95% CI 1.26 to 3.51), 3.43 (95% CI 0.95 to 12.38), 1.01 (95% CI 0.69 to 1.46), and 1.71 (95% CI 0.69 to 4.24) for all-cause mortality, CVD mortality, CVD composite and HF, respectively. The equivalent HRs for highest versus lowest quartile of SD of FPG were 1.66 (95% CI 0.96 to 2.85), 2.20 (95% CI 0.67 to 7.25), 0.94 (95% CI 0.65 to 1.35), and 2.05 (95% CI 0.80 to 5.31), respectively.

Conclusions: A greater variability in HbA was associated with elevated risk of mortality. Our findings underscore the need to achieve normal and consistent glycemic control to improve clinical outcomes among individuals with type 2 diabetes.
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http://dx.doi.org/10.1136/bmjdrc-2020-001753DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7705503PMC
November 2020

Association of poor housing conditions with COVID-19 incidence and mortality across US counties.

PLoS One 2020 2;15(11):e0241327. Epub 2020 Nov 2.

The Providence Veterans Affairs Medical Center, Lifespan Hospitals and the Warren Alpert Medical School at Brown University, Providence, Rhode Island, United States of America.

Objective: Poor housing conditions have been linked with worse health outcomes and infectious disease spread. Since the relationship of poor housing conditions with incidence and mortality of COVID-19 is unknown, we investigated the association between poor housing condition and COVID-19 incidence and mortality in US counties.

Methods: We conducted cross-sectional analysis of county-level data from the US Centers for Disease Control, US Census Bureau and John Hopkins Coronavirus Resource Center for 3135 US counties. The exposure of interest was percentage of households with poor housing conditions (one or greater of: overcrowding, high housing cost, incomplete kitchen facilities, or incomplete plumbing facilities). Outcomes were incidence rate ratios (IRR) and mortality rate ratios (MRR) of COVID-19 across US counties through 4/21/2020. Multilevel generalized linear modeling (with total population of each county as a denominator) was utilized to estimate relative risk of incidence and mortality related to poor housing conditions with adjustment for population density and county characteristics including demographics, income, education, prevalence of medical comorbidities, access to healthcare insurance and emergency rooms, and state-level COVID-19 test density. We report incidence rate ratios (IRRs) and mortality ratios (MRRs) for a 5% increase in prevalence in households with poor housing conditions.

Results: Across 3135 US counties, the mean percentage of households with poor housing conditions was 14.2% (range 2.7% to 60.2%). On April 21st, the mean (SD) number of cases and deaths of COVID-19 were 255.68 (2877.03) cases and 13.90 (272.22) deaths per county, respectively. In the adjusted models standardized by county population, with each 5% increase in percent households with poor housing conditions, there was a 50% higher risk of COVID-19 incidence (IRR 1.50, 95% CI: 1.38-1.62) and a 42% higher risk of COVID-19 mortality (MRR 1.42, 95% CI: 1.25-1.61). Results remained similar using earlier timepoints (3/31/2020 and 4/10/2020).

Conclusions And Relevance: Counties with a higher percentage of households with poor housing had higher incidence of, and mortality associated with, COVID-19. These findings suggest targeted health policies to support individuals living in poor housing conditions should be considered in further efforts to mitigate adverse outcomes associated with COVID-19.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0241327PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7605696PMC
November 2020

Secondary Prevention of Myocardial Infarction in People Living With HIV Infection.

J Am Heart Assoc 2020 09 26;9(17):e018140. Epub 2020 Aug 26.

Infectious Disease Section Michael E. DeBakey VA Medical Center Houston TX.

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http://dx.doi.org/10.1161/JAHA.120.018140DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7660762PMC
September 2020
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