Publications by authors named "Sheila M Manemann"

34 Publications

Biomarkers and indoor air quality: A translational research review.

J Clin Transl Sci 2020 Sep 4;5(1):e39. Epub 2020 Sep 4.

Well Living Lab, Inc., Mayo Clinic, Rochester, MN 55902, USA.

Introduction: Air pollution is linked to mortality and morbidity. Since humans spend nearly all their time indoors, improving indoor air quality (IAQ) is a compelling approach to mitigate air pollutant exposure. To assess interventions, relying on clinical outcomes may require prolonged follow-up, which hinders feasibility. Thus, identifying biomarkers that respond to changes in IAQ may be useful to assess the effectiveness of interventions.

Methods: We conducted a narrative review by searching several databases to identify studies published over the last decade that measured the response of blood, urine, and/or salivary biomarkers to variations (natural and intervention-induced) of changes in indoor air pollutant exposure.

Results: Numerous studies reported on associations between IAQ exposures and biomarkers with heterogeneity across study designs and methods. This review summarizes the responses of 113 biomarkers described in 30 articles. The biomarkers which most frequently responded to variations in indoor air pollutant exposures were high sensitivity C-reactive protein (hsCRP), von Willebrand Factor (vWF), 8-hydroxy-2'-deoxyguanosine (8-OHdG), and 1-hydroxypyrene (1-OHP).

Conclusions: This review will guide the selection of biomarkers for translational studies evaluating the impact of indoor air pollutants on human health.
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http://dx.doi.org/10.1017/cts.2020.532DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8057458PMC
September 2020

Rurality, Death, and Healthcare Utilization in Heart Failure in the Community.

J Am Heart Assoc 2021 Feb 3;10(4):e018026. Epub 2021 Feb 3.

Department of Health Sciences Research Mayo Clinic Rochester MN.

Background Prior reports indicate that living in a rural area may be associated with worse health outcomes. However, data on rurality and heart failure (HF) outcomes are scarce. Methods and Results Residents from 6 southeastern Minnesota counties with a first-ever code for HF ( [], code 428, and [] code I50) between January 1, 2013 and December 31, 2016, were identified. Resident address was classified according to the rural-urban commuting area codes. Rurality was defined as living in a nonmetropolitan area. Cox regression was used to analyze the association between living in a rural versus urban area and death; Andersen-Gill models were used for hospitalization and emergency department visits. Among 6003 patients with HF (mean age 74 years, 48% women), 43% lived in a rural area. Rural patients were older and had a lower educational attainment and less comorbidity compared with patients living in urban areas (<0.001). After a mean (SD) follow-up of 2.8 (1.7) years, 2440 deaths, 20 506 emergency department visits, and 11 311 hospitalizations occurred. After adjustment, rurality was independently associated with an increased risk of death (hazard ratio [HR], 1.18; 95% CI, 1.09-1.29) and a reduced risk of emergency department visits (HR, 0.89; 95% CI, 0.82-0.97) and hospitalizations (HR, 0.78; 95% CI, 0.73-0.84). Conclusions Among patients with HF, living in a rural area is associated with an increased risk of death and fewer emergency department visits and hospitalizations. Further study to identify and address the mechanisms through which rural residence influences mortality and healthcare utilization in HF is needed in order to reduce disparities in rural health.
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http://dx.doi.org/10.1161/JAHA.120.018026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955348PMC
February 2021

Patient-centered communication and outcomes in heart failure.

Am J Manag Care 2020 10;26(10):425-430

Department of Health Sciences Research, Mayo Clinic, 200 First St SW, Rochester, MN 55905. Email:

Objectives: To measure the impact of patient-centered communication on mortality and hospitalization among patients with heart failure (HF).

Study Design: This was a survey study of 6208 residents of 11 counties in southeast Minnesota with incident HF (first-ever International Classification of Diseases, Ninth Revision code 428 or International Classification of Diseases, Tenth Revision code I50) between January 1, 2013, and March 31, 2016.

Methods: Perceived patient-centered communication was assessed with the health care subscale of the Chronic Illness Resources Survey and measured as a composite score on three 5-point scales. We divided our cohort into tertiles and defined them as having fair/poor (score < 12), good (score of 12 or 13), and excellent (score ≥ 14) patient-centered communication. The survey was returned by 2868 participants (response rate: 45%), and those with complete data were retained for analysis (N = 2398). Cox and Andersen-Gill models were used to determine the association of patient-centered communication with death and hospitalization, respectively.

Results: Among 2398 participants (median age, 75 years; 54% men), 233 deaths and 1194 hospitalizations occurred after a mean (SD) follow-up of 1.3 (0.6) years. Compared with patients with fair/poor patient-centered communication, those with good (HR, 0.70; 95% CI, 0.51-0.97) and excellent (HR, 0.70; 95% CI, 0.51-0.96) patient-centered communication experienced lower risks of death after adjustment for various confounders (Ptrend = .020). Patient-centered communication was not associated with hospitalization.

Conclusions: Among community patients living with HF, excellent and good patient-centered communication is associated with a reduced risk of death. Patient-centered communication can be easily assessed, and consideration should be given toward implementation in clinical practice.
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http://dx.doi.org/10.37765/ajmc.2020.88500DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7587036PMC
October 2020

Sex Differences in Outcomes After Myocardial Infarction in the Community.

Am J Med 2021 01 3;134(1):114-121. Epub 2020 Jul 3.

Department of Cardiovascular Diseases; Department of Health Sciences Research, Mayo Clinic, Rochester, Minn. Electronic address:

Purpose: Prior studies observed that women experienced worse outcomes than men after myocardial infarction but did not convincingly establish an independent effect of female sex on outcomes, thus failing to impact clinical practice. Current data remain sparse and information on long-term nonfatal outcomes is lacking. To address these gaps in knowledge, we examined outcomes after incident myocardial infarction for women compared with men.

Methods: We studied a population-based myocardial infarction incidence cohort in Olmsted County, Minnesota, between 2000 and 2012. Patients were followed for recurrent myocardial infarction, heart failure, and death. A propensity score was constructed to balance the clinical characteristics between men and women; Cox models were weighted using inverse probabilities of the propensity scores.

Results: Among 1959 patients with incident myocardial infarction (39% women; mean age 73.8 and 64.2 for women and men, respectively), 347 recurrent myocardial infarctions, 464 heart failure episodes, 836 deaths, and 367 cardiovascular deaths occurred over a mean follow-up of 6.5 years. Women experienced a higher occurrence of each adverse event (all P <0.01). After propensity score weighting, women had a 28% increased risk of recurrent myocardial infarction (hazard ratio: 1.28, 95% confidence interval: 1.03-1.59), and there was no difference in risk for any other outcomes (all P >0.05).

Conclusion: After myocardial infarction, women experience a large excess risk of recurrent myocardial infarction but not of heart failure or death independently of clinical characteristics. Future studies are needed to understand the mechanisms driving this association.
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http://dx.doi.org/10.1016/j.amjmed.2020.05.040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7752831PMC
January 2021

Health Literacy and Outcomes Among Patients With Heart Failure: A Systematic Review and Meta-Analysis.

JACC Heart Fail 2020 06;8(6):451-460

Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota; Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota. Electronic address:

Objectives: The purpose of this study was to determine if health literacy is associated with mortality, hospitalizations, or emergency department (ED) visits among patients living with heart failure (HF).

Background: Growing evidence suggests an association between health literacy and health-related outcomes in patients with HF.

Methods: We searched Embase, MEDLINE, PsycINFO, and EBSCO CINAHL from inception through January 1, 2019, with the help of a medical librarian. Eligible studies evaluated health literacy among patients with HF and assessed mortality, hospitalizations, and ED visits for all causes with no exclusion by time, geography, or language. Two reviewers independently selected studies, extracted data, and assessed the methodological quality of the identified studies.

Results: We included 15 studies, 11 with an overall high methodological quality. Among the observational studies, an average of 24% of patients had inadequate or marginal health literacy. Inadequate health literacy was associated with higher unadjusted risk for mortality (risk ratio [RR]: 1.67; 95% confidence interval [CI]: 1.18 to 2.36), hospitalizations (RR: 1.19; 95% CI: 1.09 to 1.29), and ED visits (RR: 1.17; 95% CI: 1.03 to 1.32). When the adjusted measurements were combined, inadequate health literacy remained statistically associated with mortality (RR: 1.41; 95% CI: 1.06 to 1.88) and hospitalizations (RR: 1.12; 95% CI: 1.01 to 1.25). Among the 4 interventional studies, 2 effectively improved outcomes among patients with inadequate health literacy.

Conclusions: In this study, the estimated prevalence of inadequate health literacy was high, and inadequate health literacy was associated with increased risk of death and hospitalizations. These findings have important clinical and public health implications and warrant measurement of health literacy and deployment of interventions to improve outcomes.
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http://dx.doi.org/10.1016/j.jchf.2019.11.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7263350PMC
June 2020

Participation Bias in a Survey of Community Patients With Heart Failure.

Mayo Clin Proc 2020 05;95(5):911-919

Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN. Electronic address:

Objective: To identify differences between participants and nonparticipants in a survey of physical and psychosocial aspects of health among a population-based sample of patients with heart failure (HF).

Patients And Methods: Residents from 11 Minnesota counties with a first-ever code for HF (International Classification of Diseases, Ninth Revision 428 and Tenth Revision I50) between January 1, 2013, and December 31, 2016, were identified. Participants completed a questionnaire by mail or telephone. Characteristics and outcomes were extracted from medical records and compared between participants and nonparticipants. Response rate was calculated using guidelines of the American Association for Public Opinion Research. The association between nonparticipation and outcomes was examined using Cox proportional hazards regression for death and Andersen-Gill modeling for hospitalizations.

Results: Among 7911 patients, 3438 responded to the survey (American Association for Public Opinion Research response rate calculated using formula 2 = 43%). Clinical and demographic differences between participants and nonparticipants were noted, particularly for education, marital status, and neuropsychiatric conditions. After a mean ± SD of 1.5±1.0 years after survey administration, 1575 deaths and 5857 hospitalizations occurred. Nonparticipation was associated with a 2-fold increased risk for death (hazard ratio, 2.29; 95% CI, 2.05-2.56) and 11% increased risk for hospitalization (hazard ratio, 1.11; 95% CI, 1.02-1.22) after adjusting for age, sex, time from HF diagnosis to index date, marital status, coronary disease, arrhythmia, hyperlipidemia, diabetes, cancer, chronic kidney disease, arthritis, osteoporosis, depression, and anxiety.

Conclusion: In a large survey of patients with HF, participation was associated with notable differences in clinical and demographic characteristics and outcomes. Examining the impact of participation is critical to draw inference from studies of patient-reported measures.
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http://dx.doi.org/10.1016/j.mayocp.2019.11.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7213075PMC
May 2020

Impact of air quality on the gastrointestinal microbiome: A review.

Environ Res 2020 07 7;186:109485. Epub 2020 Apr 7.

Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA; Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA. Electronic address:

Background: Poor air quality is increasingly associated with several gastrointestinal diseases suggesting a possible association between air quality and the human gut microbiome. However, details on this remain largely unexplored as current available research is scarce. The aim of this comprehensive rigorous review was to summarize the existing reports on the impact of indoor or outdoor airborne pollutants on the animal and human gut microbiome and to outline the challenges and suggestions to expand this field of research.

Methods And Results: A comprehensive search of several databases (inception to August 9, 2019, humans and animals, English language only) was designed and conducted by an experienced librarian to identify studies describing the impact of air pollution on the human gut microbiome. The retrieved articles were assessed independently by two reviewers. This process yielded six original research papers on the animal GI gastrointestinal microbiome and four on the human gut microbiome. β-diversity analyses from selected animal studies demonstrated a significantly different composition of the gut microbiota between control and exposed groups but changes in α-diversity were less uniform. No consistent findings in α or β-diversity were reported among the human studies. Changes in microbiota at the phylum level disclosed substantial discrepancies across animal and human studies.

Conclusions: A different composition of the gut microbiome, particularly in animal models, is associated with exposure to air pollution. Air pollution is associated with various taxa changes, which however do not follow a clear pattern. Future research using standardized methods are critical to replicate these initial findings and advance this emerging field.
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http://dx.doi.org/10.1016/j.envres.2020.109485DOI Listing
July 2020

Coronary Disease Surveillance in the Community: Angiography and Revascularization.

J Am Heart Assoc 2020 04 2;9(7):e015231. Epub 2020 Apr 2.

Department of Health Sciences Research Mayo Clinic Rochester MN.

Background Temporal declines in cardiac stress tests results, coronary revascularization, and cardiovascular mortality have suggested a decline in the population burden of coronary disease until the 2000s. However, recent data indicate these favorable trends could be ending. We aimed to assess the evolution of the population burden of coronary disease in the community by examining trends in angiography and revascularization. Methods and Results We analyzed age- and sex-adjusted trends from all coronary angiographic diagnostic procedures and revascularizations performed in Olmsted County, MN from 2000 to 2018. A total of 12 981 invasive angiograms were performed among 9049 individuals (64% men; 55% aged ≥65 years). Adjusted angiography rates decreased by 30% (95% CI, 25%-34%) between 2000 and 2009 and leveled off thereafter. Including computed tomography, angiography uncovered an increase in angiography use in recent years (risk ratio=1.15 [95% CI, 1.07-1.23] for 2018 versus 2014) and a decline in the prevalence of anatomic CAD from 2000 to 2018. CAD severity declined substantially from 2000 to 2009, followed by a plateau. Among 6570 revascularizations (72% men; 57% aged ≥65 years), 77% were percutaneous coronary interventions and 23% coronary artery bypass graft surgeries. The adjusted revascularization rates declined by 34% (95% CI, 27%-39%) from 2000 to 2009, followed by a plateau (risk ratio=1.10 [95% CI, 1.00-1.22]). Conclusions Between 2000 and 2018 in the community, coronary angiography use declined initially, leveled off, and then increased. Trends in CAD severity and revascularization use decreased then plateaued. The most recent trends are concerning as they suggest the burden of coronary disease is no longer declining. This warrants reinvigorated primary prevention and population surveillance.
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http://dx.doi.org/10.1161/JAHA.119.015231DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7428619PMC
April 2020

Risk Factors for Heart Failure in the Community: Differences by Age and Ejection Fraction.

Am J Med 2020 06 17;133(6):e237-e248. Epub 2019 Nov 17.

Department of Health Sciences Research, Mayo Clinic, Rochester, Minn; Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn.

Background: Differences in comorbid conditions in patients with heart failure compared with population controls, and whether differences exist by type of heart failure or age, have not been well documented.

Methods: The prevalence of 17 chronic conditions were obtained in 2643 patients with incident heart failure from 2000 to 2013 and controls matched 1:1 on sex and age from Olmsted County, Minnesota. Logistic regression determined associations of each condition with heart failure.

Results: Among 2643 matched pairs (mean age 76.2 years, 45.6% men), the comorbidities with the largest attributable risk of heart failure were arrhythmia (48.7%), hypertension (28.4%), and coronary artery disease (33.9%); together these explained 73.0% of heart failure. Similar associations were observed for patients with reduced and preserved ejection fraction, with the exception of hypertension. The risk of heart failure attributable to hypertension was 2-fold higher in patients with heart failure with preserved ejection fraction (38.7%) than in patients with heart failure with reduced ejection fraction (17.8%). Hypertension, coronary artery disease, arrhythmia, and diabetes were more strongly associated with heart failure in younger (≤75 years) compared to older (>75 years) persons.

Conclusions: Patients with heart failure have a higher prevalence of many chronic conditions than controls. Similar associations were observed in patients with reduced and preserved ejection fraction, with the exception of hypertension, which was more strongly associated with heart failure with preserved ejection fraction. Finally, some cardiometabolic risk factors were more strongly associated with heart failure in younger persons, highlighting the importance of optimizing prevention and treatment of risk factors and, in particular, cardiometabolic risk factors.
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http://dx.doi.org/10.1016/j.amjmed.2019.10.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7558500PMC
June 2020

Galectin-3 Levels and Outcomes After Myocardial Infarction: A Population-Based Study.

J Am Coll Cardiol 2019 05;73(18):2286-2295

Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota; Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota. Electronic address:

Background: Galectin-3 (Gal-3) is implicated in cardiac fibrosis, but its association with adverse outcomes after myocardial infarction (MI) is unknown.

Objectives: The purpose of this study was to examine the prognostic value of Gal-3 in a community cohort of incident MI.

Methods: A population-based incidence MI cohort was prospectively assembled in Olmsted County, Minnesota, between 2002 and 2012. Gal-3 levels were measured at the time of MI. Patients were followed for heart failure (HF) and death.

Results: A total of 1,342 patients were enrolled (mean age 67.1 years; 61.3% male; 78.8% non-ST-segment elevation MI). Patients with elevated Gal-3 were older and had more comorbidities. Over a mean follow-up of 5.4 years, 484 patients (36.1%) died and 368 (27.4%) developed HF. After adjustment for age, sex, comorbidities, and troponin, patients with Gal-3 values in tertiles 2 and 3 had a 1.3-fold (95% confidence interval [CI]: 0.9-fold to 1.7-fold) and a 2.4-fold (95% CI: 1.8-fold to 3.2-fold) increased risk of death, respectively (p < 0.001) compared with patients with Gal-3 values in tertile 1. Patients with Gal-3 values in tertiles 2 and 3 had a higher risk of HF with hazard ratios of 1.4 (95% CI: 1.0 to 2.0) and 2.3 (95% CI: 1.6 to 3.2), respectively (p < 0.001). With further adjustment for soluble suppression of tumorigenicity-2, elevated Gal-3 remained associated with increased risk of death and HF. The increased risk of HF did not differ by HF type and was independent of the occurrence of recurrent MI.

Conclusions: Gal-3 is an independent predictor of mortality and HF post-MI. These findings suggest a role for measuring Gal-3 levels for risk stratification post-MI.
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http://dx.doi.org/10.1016/j.jacc.2019.02.046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6512841PMC
May 2019

Grip strength predicts cardiac adverse events in patients with cardiac disorders: an individual patient pooled meta-analysis.

Heart 2019 06 19;105(11):834-841. Epub 2018 Nov 19.

Cardiology Unit, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy.

Objective: Grip strength is a well-characterised measure of weakness and of poor muscle performance, but there is a lack of consensus on its prognostic implications in terms of cardiac adverse events in patients with cardiac disorders.

Methods: Articles were searched in PubMed, Cochrane Library, BioMed Central and EMBASE. The main inclusion criteria were patients with cardiac disorders (ischaemic heart disease, heart failure (HF), cardiomyopathies, valvulopathies, arrhythmias); evaluation of grip strength by handheld dynamometer; and relation between grip strength and outcomes. The endpoints of the study were cardiac death, all-cause mortality, hospital admission for HF, cerebrovascular accident (CVA) and myocardial infarction (MI). Data of interest were retrieved from the articles and after contact with authors, and then pooled in an individual patient meta-analysis. Univariate and multivariate logistic regression was performed to define predictors of outcomes.

Results: Overall, 23 480 patients were included from 7 studies. The mean age was 62.3±6.9 years and 70% were male. The mean follow-up was 2.82±1.7 years. After multivariate analysis grip strength (difference of 5 kg, 5× kg) emerged as an independent predictor of cardiac death (OR 0.84, 95% CI 0.79 to 0.89, p<0.0001), all-cause death (OR 0.87, 95% CI 0.85 to 0.89, p<0.0001) and hospital admission for HF (OR 0.88, 95% CI 0.84 to 0.92, p<0.0001). On the contrary, we did not find any relationship between grip strength and occurrence of MI or CVA.

Conclusion: In patients with cardiac disorders, grip strength predicted cardiac death, all-cause death and hospital admission for HF.

Trial Registration Number: CRD42015025280.
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http://dx.doi.org/10.1136/heartjnl-2018-313816DOI Listing
June 2019

Fall Risk and Outcomes Among Patients Hospitalized With Cardiovascular Disease in the Community.

Circ Cardiovasc Qual Outcomes 2018 08;11(8):e004199

Department of Health Sciences Research (S.M.M., A.M.C., S.A.W., R.J., V.L.R.).

Background As the population with cardiovascular disease ages, geriatric conditions are of increasing relevance. A possible geriatric prognostic indicator may be a fall risk score, which is mandated by The Joint Commission to be measured on all hospitalized patients. The prognostic value of a fall risk score on outcomes after dismissal is not well known. Thus, we aimed to determine whether a fall risk score is associated with death and hospital readmissions in patients with a recent incident cardiovascular disease event. Methods and Results In this retrospective cohort study, Olmsted County, MN patients with incident heart failure, myocardial infarction, or atrial fibrillation between August 1, 2005, and December 31, 2011, who were hospitalized within 180 days after the event were studied. Fall risk was measured by the Hendrich II fall risk model. Patients were followed for death or readmission within 30 days or 1 year. Among 2456 hospitalized patients with recent incident cardiovascular disease (549 heart failure, 784 myocardial infarction, 1123 atrial fibrillation; mean [SD] age, 71 [15] years; 55% men), the fall risk score was high in 22% of patients and moderate in 38%. The risk of death was increased if the fall risk score was increased, independent of age and comorbidities (moderate hazard ratio, 1.51; 95% CI, 1.09-2.08; high hazard ratio, 3.49; 95% CI, 2.52-4.85). Similarly, the risk of 30-day readmissions was substantially increased with a greater fall risk score (moderate hazard ratio, 1.29; 95% CI, 1.03-1.62; high hazard ratio, 1.63; 95% CI, 1.23-2.15). Results were similar for readmissions within 1 year. Conclusions More than half of hospitalized patients with recent incident cardiovascular disease have an elevated fall risk score, which is associated with an increased risk in readmissions and death. These results delineate an approach for risk stratification and management that may prevent readmissions and improve survival.
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http://dx.doi.org/10.1161/CIRCOUTCOMES.117.004199DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6205191PMC
August 2018

Perceived Social Isolation and Outcomes in Patients With Heart Failure.

J Am Heart Assoc 2018 05 23;7(11). Epub 2018 May 23.

Department of Health Sciences Research, Mayo Clinic, Rochester, MN.

Background: Perceived social isolation has been shown to have a negative impact on health outcomes, particularly among older adults. However, these relationships have not been fully examined among patients with heart failure.

Methods And Results: Residents from 11 southeast Minnesota counties with a first-ever () code 428 for heart failure between January 1, 2013, and March 31, 2015 (N=3867), were prospectively surveyed to measure perceived social isolation. A total of 2003 patients returned the survey (response rate, 52%); 1681 patients completed all questions and were retained for analysis. Among these patients (53% men; mean age, 73 years), ≈19% (n=312) had moderate perceived social isolation and 6% (n=108) had high perceived social isolation. After adjustment, patients reporting moderate perceived social isolation did not have an increased risk of death, hospitalizations, or emergency department visits compared with patients reporting low perceived social isolation; however, patients reporting high perceived social isolation had >3.5 times increased risk of death (hazard ratio, 3.74; 95% confidence interval [CI], 1.82-7.70), 68% increased risk of hospitalization (hazard ratio, 1.68; 95% CI, 1.18-2.39), and 57% increased risk of emergency department visits (hazard ratio, 1.57; 95% CI, 1.09-2.27). Compared with patients who self-reported low perceived social isolation, patients reporting moderate perceived social isolation had a 16% increased risk of outpatient visits (rate ratio, 1.16; 95% CI, 1.03-1.31), whereas those reporting high perceived social isolation had a 26% increased risk (rate ratio, 1.26; 95% CI, 1.04-1.53).

Conclusions: In patients with heart failure, greater perceived social isolation is associated with an increased risk of death and healthcare use. Assessing perceived social isolation during the clinical encounter with a brief screening tool may help identify patients with heart failure at greater risk of poor outcomes.
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http://dx.doi.org/10.1161/JAHA.117.008069DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6015354PMC
May 2018

Multimorbidity and Functional Limitation in Individuals with Heart Failure: A Prospective Community Study.

J Am Geriatr Soc 2018 07 30;66(6):1101-1107. Epub 2018 Mar 30.

Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota.

Objectives: To characterize the individual and combined effects of multimorbidity and functional limitation on healthcare use and mortality in a large, community cohort of individuals with heart failure (HF).

Design: Prospective cohort study.

Setting: Eleven southeastern Minnesota counties.

Participants: Individuals (mean age 74, 54% male) with a first-ever HF code (International Classification of Diseases, Ninth Revision code 428 or Tenth Revision code I50) between January 1, 2013 and March 31, 2016 (N=2,692).

Measurements: Eight activities of daily living measured using a survey on a Likert scale (1=without any difficulty, 5=unable to do; median=8). Participants with a score greater than 8 were categorized as having functional limitation. Multimorbidity was defined as having 2 or more noncardiac comorbidities.

Results: Twenty-five percent of participants had neither multimorbidity nor functional limitation, 35% had multimorbidity, 9% had functional limitation, and 31% had both. After adjustment, participants with multimorbidity and functional limitation had greater risks of all outcomes (death: hazard ratio (HR)=4.92, 95% confidence interval (CI)=3.03-8.00; emergency department (ED) visit: HR=3.67, 95% CI=2.94-4.59; hospitalization: HR=3.66, 95% CI=2.85-4.70; outpatient visit: HR=1.73, 95% CI=1.52-1.96) than those with neither. Participants with functional limitation alone had greater risks of death (HR=4.84, 95% CI=2.78-8.43), ED visits (HR=2.35, 95% CI=1.75-3.16), and hospitalizations (HR=2.10, 95% CI=1.52-2.88) but not outpatient visits. Those with multimorbidity alone had similar risks of ED visits and hospitalizations as those with functional limitation alone but were more likely to have outpatient visits (HR=1.50, 95% CI=1.34-1.67).

Conclusion: Individuals with both multimorbidity and functional limitation have the highest risk of death and healthcare use. Individuals with only functional limitation have similar rates of hospitalizations and ED visits as those with only multimorbidity, underscoring the need to consider both when managing individuals with HF.
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http://dx.doi.org/10.1111/jgs.15336DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6152830PMC
July 2018

Health Literacy and Outcomes in Patients With Heart Failure: A Prospective Community Study.

Mayo Clin Proc 2018 01 6;93(1):9-15. Epub 2017 Dec 6.

Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.

Objective: To examine the impact of health literacy on hospitalizations and death in a population of patients with heart failure (HF).

Patients And Methods: Residents from the 11-county region in southeast Minnesota with a first-ever International Classification of Diseases, Ninth Revision code 428 or Tenth Revision code 150 (n=5121) from January 1, 2013, through December 31, 2015, were identified and prospectively surveyed to measure health literacy using established screening questions. A total of 2647 patients returned the survey (response rate, 52%); 2487 patients with complete health literacy data were retained for analysis. Health literacy, measured as a composite score on three 5-point scales, was categorized as adequate (≥8) or low (<8). Cox proportional hazards regression and Andersen-Gill models were used to examine the association of health literacy with mortality and hospitalization.

Results: Of 2487 patients (mean age, 73.5 years; 53.6% male [n=1333]), 10.5% (n= 261) had low health literacy. After mean ± SD follow-up of 15.5±7.2 months, 250 deaths and 1584 hospitalizations occurred. Low health literacy was associated with increased mortality and hospitalizations. After adjusting for age, sex, comorbidity, education, and marital status, the hazard ratios for death and hospitalizations in patients with low health literacy were 1.91 (95% CI, 1.38-2.65; P<.001) and 1.30 (95% CI, 1.02-1.66; P=.03), respectively, compared with patients with adequate health literacy.

Conclusion: Low health literacy is associated with increased risks of hospitalization and death in patients with HF. The clinical evaluation of health literacy could help design interventions individualized for patients with low health literacy.
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http://dx.doi.org/10.1016/j.mayocp.2017.09.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5756510PMC
January 2018

Contemporary Risk Stratification After Myocardial Infarction in the Community: Performance of Scores and Incremental Value of Soluble Suppression of Tumorigenicity-2.

J Am Heart Assoc 2017 Oct 20;6(10). Epub 2017 Oct 20.

Department of Health Sciences Research, Mayo Clinic, Rochester, MN

Background: Current American Heart Association/American College of Cardiology guidelines recommend the GRACE (Global Registry of Acute Coronary Events) and TIMI (Thrombolysis in Myocardial Infarction) scores to assess myocardial infarction (MI) prognosis. Changes in the epidemiological characteristics of MI and the availability of new biomarkers warrant an assessment of the performance of these scores in contemporary practice. We assessed the following: (1) the performance of GRACE and TIMI to predict 1-year mortality in a cohort of patients stratified by ST-segment elevation MI (STEMI) and non-STEMI (NSTEMI) and (2) the incremental discriminatory power of soluble suppression of tumorigenicity-2, a myocardial fibrosis biomarker.

Methods And Results: Olmsted County, Minnesota, residents with incident MI (N=1401) were recruited prospectively from November 1, 2002 to December 31, 2012 (mean age, 67 years; 61% men; 79% with NSTEMI). Baseline data were used to calculate risk scores; soluble suppression of tumorigenicity-2 was measured in stored plasma samples obtained at index MI. -statistics adapted to survival data were used to assess the discriminatory power of the risk scores and the improvement gained by adding other markers. During the first year of follow-up, 190 patients (14%) died. The discriminatory performance to predict death was reasonable for GRACE and poor for TIMI, and was generally worse in those with NSTEMI versus those with STEMI. In people with NSTEMI, sequential addition of comorbidities and soluble suppression of tumorigenicity-2 substantially improved the -statistic over GRACE (from 0.78 to 0.80 to 0.84) and TIMI (from 0.61 to 0.73 to 0.81), respectively (all ≤0.05).

Conclusions: Guideline-recommended scores for risk assessment after MI underperform in contemporary community patients, particularly those with NSTEMI, which now represents most infarcts. Incorporating comorbidities and soluble suppression of tumorigenicity-2 substantially improves risk prediction, thereby delineating opportunities to improve clinical care.
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http://dx.doi.org/10.1161/JAHA.117.005958DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5721833PMC
October 2017

Skilled Nursing Facility Use and Hospitalizations in Heart Failure: A Community Linkage Study.

Mayo Clin Proc 2017 Mar 13. Epub 2017 Mar 13.

Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN; Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN. Electronic address:

Objectives: To examine the effect of skilled nursing facility (SNF) use on hospitalizations in patients with heart failure (HF) and to examine predictors of hospitalization in patients with HF admitted to a SNF.

Patients And Methods: Olmsted County, Minnesota, residents with first-ever HF from January 1, 2000, through December 31, 2010, were identified, and clinical data were linked to SNF utilization data from the Centers for Medicare and Medicaid Services. Andersen-Gill models were used to determine the association between SNF use and hospitalizations and to determine predictors of hospitalization.

Results: Of 1498 patients with incident HF (mean ± SD age, 75±14 years; 45% male), 605 (40.4%) were admitted to a SNF after HF diagnosis (median follow-up, 3.6 years; range, 0-13.0 years). Of those with a SNF admission, 225 (37%) had 2 or more admissions. After adjustment for age, sex, ejection fraction, and comorbidities, SNF use was associated with a 50% increased risk of hospitalization compared with no SNF use (adjusted hazard ratio, 1.52; 95% CI, 1.31-1.76). In SNF users, arrhythmia, asthma, chronic kidney disease, and the number of activities of daily living requiring assistance were independently associated with an increased risk of hospitalization.

Conclusion: Approximately 40% of patients with HF were admitted to a SNF at some point after diagnosis. Compared with SNF nonusers, SNF users were more likely to be hospitalized. Characteristics associated with hospitalization in SNF users were mostly noncardiovascular, including reduced ability to perform activities of daily living. These findings underscore the effect of physical functioning on hospitalizations in patients with HF in SNFs and the importance of strategies to improve physical functioning.
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http://dx.doi.org/10.1016/j.mayocp.2017.01.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5597448PMC
March 2017

Prognostic Value of Soluble ST2 After Myocardial Infarction: A Community Perspective.

Am J Med 2017 09 23;130(9):1112.e9-1112.e15. Epub 2017 Mar 23.

Division of Cardiovascular Diseases in the Department of Internal Medicine, Mayo Clinic, Rochester, Minn.

Background: Soluble ST2 (sST2) is a marker of cardiac mechanical strain hypothesized to adversely impact short-term prognosis after myocardial infarction. We examined the association of sST2 with longer-term outcomes after myocardial infarction in a geographically defined community.

Methods: Olmsted County, Minnesota residents who experienced an incident (first-ever) myocardial infarction between November 1, 2002 and December 31, 2012 were prospectively enrolled; sST2 levels were measured. Patients were followed for heart failure and death.

Results: We studied 1401 patients with incident myocardial infarction (mean age 67 years; 61% men; 79% non-ST-elevation myocardial infarction). Median sST2 (ng/mL) was 48.7 (25-75 percentile 32.5-103.3). Soluble ST2 was elevated in 51% of patients. Higher values of sST2 were associated with increased age, female sex, and comorbidities. During 5 years of follow-up, 388 persons died and 360 developed heart failure. After adjustment for age, sex, comorbidities, Killip class, and troponin T, the hazard ratios for death were 1.73 (95% confidence interval [CI], 1.22-2.45) and 3.57 (95% CI, 2.57-4.96) for sST2 tertiles 2 and 3, respectively (P <.001). For heart failure, the hazard ratios were 1.67 (95% CI, 1.18-2.37) and 2.88 (95% CI, 2.05-4.05), respectively (P <.001). Results were similar among 30-day survivors.

Conclusions: In the community, sST2 elevation is present in half of myocardial infarctions. Higher values of sST2 are associated with a large excess risk of death and heart failure independently of other prognostic indicators. Measurement of sST2 should be considered for risk stratification after myocardial infarction.
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http://dx.doi.org/10.1016/j.amjmed.2017.02.034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5572469PMC
September 2017

Multimorbidity and the risk of hospitalization and death in atrial fibrillation: A population-based study.

Am Heart J 2017 Mar 9;185:74-84. Epub 2016 Dec 9.

Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.

Patients with atrial fibrillation (AF) have many comorbidities and excess risks of hospitalization and death. Whether the impact of comorbidities on outcomes is greater in AF than the general population is unknown.

Methods: One thousand four hundred thirty patients with AF and community controls matched 1:1 on age and sex were obtained from Olmsted County, Minnesota. Andersen-Gill and Cox regression estimated associations of 19 comorbidities with hospitalization and death, respectively.

Results: AF cases had a higher prevalence of most comorbidities. Hypertension (25.4%), coronary artery disease (17.7%), and heart failure (13.3%) had the largest attributable risk of AF; these along with obesity and smoking explained 51.4% of AF. Over a mean follow-up of 6.3 years, patients with AF experienced higher rates of hospitalization and death than did population controls. However, the impact of comorbidities on hospitalization and death was generally not greater in patients with AF compared with controls, with the exception of smoking. Ever smokers with AF experienced higher-than-expected risks of hospitalization and death, with observed vs expected (assuming additivity of effects) hazard ratios compared with never smokers without AF of 1.78 (1.56-2.02) vs 1.52 for hospitalization and 2.41 (2.02-2.87) vs 1.84 for death.

Conclusions: Patients with AF have a higher prevalence of most comorbidities; however, the impact of comorbidities on hospitalization and death is generally similar in AF and controls. Smoking is a notable exception; ever smokers with AF experienced higher-than-expected risks of hospitalization and death. Thus, interventions targeting modifiable behaviors may benefit patients with AF by reducing their risk of adverse outcomes.
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http://dx.doi.org/10.1016/j.ahj.2016.11.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5343767PMC
March 2017

Burden and Timing of Hospitalizations in Heart Failure: A Community Study.

Mayo Clin Proc 2017 02;92(2):184-192

Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.

Objective: To study the temporal distribution and causes of hospitalizations after heart failure (HF) diagnosis.

Patients And Methods: Hospitalizations were studied in 1972 Olmsted County, Minnesota, residents with incident HF from January 1, 2000, to December 31, 2011. All hospitalizations were examined for the 2 years following incident HF, and each was categorized as due to HF, other cardiovascular causes, or noncardiovascular causes. Negative binomial regression examined associations between time periods (0-30, 31-182, 183-365, and 366-730 days after diagnosis) and hospitalizations.

Results: During the 2 years after diagnosis, 3495 hospitalizations were observed among 1336 of the 1972 patients with HF. The age- and sex-adjusted rates of hospitalizations were highest in the first 30 days after diagnosis (3.33 per person-year vs 1.33, 1.07, and 1.00 per person-year for 31-182 days, 183-365 days, and 366-730 days, respectively). The rates of hospitalizations were similar across sex, presentation of HF (inpatient or outpatient), and type of HF (preserved or reduced ejection fraction). Patients diagnosed as inpatients who had long hospital stays (>5 days) experienced more than a 30% increased risk of rehospitalization within 30 days of dismissal. Importantly, most hospitalizations (2222 of 3495 [63.6%]) were due to noncardiovascular causes, and a minority (440 of 3495 [12.6%]) were due to HF. The rates of noncardiovascular hospitalizations were higher than those for HF or other cardiovascular hospitalizations across all follow-up for all time periods after HF.

Conclusion: Patients with HF experience high rates of hospitalizations, particularly within the first 30 days, and mostly for noncardiovascular causes. To reduce hospitalizations in patients with HF, an integrated approach focusing on comorbidities is required.
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http://dx.doi.org/10.1016/j.mayocp.2016.11.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5341602PMC
February 2017

Atherosclerotic Burden and Heart Failure After Myocardial Infarction.

JAMA Cardiol 2016 05;1(2):156-62

Division of Cardiovascular Diseases, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota.

Importance: Whether the extent of coronary artery disease (CAD) is associated with the occurrence of heart failure (HF) after myocardial infarction (MI) is not known. Furthermore, whether this association might differ by HF type according to preserved or reduced ejection fraction (EF) has yet to be determined.

Objectives: To evaluate in a community cohort of patients with incident (first-ever) MI the association of angiographic CAD with subsequent HF and to examine the prognostic role of CAD according to HF subtypes: HF with reduced EF and HF with preserved EF.

Design, Setting, And Participants: A population-based cohort study was conducted in 1922 residents of Olmsted County, Minnesota, with incident MI diagnosed between January 1, 1990, and December 31, 2010, and no prior HF; study participants were followed up through March 31, 2013. The extent of angiographic CAD was determined at baseline and categorized according to the number of major epicardial coronary arteries with 50% or more lumen diameter obstruction.

Main Outcomes And Measures: The primary end point was time to incident HF. The primary exposure variable was the extent of CAD as expressed by the number of major coronary arteries with significant obstruction (0-, 1-, 2-, or 3-vessel disease) obtained from coronary angiograms performed no more than 1 day after the MI. Heart failure was ascertained by the Framingham criteria and classified by type according to EF (50% cutoff).

Results: Of the 1922 participants, 1258 (65.4%) were men (mean [SD] age, 64 [13] years). During a mean follow-up period of 6.7 (5.9) years, 588 patients (30.6%) developed HF. With death and recurrent MI modeled as competing risks, the cumulative incidence rates of post-MI HF among patients with 0 or 1, 2, and 3 diseased vessels were 10.7%, 14.6%, and 23.0% at 30 days; and 14.7%, 20.6%, and 29.8% at 5 years, respectively (P < .001 for trend). After adjustment for clinical characteristics in a Cox proportional hazards regression model, the hazard ratios (95% CIs) for HF were 1.25 (0.99-1.59) and 1.75 (1.40-2.20) in patients with 2 and 3 vessels vs 0 or 1 occluded vessel, respectively (P < .001 for trend). The increased risk with a greater number of occluded vessels was independent of the occurrence of a recurrent MI and did not differ appreciably by HF type.

Conclusions And Relevance: The extent of angiographic CAD is an indicator of post-MI HF regardless of HF type and independent of recurrent MI. These data underscore the need to further investigate the processes taking place in the transition from myocardial injury to HF.
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http://dx.doi.org/10.1001/jamacardio.2016.0074DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4957651PMC
May 2016

Heart Failure After Myocardial Infarction Is Associated With Increased Risk of Cancer.

J Am Coll Cardiol 2016 07;68(3):265-271

Department of Health Sciences Research and Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota. Electronic address:

Background: Heart failure (HF) is associated with excess morbidity and mortality for which noncardiac causes are increasingly recognized. The authors previously described an increased risk of cancer among HF patients compared with community controls.

Objectives: This study examined whether HF was associated with an increased risk of subsequent cancer among a homogenous population of first myocardial infarction (MI) survivors.

Methods: A prospective cohort study was conducted among Olmsted County, Minnesota, residents with incident MI from 2002 to 2010. Patients with prior cancer or HF diagnoses were excluded.

Results: A total of 1,081 participants (mean age 64 ± 15 years; 60% male) were followed for 5,327 person-years (mean 4.9 ± 3.0 years). A total of 228 patients developed HF, and 98 patients developed cancer (excluding nonmelanoma skin cancer). Incidence density rates for cancer diagnosis (per 1,000 person-years) were 33.7 for patients with HF and 15.6 for patients without HF (p = 0.002). The hazard ratio (HR) for cancer associated with HF was 2.16 (95% confidence interval [CI]: 1.39 to 3.35); adjusted for age, sex, and Charlson comorbidity index; HR: 1.71 (95% CI: 1.07 to 2.73). The HRs for mortality associated with cancer were 4.90 (95% CI: 3.10 to 7.74) for HF-free and 3.91 (95% CI: 1.88 to 8.12) for HF patients (p for interaction = 0.76).

Conclusions: Patients who develop HF after MI have an increased risk of cancer. This finding extends our previous report of an elevated cancer risk after HF compared with controls, and calls for a better understanding of shared risk factors and underlying mechanisms.
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http://dx.doi.org/10.1016/j.jacc.2016.04.053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4947209PMC
July 2016

Multimorbidity in Heart Failure: Effect on Outcomes.

J Am Geriatr Soc 2016 07 27;64(7):1469-74. Epub 2016 Jun 27.

Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota.

Objectives: To investigate the effect of the number and type of comorbid conditions on death and hospitalizations in individuals with incident heart failure (HF).

Design: Population-based cohort study.

Setting: Olmsted County, Minnesota.

Participants: Olmsted County, Minnesota, residents with incident HF from 2000 to 2010 (mean age 76 ± 14, 56% female) (N = 1,714).

Measurements: The prevalence of 16 chronic conditions obtained at HF diagnosis classified into three groups: cardiovascular (CV) related, other physical, and mental.

Results: The mean number of conditions per participant was 2.6 ± 1.5 for CV-related conditions, 1.3 ± 1.1 for other physical conditions, and 0.30 ± 0.61 for mental conditions. After a mean follow-up of 4.2 years, 1,073 deaths and 6,306 hospitalizations had occurred. After adjustment for age, sex, ejection fraction, in- or outpatient status, and number of other conditions, an increase of one other physical condition was associated with a 14% (HR = 1.14, 95% CI = 1.08-1.20) greater risk of death and a 26% (HR = 1.26, 95% CI = 1.20-1.32) greater risk of hospitalization, and an increase of one mental condition was associated with a 31% (HR = 1.31, 95% CI = 1.19-1.44) greater risk of death and an 18% (HR = 1.18, 95% CI = 1.07-1.29) greater risk of hospitalization. In contrast, an increase of one CV-related condition was not associated with greater risk of death and was associated with a 10% (HR = 1.10, 95% CI = 1.06-1.15) greater risk of hospitalization.

Conclusion: CV-related conditions are the most common type of comorbid conditions in individuals with HF, but other physical and mental conditions are more strongly associated with death and hospitalizations. This underscores the effect of non-CV conditions on outcomes in HF.
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http://dx.doi.org/10.1111/jgs.14206DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4943753PMC
July 2016

Social and behavioural factors associated with frailty trajectories in a population-based cohort of older adults.

BMJ Open 2016 05 27;6(5):e011410. Epub 2016 May 27.

Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.

Objective: The goal of this study was to identify distinct frailty trajectories (clusters of individuals following a similar progression of frailty over time) in an ageing population and to determine social and behavioural factors associated with frailty trajectories.

Design: Population-based cohort study.

Setting: Olmsted County, Minnesota.

Participants: Olmsted County, Minnesota residents aged 60-89 in 2005.

Primary Outcome Measure: Changes in frailty over an 8-year period from 2005 to 2012, measured by constructing a yearly frailty index. Frailty trajectories by decade of age were determined using k-means cluster modelling for longitudinal data.

Results: After adjustment for age and sex, all social and behavioural factors (education, marital status, living arrangements, smoking status and alcohol use) were significantly associated with frailty trajectories in those aged 60-69 and 70-79 years. After further adjustment for baseline frailty, the likelihood of being in the high frailty trajectory was greatest among those reporting concerns from relatives/friends about alcohol consumption (OR (95% CI) 2.26 (1.19 to 4.29)) and those with less than a high school education (OR (95% CI) 1.98 (1.32 to 2.96)) in the 60-69 year olds. In the 70-79 year olds, the largest associations were observed among those with concerns from oneself about alcohol consumption (OR (95% CI) 1.92 (1.23 to 3.00)), those with less than a high school education (OR (95% CI) 1.57 (1.12 to 2.22)), and those living with family (vs spouse; OR (95% CI) 1.76 (1.05 to 2.94)). No factors remained associated with frailty trajectories in the 80-89 year olds after adjustment for baseline frailty.

Conclusions: Social and behavioural factors are associated with frailty, with stronger associations observed in younger ages. Recognition of social and behavioural factors associated with increasing frailty may inform interventions for individuals at risk of worsening frailty, specifically when targeted at younger individuals.
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http://dx.doi.org/10.1136/bmjopen-2016-011410DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4885446PMC
May 2016

Frailty Trajectories in an Elderly Population-Based Cohort.

J Am Geriatr Soc 2016 Feb;64(2):285-92

Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota.

Objectives: To identify distinct frailty trajectories (clusters of individuals following a similar progression of frailty over time) in an aging population and to estimate associations between frailty trajectories and emergency department visits, hospitalizations, and all-cause mortality.

Design: Population-based cohort study.

Setting: Olmsted County, Minnesota.

Participants: Olmsted County, Minnesota residents aged 60-89 in 2005.

Measurements: Longitudinal changes in frailty between 2005 and 2012 were measured by constructing a yearly Rockwood frailty index incorporating body mass index, 17 comorbidities, and 14 activities of daily living. The frailty index measures variation in health status as the proportion of deficits present of the 32 considered (range 0-1).

Results: Of the 16,443 Olmsted County residents aged 60-89 in 2005, 12,270 (74.6%) had at least 3 years of frailty index measures and were retained for analysis. The median baseline frailty index increased with age (0.11 for 60-69, 0.14 for 70-79, 0.19 for 80-89). Three distinct frailty trajectories were identified in individuals aged 60-69 at baseline and two trajectories in those aged 70-79 and 80-89. Within each decade of age, increasing frailty trajectories were associated with greater risks of emergency department visits, hospitalization, and all-cause mortality, even after adjustment for baseline frailty index.

Conclusion: The number of frailty trajectories differed according to age. Within each age group, those in the highest frailty trajectory had greater healthcare use and worse survival. Frailty trajectories may offer a way to target aging individuals at high risk of hospitalization or death for therapeutic or preventive interventions.
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http://dx.doi.org/10.1111/jgs.13944DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4762174PMC
February 2016

Mortality Associated With Heart Failure After Myocardial Infarction: A Contemporary Community Perspective.

Circ Heart Fail 2016 Jan 23;9(1):e002460. Epub 2015 Dec 23.

From the Department of Health Sciences Research, Division of Epidemiology (Y.G., S.A.W., C.B., A.M.C., S.M.M., R.J., V.L.R.) and Department of Cardiovascular Diseases (M.E.-S., S.M.D., V.L.R.), Mayo Clinic, Rochester, MN; Department of Internal Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY (C.B.); and Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Y.G.).

Background: Contemporary data are lacking on the prognostic importance of heart failure (HF) after myocardial infarction (MI). We evaluated the prognostic impact of HF post MI according to preserved/reduced ejection fraction and the timing of its occurrence.

Methods And Results: All Olmsted County, Minnesota, residents (n=2596) with incident MI diagnosed in 1990 to 2010 and no prior HF were followed through March 2013. Cox models were used to examine (1) the hazard ratios for death associated with HF type and timing and (2) secular trends in survival by HF status. During a mean follow-up of 7.6 years, there were 1116 deaths, 634 in the 902 patients who developed HF (70%) and 482 in the 1694 patients who did not develop HF (28%). After adjustment for age and sex, HF as a time-dependent variable was strongly associated with mortality (hazard ratio =3.31, 95% confidence interval: 2.93-3.75), particularly from cardiovascular causes (hazard ratio =4.20, 95% confidence interval: 3.50-5.03). Further adjustment for MI severity and comorbidity, acute treatment, and recurrent MI moderately attenuated these associations (hazard ratio =2.49 and 2.94 for all-cause and cardiovascular mortality, respectively). Mortality did not differ by ejection fraction, but was higher for delayed- versus early-onset HF (P for heterogeneity =0.002). The age- and sex-adjusted 5-year survival estimates in 2001 to 2010 versus 1990 to 2000 were 82% and 81% among HF-free and 61% and 54% among HF patients, respectively (P for heterogeneity of trends =0.05).

Conclusions: HF markedly increases the risk of death after MI. This excess risk is similar regardless of ejection fraction but greater for delayed- versus early-onset HF. Mortality after MI declined over time, primarily as a result of improved HF survival.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.115.002460DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4692179PMC
January 2016

Approaching patient engagement in research: what do patients with cardiovascular disease think?

Patient Prefer Adherence 2015 27;9:1061-4. Epub 2015 Jul 27.

Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA ; Department of Health Sciences Research, Mayo Clinic, Rochester MN, USA.

Movement toward patient-centered health care must be supported by an evidence base informed by greater patient engagement in research. Efforts to better understand patients' interest in and perspectives on involvement in the research process are fundamental to supporting movement of research programs toward greater patient engagement. We describe preliminary efforts to engage members of a community group of patients living with heart disease to better understand their interest and perspectives on involvement in research. A semi-structured focus group guide was developed to probe willingness to participate in the following three phases of research: preparation, execution, and translation. The focus group discussion, and our summary of key messages gleaned from said discussion, was organized around the phases of research that patients may be involved in, with the goal of delineating degrees of interest expressed for engagement in each phase. Consistent with what is known from the literature, a clear preference for engagement during the preparation and translation phase of the research process emerged. This preliminary conversation will guide our ongoing research efforts toward greater inclusion of patients throughout the research process.
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http://dx.doi.org/10.2147/PPA.S84980DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4524577PMC
August 2015

A contemporary appraisal of the heart failure epidemic in Olmsted County, Minnesota, 2000 to 2010.

JAMA Intern Med 2015 Jun;175(6):996-1004

Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota3Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota.

Importance: Heart failure (HF) is commonly referred to as an epidemic, posing major clinical and public health challenges. Yet, contemporary data on its magnitude and implications are scarce.

Objective: To evaluate recent trends in HF incidence and outcomes overall and by preserved ejection fraction (HFpEF) or reduced ejection fraction (HFrEF).

Design, Setting, And Participants: Incidence rates of HF in Olmsted County, Minnesota (population, approximately 144,248), between January 1, 2000, and December 31, 2010, were assessed.

Main Outcomes And Measures: Patients identified with incident HF (n = 2762) (mean age, 76.4 years; 43.1% male) were followed up for all-cause and cause-specific hospitalizations (through December 2012) and death (through March 2014).

Results: The age- and sex-adjusted incidence of HF declined substantially from 315.8 per 100,000 in 2000 to 219.3 per 100,000 in 2010 (annual percentage change, -4.6), equating to a rate reduction of 37.5% (95% CI, -29.6% to -44.4%) over the last decade. The incidence declined for both HF types but was greater (interaction P = .08) for HFrEF (-45.1%; 95% CI, -33.0% to -55.0%) than for HFpEF (-27.9%; 95% CI, -12.9% to -40.3%). Mortality was high (24.4% for age 60 years and 54.4% for age 80 years at 5 years of follow-up), frequently ascribed to noncardiovascular causes (54.3%), and did not decline over time. The risk of cardiovascular death was lower for HFpEF than for HFrEF (multivariable-adjusted hazard ratio, 0.79; 95% CI, 0.67-0.93), whereas the risk of noncardiovascular death was similar (1.07; 95% CI, 0.89-1.29). Hospitalizations were common (mean, 1.34; 95% CI, 1.25-1.44 per person-year), particularly among men, and did not differ between HFpEF and HFrEF. Most hospitalizations (63.0%) were due to noncardiovascular causes. Hospitalization rates for cardiovascular causes did not change over time, whereas those for noncardiovascular causes increased.

Conclusions And Relevance: Over the last decade, the incidence of HF declined substantially, particularly for HFrEF, contrasting with no apparent change in mortality. Noncardiovascular conditions have an increasing role in hospitalizations and remain the most frequent cause of death. These results underscore the need to augment disease-centric management approaches with holistic strategies to reduce the population burden of HF.
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http://dx.doi.org/10.1001/jamainternmed.2015.0924DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4451405PMC
June 2015

Acute coronary syndromes in the community.

Mayo Clin Proc 2015 May 18;90(5):597-605. Epub 2015 Mar 18.

Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN. Electronic address:

Objectives: To measure the incidence of acute coronary syndrome (ACS), defined as first-ever myocardial infarction (MI) or unstable angina (UA); evaluate recent temporal trends; and determine whether survival after ACS has changed over time and differs by type.

Patients And Methods: This was a population surveillance study conducted in Olmsted County, Minnesota (population: 144,248). All persons hospitalized with incident ACS between January 1, 2005, and December 31, 2010, were identified using International Classification of Diseases, Ninth Revision codes, natural language processing of the medical records, and biomarkers. Myocardial infarction was validated by epidemiologic criteria and UA by the Braunwald classification. Patients were followed through June 30, 2013, for death.

Results: Of 1244 incident ACS cases, 35% (n=438) were UA and 65% (n=806) were MI. The standardized rates (per 100,000) of ACS were 284 (95% CI, 248-319) in 2005 and 184 (95% CI, 157-210) in 2010 (2010 vs 2005: rate ratio, 0.62; 95% CI, 0.53-0.73), indicating a 38% decline (similar for MI and UA). The 30-day case fatality rates did not differ by year of diagnosis but were worse for MI (8.9%; 95% CI, 6.9%-10.9%) compared with UA (1.9%; 95% CI, 0.6%-3.1%). Among 30-day survivors, the risk of death did not differ by ACS type or diagnosis year.

Conclusion: In the community, UA constitutes 35% of ACS. The incidence of ACS has declined in recent years, and trends were similar for UA and MI, reaffirming a substantial decline in all acute manifestations of coronary disease. Survival after ACS did not change over time, but 30-day survival was worse for MI compared with UA.
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http://dx.doi.org/10.1016/j.mayocp.2015.02.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4420654PMC
May 2015

Activities of daily living and outcomes in heart failure.

Circ Heart Fail 2015 Mar 25;8(2):261-7. Epub 2015 Feb 25.

From the Division of Cardiovascular Diseases, Department of Medicine (S.M.D., V.L.R.), Department of Health Sciences Research (S.M.D., S.M.M., A.M.C., R.J., S.A.W., V.L.R.), and Department of Physical Medicine and Rehabilitation (A.L.C.), Mayo Clinic, Rochester, MN.

Background: Chronic disease can contribute to functional disability, which can degrade quality of life. However, the prevalence of functional disability and its association with outcomes among patients with heart failure requires further study.

Methods And Results: Southeastern Minnesota residents with heart failure were enrolled from September 2003 through January 2012 into a cohort study with follow-up through December 2012. Difficulty with 9 activities of daily living (ADLs) was assessed by a questionnaire. Patients were divided into 3 categories of ADL difficulty (no/minimal, moderate, severe). The associations of ADL difficulty with mortality and hospitalization were assessed using Cox and Andersen-Gill models. Among 1128 patients (mean age, 74.7 years; 49.2% female), a majority (59.4%) reported difficulty with one or more ADLs at enrollment, with 272 (24.1%) and 146 (12.9%) experiencing moderate and severe difficulty, respectively. After a mean (SD) follow-up of 3.2 (2.4) years, 614 patients (54.4%) had died. Mortality increased with increasing ADL difficulty; the hazard ratio (95% confidence interval) for death was 1.49 (1.22-1.82) and 2.26 (1.79-2.86) for those with moderate and severe difficulty, respectively, compared to those with no/minimal difficulty (Ptrend<0.001). Patients with moderate and severe difficulty were at an increased risk for all-cause and noncardiovascular hospitalization. In a second assessment, 17.7% of survivors reported more difficulty with ADLs and patients with persistently severe or worsening difficulty were at an increased risk for death (hazard ratio, 2.10; 95% confidence interval, 1.71-2.58; P<0.001) and hospitalization (hazard ratio, 1.51; 95% confidence interval, 1.31-1.74; P<0.001).

Conclusions: Functional disability is common in patients with heart failure, can progress over time, and is associated with adverse prognosis.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.114.001542DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4366326PMC
March 2015