Evaluating Outcomes and Time Delays of a Non-Trainee-Driven Hospitalist Procedure Service.

BACKGROUND AND OBJECTIVES: Ultrasound guidance has become standard of care in hospital medicine for invasive bedside procedures, especially central venous catheter placement. Despite ultrasound-guided bedside procedures having a high degree of success, only a few hospitalists perform them. This is because these are usually performed by radiologists or in the setting of trainee-run procedure teams. We sought to determine the impact of a non-trainee driven , hospitalist-run procedure service relative to time from consult to procedure. METHODS: The University of Alabama at Birmingham Hospital (UAB), Department of Hospital Medicine, trained 8 non-trainee hospitalist physicians (from existing staff) to implement the ultrasound-guided procedure service. This study examines consult to procedure completion time since the implementation of the procedure service (2014 to 2020). Univariate analyses are used to analyze pre-implementation (2012-2014), pilot (2014-2016), and post-implementation data (2016-2018 initial, and 2018-2020 sustained). RESULTS: Results suggest a 50% reduction in time from consult to procedure completion when compared with the period before implementation of the nontrainee hospitalist procedure service. CONCLUSIONS: A hospitalist procedure service, which does not include trainees, results in less time lag from consult to procedure completion time, which could increase patient satisfaction and improve throughput. As such, this study has wide generalizability to community hospitals and other nonacademic medical centers that may not have trainees.

Implementation Research at NHLBI: Methodological and Design Challenges and Lessons Learned from the DECIPHeR Initiative.

NHLBI funded seven projects as part of the Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease Risk (DECIPHeR) Initiative. They were expected to collaborate with community partners to (1) employ validated theoretical or conceptual implementation research frameworks, (2) include implementation research study designs, (3) include implementation measures as primary outcomes, and (4) inform our understanding of mediators and mechanisms of action of the implementation strategy. Several projects focused on late-stage implementation strategies that optimally and sustainably delivered two or more evidence-based multilevel interventions to reduce or eliminate cardiovascular and/or pulmonary health disparities and to improve population health in high-burden communities. Projects that were successful in the three-year planning phase transitioned to a 4-year execution phase. NHLBI formed a Technical Assistance Workgroup during the planning phase to help awardees refine study aims, strengthen research designs, detail analytic plans, and to use valid sample size methods. This paper highlights methodological and study design challenges encountered during this process. Important lessons learned included (1) the need for greater emphasis on implementation outcomes, (2) the need to clearly distinguish between intervention and implementation strategies in the protocol, (3) the need to address clustering due to randomization of groups or clusters, (4) the need to address the cross-classification that results when intervention agents work across multiple units of randomization in the same arm, (5) the need to accommodate time-varying intervention effects in stepped-wedge designs, and (6) the need for data-based estimates of the parameters required for sample size estimation.

Earlier treatment in adults with high lifetime risk of cardiovascular diseases: What prevention trials are feasible and could change clinical practice? Report of a National Heart, Lung, and Blood Institute (NHLBI) Workshop.

More than half of U.S. young adults have low ten-year but high lifetime risk of cardiovascular disease (CVD). Improving primary prevention in young adulthood may help reduce persistent CVD disparities and overall CVD morbidity and mortality. The National Heart, Lung, and Blood Institute (NHLBI) convened a workshop in 2021 to identify potential trial opportunities in CVD prevention in young adults. The workshop identified promising interventions that could be tested, including interventions that focus on a single cardiovascular risk factor (e.g., lipids or inflammation) to multiple risk factor interventions (e.g., multicomponent lifestyle interventions or fixed-low dose combination of medications). Given the sample size and duration for a trial with hard endpoints, more research is needed on the utility of intermediate endpoints identified noninvasively such as subclinical coronary atherosclerosis as a surrogate endpoint. For now, clinical outcomes trials with hard endpoints will more likely change clinical practice. Trial efficiency depends on accurate identification of high-risk young adults, which can potentially be done using traditional risk equations, coronary artery calcium screening, computerized tomography coronary angiography, and polygenic risk scores. Trials in young adults should include enhanced recruitment strategies with intense community engagement to enroll a trial population that is racially, ethnically, geographically, and socially diverse. Despite the challenges in conducting large prevention trials in young adults, recent advances including innovation in clinical trial conduct, new therapies and successful interventions in older populations, and an increasing recognition of a lifespan approach to risk assessment have made such trials more feasible than ever. Disclosures: The views expressed in this manuscript are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute; the National Institutes of Health; or the U.S. Department of Health and Human Services.

National Heart, Lung, and Blood Institute: Social Determinants of Health Research, Fiscal Year 2008-2020.

INTRODUCTION: Social determinants of health influence the prevention, treatment, and progression of chronic diseases, including heart, lung, blood, and sleep diseases and conditions. Healthy People 2020 classifies Social Determinants of Health into 5 subcategories: (1) Neighborhood and Built Environment, (2) Education, (3) Economic Stability, (4) Social and Community Context, and (5) Health and Health Care. This study's goal is to characterize the National Heart, Lung, and Blood Institute's Fiscal Year 2008-2020 funding in overall Social Determinants of Health research and in the Healthy People 2020 subcategories. METHODS: The Social Determinants of Health Research, Condition, and Disease Categorization code was used to identify funded grants in this area. Natural language processing methods further categorized grants into the 5 Healthy People 2020 Social Determinants of Health subcategories. RESULTS: There were 915 (∼4.3%) social determinants of health‒funded grants from 2008 to 2020 representing $1,034 billion in direct costs. Most grants were relevant to cardiovascular diseases (n=653), with a smaller number relevant to lung diseases (n=186), blood diseases (n=47), and translational and implementation science (n=29). Grants fit multiple Social Determinants of Health subcategories with the majority identified as Health and Health Care (62%) and Economic Stability (61%). The number of National Heart, Lung, and Blood Institute social determinants of health grants awarded increased by 127% from Fiscal Year 2008 to Fiscal Year 2020. CONCLUSIONS: This study identifies Social Determinants of Health grants funded by the National Heart, Lung, and Blood Institute during 2008‒2020. Enhancing the understanding of these determinants and developing effective interventions will ultimately help to advance the mission of the National Heart, Lung, and Blood Institute.

Primary Prevention Trial Designs Using Coronary Imaging: A National Heart, Lung, and Blood Institute Workshop.

Coronary artery calcium (CAC) is considered a useful test for enhancing risk assessment in the primary prevention setting. Clinical trials are under consideration. The National Heart, Lung, and Blood Institute convened a multidisciplinary working group on August 26 to 27, 2019, in Bethesda, Maryland, to review available evidence and consider the appropriateness of conducting further research on coronary artery calcium (CAC) testing, or other coronary imaging studies, as a way of informing decisions for primary preventive treatments for cardiovascular disease. The working group concluded that additional evidence to support current guideline recommendations for use of CAC in middle-age adults is very likely to come from currently ongoing trials in that age group, and a new trial is not likely to be timely or cost effective. The current trials will not, however, address the role of CAC testing in younger adults or older adults, who are also not addressed in existing guidelines, nor will existing trials address the potential benefit of an opportunistic screening strategy made feasible by the application of artificial intelligence. Innovative trial designs for testing the value of CAC across the lifespan were strongly considered and represent important opportunities for additional research, particularly those that leverage existing trials or other real-world data streams including clinical computed tomography scans. Sex and racial/ethnic disparities in cardiovascular disease morbidity and mortality, and inclusion of diverse participants in future CAC trials, particularly those based in the United States, would enhance the potential impact of these studies.

Maternal Morbidity and Mortality: Are We Getting to the "Heart" of the Matter?

Cardiovascular disease (CVD), including hypertensive disorders of pregnancy (HDP) and peripartum cardiomyopathy, is a leading cause of pregnancy-related death in the United States. Women who are African American or American Indian/Alaskan Native, have HDP, are medically underserved, are older, or are obese have a major risk for the onset and/or progression of CVD during and after pregnancy. Paradoxically, women with no preexisting chronic conditions or risk factors also experience significant pregnancy-related cardiovascular (CV) complications. The question remains whether substantial physiologic stress on the CV system during pregnancy reflected in hemodynamic, hematological, and metabolic changes uncovers subclinical prepregnancy CVD in these otherwise healthy women. Equally important and similarly understudied is the concept that women's long-term CV health could be detrimentally affected by adverse pregnancy outcomes, such as preeclampsia, gestational hypertension, and diabetes, and preterm birth. Thus, a critical life span perspective in the assessment of women's CV risk factors is needed to help women and health care providers recognize and appreciate not only optimal CV health but also risk factors present before, during, and after pregnancy. In this review article, we highlight new advancements in understanding adverse, pregnancy-related CV conditions and will discuss promising strategies or interventions for their prevention, diagnosis, and treatment.

Health Equity Among Black Women in the United States.

Black women in the United States have experienced substantial improvements in health during the last century, yet health disparities persist. These health disparities are in large part a reflection of the inequalities experienced by Black women on a host of social and economic measures. In this paper, we examine the structural contributors to social and economic conditions that create the landscape for persistent health inequities among Black women. Demographic measures related to the health status and health (in)equity of Black women are reviewed. Current rates of specific physical and mental health outcomes are examined in more depth, including maternal mortality and chronic conditions associated with maternal morbidity. We conclude by highlighting the necessity of social and economic equity among Black women for health equity to be achieved.

Challenges and Opportunities for the Prevention and Treatment of Cardiovascular Disease Among Young Adults: Report From a National Heart, Lung, and Blood Institute Working Group.

Improvements in cardiovascular disease (CVD) rates among young adults in the past 2 decades have been offset by increasing racial/ethnic and gender disparities, persistence of unhealthy lifestyle habits, overweight and obesity, and other CVD risk factors. To enhance the promotion of cardiovascular health among young adults 18 to 39 years old, the medical and broader public health community must understand the biological, interpersonal, and behavioral features of this life stage. Therefore, the National Heart, Lung, and Blood Institute, with support from the Office of Behavioral and Social Science Research, convened a 2-day workshop in Bethesda, Maryland, in September 2017 to identify research challenges and opportunities related to the cardiovascular health of young adults. The current generation of young adults live in an environment undergoing substantial economic, social, and technological transformations, differentiating them from prior research cohorts of young adults. Although the accumulation of clinical and behavioral risk factors for CVD begins early in life, and research suggests early risk is an important determinant of future events, few trials have studied prevention and treatment of CVD in participants <40 years old. Building an evidence base for CVD prevention in this population will require the engagement of young adults, who are often disconnected from the healthcare system and may not prioritize long-term health. These changes demand a repositioning of existing evidence-based treatments to accommodate new sociotechnical contexts. In this article, the authors review the recent literature and current research opportunities to advance the cardiovascular health of today's young adults.

Perceived Discrimination Based on Criminal Record in Healthcare Settings and Self-Reported Health Status among Formerly Incarcerated Individuals.

Perceived discrimination based on criminal record is associated with social determinants of health such as housing and employment. However, there is limited data on discrimination based on criminal record within health care settings. We examined how perceived discrimination based on criminal record within health care settings, among individuals with a history of incarceration, was associated with self-reported general health status. We used data from individuals recruited from 11 sites within the Transitions Clinic Network (TCN) who were released from prison within the prior 6 months, had a chronic health condition and/or were age 50 or older, and had complete information on demographics, medical history, self-reported general health status, and self-reported perceived discrimination (n = 743).Study participants were mostly of minority racial and ethnic background (76%), and had a high prevalence of self-reported chronic health conditions with half reporting mental health conditions and substance use disorders (52% and 50%, respectively), and 85% reporting one or more chronic medical conditions. Over a quarter (27%, n = 203) reported perceived discrimination by health care providers due to criminal record with a higher proportion of individuals with fair or poor health reporting discrimination compared to those in good or excellent health (33% vs. 23%; p = .002). After adjusting for age and reported chronic conditions, participants reporting discrimination due to criminal record had 43% increased odds of reporting fair/poor health (AOR 1.43, 95% CI 1.01-2.03). Race and ethnicity did not modify this relationship.Participants reporting discrimination due to criminal record had increased odds of reporting fair/poor health. The association between perceived discrimination by health care providers due to criminal record and health should be explored in future longitudinal studies among individuals at high risk of incarceration.Clinical Trial Registration: NCT01863290.

Emerging Concepts in Precision Medicine and Cardiovascular Diseases in Racial and Ethnic Minority Populations.

Cardiovascular diseases remain the leading cause of mortality and a major contributor to preventable deaths worldwide. The dominant modifiable risk factors and the social and environmental determinants that increase cardiovascular risk are known, and collectively, are as important in racial and ethnic minority populations as they are in majority populations. Their prevention and treatment remain the foundation for cardiovascular health promotion and disease prevention. Genetic and epigenetic factors are increasingly recognized as important contributors to cardiovascular risk and provide an opportunity for advancing precision cardiovascular medicine. In this review, we explore emerging concepts at the interface of precision medicine and cardiovascular disease in racial and ethnic minority populations. Important among these are the lack of racial and ethnic diversity in genomics studies and biorepositories; the resulting misclassification of benign variants as pathogenic in minorities; and the importance of ensuring ancestry-matched controls in variant interpretation. We address the relevance of epigenetics, pharmacogenomics, genetic testing and counseling, and their social and cultural implications. We also examine the potential impact of precision medicine on racial and ethnic disparities. The National Institutes of Health's All of Us Research Program and the National Heart, Lung, and Blood Institute's Trans-Omics for Precision Medicine Initiative are presented as examples of research programs at the forefront of precision medicine and diversity to explore research implications in minorities. We conclude with an overview of implementation research challenges in precision medicine and the ethical implications in minority populations. Successful implementation of precision medicine in cardiovascular disease in minority populations will benefit from strategies that directly address diversity and inclusion in genomics research and go beyond race and ethnicity to explore ancestry-matched controls, as well as geographic, cultural, social, and environmental determinants of health.

Assessment of Cardiovascular Health among Community-Dwelling Men with Incarceration History.

Returning to the community after incarceration is a particularly vulnerable time with significantly increased risk of death in the first 2 weeks. The elevated risk of death persists as long as 2 years, with cardiovascular disease (CVD) among the leading causes. African-Americans, especially African-American men, have higher rates of incarceration and community supervision (e.g., probation and parole) and an earlier onset of hypertension compared to Whites. Few studies have objectively assessed the cardiovascular health profile of criminal justice involved individuals. This study is designed to determine the cardiovascular health profile among men in community corrections and/or transitional housing, identify the prevalence of key CVD risk factors, and assess if risk varies by race/ethnicity. We recruited 100 adult men (mean age = 42.7, SD = 11.35, 60% White, 40% non-Hispanic White) with a history of incarceration in jail or prison of ≥ 6 months during their most recent incarceration and enrolled in a community corrections program. Using the American Heart Association's Life's Simple 7™ (LS-7), measures of each of the LS-7 components (body mass index, blood pressure, lipids, blood glucose, smoking, diet, and physical activity) were obtained, and LS-7 scores were generated for each measure using AHA-defined categories of poor (1 point), intermediate (2 points), and ideal (3 points) and summed to yield a total score ranging from poor for all (7 points) to ideal for all (21 points). Mann-Whitney U tests were performed to assess differences in LS-7 scores (poor, intermediate, ideal) by race/ethnicity. Additionally, an independent samples t test was conducted for race/ethnicity and LS-7 total score. Mann-Whitney U tests for LS-7 categories and race/ethnicity indicated a greater number of non-Whites had poor blood pressure (p < .01) and diet (p < .05) as compared to Whites. The independent samples t test demonstrated significantly lower LS-7 scores for non-Whites compared to Whites. To our knowledge, this is the first study to evaluate cardiovascular health among individuals with a history of incarceration using the LS-7 metric, which included objective measures for four of the seven LS-7 metrics. Non-Whites, which included African-Americans, Hispanics, and American Indians, were more likely than Whites to fall into the poor category for both diet and blood pressure and had significantly lower total LS-7 scores than Whites, indicating they have worse scores across all seven of the LS-7 measures. Similar to what is found among non-incarcerated samples, non-Whites with incarceration histories are at elevated risk for cardiovascular events relative to their White peers.

Stress and Achievement of Cardiovascular Health Metrics: The American Heart Association Life's Simple 7 in Blacks of the Jackson Heart Study.

BACKGROUND: Ideal cardiovascular health metrics (defined by the American Heart Association Life's Simple 7 [LS7]) are suboptimal among blacks, which results in high risk of cardiovascular disease. We examined the association of multiple stressors with LS7 components among blacks. METHODS AND RESULTS: Using a community-based cohort of blacks (N=4383), we examined associations of chronic stress, minor stressors, major life events, and a cumulative stress score with LS7 components (smoking, diet, physical activity, body mass index, blood pressure, total cholesterol, and fasting plasma glucose) and an LS7 composite score. Multivariable logistic regression assessed the odds of achieving intermediate/ideal levels of cardiovascular health adjusted for demographic, socioeconomic, behavioral, and biomedical factors. The LS7 components with the lowest percentages of intermediate/ideal cardiovascular health levels were diet (39%), body mass index (47%), and physical activity (51%). Higher chronic, minor, and cumulative stress scores were associated with decreased odds (odds ratio [OR]) of achieving intermediate/ideal levels for smoking (OR [95% confidence interval], 0.80 [0.73-0.88], 0.84 [0.75-0.94], and 0.81 [0.74-0.90], respectively). Participants with more major life events had decreased odds of achieving intermediate/ideal levels for smoking (OR, 0.84; 95% confidence interval, 0.76-0.92) and fasting plasma glucose (OR, 0.90; 95% confidence interval, 0.82-0.98). Those with higher scores for minor stressors and major life events were less likely to achieve intermediate or ideal LS7 composite scores (OR [95% confidence interval], 0.89 [0.81-0.97] and 0.91 [0.84-0.98], respectively). CONCLUSIONS: Blacks with higher levels of multiple stress measures are less likely to achieve intermediate or ideal levels of overall cardiovascular health (LS7 composite score), specific behaviors (smoking), and biological factors (fasting plasma glucose).

Reducing Cardiovascular Disparities Through Community-Engaged Implementation Research: A National Heart, Lung, and Blood Institute Workshop Report.

Cardiovascular disparities remain pervasive in the United States. Unequal disease burden is evident among population groups based on sex, race, ethnicity, socioeconomic status, educational attainment, nativity, or geography. Despite the significant declines in cardiovascular disease mortality rates in all demographic groups during the last 50 years, large disparities remain by sex, race, ethnicity, and geography. Recent data from modeling studies, linked micromap plots, and small-area analyses also demonstrate prominent variation in cardiovascular disease mortality rates across states and counties, with an especially high disease burden in the southeastern United States and Appalachia. Despite these continued disparities, few large-scale intervention studies have been conducted in these high-burden populations to examine the feasibility of reducing or eliminating cardiovascular disparities. To address this challenge, on June 22 and 23, 2017, the National Heart, Lung, and Blood Institute convened experts from a broad range of biomedical, behavioral, environmental, implementation, and social science backgrounds to summarize the current state of knowledge of cardiovascular disease disparities and propose intervention strategies aligned with the National Heart, Lung, and Blood Institute mission. This report presents the themes, challenges, opportunities, available resources, and recommended actions discussed at the workshop.

Designing Faith-Based Blood Pressure Interventions to Reach Young Black Men.

INTRODUCTION: This community-based participatory research pilot study explored multilevel perceptions and strategies for developing future faith-based organization blood pressure interventions for young black men. METHODS: Community partners recruited the sample through two, southeastern U.S. urban churches as potential intervention hubs; academic partners conducted phone interviews with church leader key informants, and three focus groups with black men aged 18-50 years. Qualitative content analysis helped generate themes from: key informant questions assessing organizational assets and capacities, and factors influencing participation; and focus group questions assessing lifestyle and self-management behaviors. Questions assessing themes on blood pressure intervention strategies were asked. Data were collected in 2016 and analyzed in 2016-2017. RESULTS: The sample included 21 key informants and 19 young black men. Key informants' leadership experience averaged 16.6 (SD=12.1) years and 28.6% were male. Focus group participants were primarily single (55.6%), college educated (61.1%), and employed (77.8%). Mean blood pressure was 131.1 (SD=15.3)/79.5 (SD=11.2) mmHg, 33.3% self-reported having hypertension, 88.9% report a family history of hypertension, and 88.9% see a provider annually. For key informants, young black men lack understanding of hypertension despite available resources, and pastors are important role models and advocates. For focus group participants, hidden sodium and stressful, busy schedules impact lifestyle behaviors; and church support for busy schedules are important. Common strategies included incentive-laden, activity-integrated programs, and male social context (testimonials, peer mentoring, engagement outside of the church). CONCLUSIONS: Findings and lessons learned will help design future community-based participatory research, faith-based organization-led blood pressure interventions relevant to young black men. SUPPLEMENT INFORMATION: This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health.

Development of a Multifaceted Health Disparities Curriculum for Medical Residents.

BACKGROUND AND OBJECTIVES: Health disparities education is required during residency training. However, residency program directors cite numerous barriers to implementing disparities curricula, and few publications describing successful disparities curricula exist in the literature. In this report, we describe the development, implementation, and early evaluation of a longitudinal health disparities curriculum for resident physicians. We provide resource references, process, and didactic toolkits to facilitate use by other residency programs. METHODS: We used a standard, six-step model for curricular design, implementation, and evaluation. We assessed feasibility of curricular development including practicality (program cost and time requirements) and demand (resident engagement). We also assessed program and learner outcomes, including number of didactic and clinic sessions delivered and resident preparedness, attitudes, and skill in caring for vulnerable patients. RESULTS: We designed, implemented, and evaluated our curriculum in less than 1 year, with no external funding. Time costs included 100 chief resident and 20 faculty hours for curricular development, followed by 20 chief resident and 16 faculty hours for implementation. In the first year of our curriculum, 21% of residents (16 of 75) participated. We created eight didactic sessions and delivered four as intended. Residents provided 84 free clinic sessions for uninsured patients and reported increased preparedness and skill caring for vulnerable patients in 15 of 20 measured domains. Residents also reported 20 commitments to change on themes that comprehensively reflected the content of our first curricular year. CONCLUSIONS: It is possible to design a disparities curriculum, overcome cited barriers, and improve educational outcomes related to the care of vulnerable patients.

Cardiovascular Disease in Incarcerated Populations.

Currently, 2.2 million individuals are incarcerated, and more than 11 million have been released from U.S. correctional facilities. Individuals with a history of incarceration are more likely to be of racial and ethnic minority populations, poor, and have higher rates of cardiovascular risk factors, especially smoking and hypertension. Cardiovascular disease is a leading cause of death among incarcerated individuals, and those recently released have a higher risk of being hospitalized and dying of cardiovascular disease compared with the general population, even after accounting for differences in racial identity and socioeconomic status. In this review, the authors: 1) present information on the cardiovascular health of justice-involved populations, and unique prevention and care conditions in correctional facilities; 2) identify knowledge gaps; and 3) propose promising areas for research to improve the cardiovascular health of this population. An Executive Summary of a National Heart, Lung, and Blood Institute workshop on this topic is available.

Physical Activity and Incident Hypertension in African Americans: The Jackson Heart Study.

There is limited empirical evidence to support the protective effects of physical activity in the prevention of hypertension among African Americans. The purpose of this study was to examine the association of physical activity with incident hypertension among African Americans. We studied 1311 participants without hypertension at baseline enrolled in the Jackson Heart Study, a community-based study of African Americans residing in Jackson, Mississippi. Overall physical activity, moderate-vigorous physical activity, and domain-specific physical activity (work, active living, household, and sport/exercise) were assessed by self-report during the baseline examination (2000-2004). Incident hypertension, assessed at examination 2 (2005-2008) and examination 3 (2009-2013), was defined as the first visit with systolic/diastolic blood pressure ≥140/90 mm Hg or self-reported antihypertensive medication use. Over a median follow-up of 8.0 years, there were 650 (49.6%) incident hypertension cases. The multivariable-adjusted hazard ratios (95% confidence interval) for incident hypertension comparing participants with intermediate and ideal versus poor levels of moderate-vigorous physical activity were 0.84 (0.67-1.05) and 0.76 (0.58-0.99), respectively (P trend=0.038). A graded, dose-response association was also present for sport/exercise-related physical activity (Quartiles 2, 3, and 4 versus Quartile 1: 0.92 [0.68-1.25], 0.87 [0.67-1.13], 0.75 [0.58-0.97], respectively; P trend=0.032). There were no statistically significant associations observed for overall physical activity, or work, active living, and household-related physical activities. In conclusion, the results of the current study suggest that regular moderate-vigorous physical activity or sport/exercise-related physical activity may reduce the risk of developing hypertension in African Americans.

Effects of Concurrent Depressive Symptoms and Perceived Stress on Cardiovascular Risk in Low- and High-Income Participants: Findings From the Reasons for Geographical and Racial Differences in Stroke (REGARDS) Study.

BACKGROUND: Psychosocial risk for cardiovascular disease (CVD) may be especially deleterious in persons with low socioeconomic status. Most work has focused on psychosocial factors individually, but emerging research suggests that the confluence of psychosocial risk may be particularly harmful. Using data from the Reasons for Geographical and Racial Differences in Stroke (REGARDS) study, we examined associations among depressive symptoms and stress, alone and in combination, and incident CVD and all-cause mortality as a function of socioeconomic status. METHODS AND RESULTS: At baseline, 22 658 participants without a history of CVD (58.8% female, 41.7% black, mean age 63.9±9.3 years) reported on depressive symptoms, stress, annual household income, and education. Participants were classified into 1 of 3 psychosocial risk groups at baseline: (1) neither depressive symptoms nor stress, (2) either depressive symptoms or stress, or (3) both depressive symptoms and stress. Cox proportional hazards models were used to predict physician-adjudicated incident total CVD events (nonfatal myocardial infarction, nonfatal stroke, and cardiovascular death) and all-cause mortality over a median of 7.0 years (interquartile range 5.4-8.3 years) of follow-up. In fully adjusted models, participants with both depressive symptoms and stress had the greatest elevation in risk of developing total CVD (hazard ratio 1.48, 95% CI 1.21-1.81) and all-cause mortality (hazard ratio 1.33, 95% CI 1.13-1.56) but only for those with low income (<$35 000) and not high (≥$35 000) income. This pattern of results was not observed in models stratified by education. CONCLUSIONS: Findings suggest that screening for a combination of elevated depressive symptoms and stress in low-income persons may help identify those at increased risk of incident CVD and mortality.