Raegan. W. Durant

BACKGROUND: Increased burden of socially determined vulnerabilities (SDV), which include nonmedical conditions that contribute to patient health, is associated with incident heart failure (HF). Mediators of this association have not been examined. We aimed to determine if a healthy lifestyle mediates the association between SDV and HF. METHODS: We included adults aged 45 to 64 years old across the United States from the REGARDS cohort study (Reasons for Geographic and Racial Differences in Stroke) without evidence of HF at baseline. The primary exposure was a count of SDV based on the Healthy People 2030 framework. The primary outcome was incident HF. We assessed the role of a healthy behavior score (HBS range, 0–8) and its components (adherence to a Mediterranean diet, physical activity, lack of sedentary lifestyle, and smoking abstinence) as potential mediators of the association between SDV and incident HF. RESULTS: We included 13 on 525 participants. The median HBS was 4, with 16% with low HBS (0–2), 55% with moderate HBS (3–5), and 29% with high HBS (6–8). Increasing burden of SDV was associated with a stepwise increase in incident HF (adjusted hazard ratio, 1.84 [95% CI, 1.32–2.52] for 1 SDV, 2.59 [95% CI, 1.87–3.60] for 2 SDV, and 4.20 [95% CI, 3.08–5.73] for ≥3 SDV). There was no statistically significant mediation of HBS for the association of SDV count of 1 and incident HF. HBS score mediated 10.6% of the association between SDV count of 2 and incident HF and 11.1% of the association for those with ≥3 SDV. This increased to 10.8% and 18.3%, respectively, in the complete case analysis. Regarding individual components of HBS as mediators, only avoidance of a sedentary lifestyle was statistically significant (8.6% mediation) for the association of SDV count of 2 and incident HF. CONCLUSIONS: A healthy lifestyle plays a small role in mediating the association between high SDV count and incident HF.

Background: Cognitive impairment is common among adults with heart failure (HF) and associated with poor outcomes. However, less is known about the trajectory of cognitive decline after a first HF hospitalization. We examined the rate of cognitive decline among adults with incident HF hospitalization compared with those without HF hospitalization. Methods and Results: The REGARDS (Reasons for Geographic and Racial Differences in Stroke) study is a prospective longitudinal study of 23 894 participants aged ≥45 years free of HF at baseline. HF hospitalization was expert adjudicated. Changes in global cognitive function (primary outcome) were assessed with the Six‐Item Screener (range, 0–6). Secondary outcomes included change in Word List Learning (range, 0–30), Word List Delayed Recall (WLD; range, 0–10), and Animal Fluency Test (range, 0+). Segmented linear mixed‐effects regression models were used. Over 5 years, mean scores across all 4 cognitive tests declined for all participants regardless of HF status. Those with incident HF hospitalization experienced faster declines in the Six‐Item Screener versus those who were HF free (difference, −0.031 [95% CI, −0.047 to −0.016]; P <0.001), a finding that persisted in fully adjusted models. Those with incident HF hospitalization did not experience faster declines in Word List Learning, Word List Delayed Recall, or Animal Fluency Test scores compared with those without HF hospitalization. Participants with hospitalization for HF with preserved, compared with reduced, ejection fraction had faster decline in Animal Fluency Test. Conclusions: Global cognitive decline occurred faster among adults with incident HF hospitalization compared with those who remained free of HF hospitalization. This pattern was not seen for the other cognitive domains.

Background Among individuals with heart failure (HF), racial differences in comorbidities may be mediated by social determinants of health (SDOH). Methods Black and White US community-dwelling participants in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study aged ≥ 45 years with an adjudicated HF hospitalization between 2003 and 2017 were included in this cross-sectional analysis. We assessed whether higher prevalence of comorbidities in Black participants compared to White participants were mediated by SDOH in socioeconomic, environment/housing, social support, and healthcare access domains, using the inverse odds weighting method. Results Black (n = 240) compared to White (n = 293) participants with HF with preserved ejection fraction (HFpEF) had higher prevalence of diabetes [1.38 (95% CI 1.18–1.61)], chronic kidney disease [1.21 (95% CI 1.01–1.45)], and anemia [1.33 (95% CI 1.02–1.75)] and lower prevalence of atrial fibrillation [0.80 (95% CI (0.65–0.98)]. Black (n = 314) compared to White (n = 367) participants with HF with reduced ejection fraction (HFrEF) had higher prevalence of hypertension [1.04 (95% CI 1.02–1.07)] and diabetes [1.26 (95% CI 1.09–1.45)] and lower prevalence of coronary artery disease [0.86 (95% CI 0.78–0.94)] and atrial fibrillation [0.70 (95% CI 0.58–0.83)]. Socioeconomic status explained 14.5%, 26.5% and 40% of excess diabetes, anemia, and chronic kidney disease among Black adults with HFpEF; however; mediation was not statistically significant and no other SDOH substantially mediated differences in comorbidity prevalence. Conclusions Socioeconomic status partially mediated excess diabetes, anemia, and chronic kidney disease experienced by Black adults with HFpEF, but differences in other comorbidities were not explained by other SDOH examined.

Background: Self‐care for adults with hypertension includes adherence to lifestyle behaviors and medication. For unpaid caregivers with hypertension, the burden of family caregiving may adversely impact self‐care. We examined the association between caregiver strain and hypertension self‐care among caregivers with hypertension. Methods and Results: We included participants of the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study who identified as caregivers and had hypertension. Caregiver strain, assessed by self‐report, was categorized as “none/some” or “high.” Hypertension self‐care was assessed individually across 5 domains (Dietary Approaches to Stop Hypertension [DASH] diet, physical activity, alcohol use, cigarette smoking, and medication adherence) and a composite self‐care score summing performance across them. The association between caregiver strain and hypertension self‐care was examined with multivariable linear regression. Among the 2128 caregivers with hypertension, 18.1% reported high caregiver strain. Caregivers with high strain versus those with none/some were less adherent to the DASH diet (50.8% versus 38.9%, P P P P <0.001). In an age‐adjusted model, high caregiver strain was associated with worse hypertension self‐care (β=−0.37 [95% CI, −0.61 to −0.13]); this remained significant but was reduced in magnitude after adjustment for sociodemographics (β=−0.35 [−0.59 to −0.11]), comorbidities (β=−0.34 [−0.57 to −0.10]), caregiving intensity (β=−0.34 [−0.59 to 0.10]), and psychological factors (β=−0.26 [−0.51 to 0.00]). Conclusions: High caregiver strain was associated with worse hypertension self‐care overall and across individual domains. Increased awareness of caregiver strain and its potential impact on hypertension self‐care is warranted.

Past state-sponsored precollege school segregation in the US has been directly associated with adult health outcomes, including cognition, cardiovascular

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Background: Sudden cardiac death (SCD) is a common cause of death in the United States. Few previous studies have investigated the associations of diet scores and dietary patterns with risk of SCD. We investigated the associations of the Mediterranean diet score and various dietary patterns with risk of SCD in participants in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study cohort. Methods and Results: Diet was assessed with a food frequency questionnaire administered at baseline in REGARDS. The Mediterranean diet score was derived based on the consumption of specific food groups considered beneficial or detrimental components of that diet. Dietary patterns were derived previously using factor analysis, and adherence to each pattern was scored. SCD events were ascertained through regular contacts. Cox proportional hazards regression was used to examine the risk of SCD events associated with the Mediterranean diet score and adherence to each of the 5 dietary patterns overall and stratifying on history of coronary heart disease at baseline. The analytic sample included 21 069 participants with a mean 9.8±3.8 years of follow‐up. The Mediterranean diet score showed a trend toward an inverse association with risk of SCD after multivariable adjustment (hazard ratio [HR] comparing highest with lowest group, 0.74; 95% CI, 0.55–1.01; P _trend =0.07). There was a trend toward a positive association of the Southern dietary pattern with risk of SCD (HR comparing highest with lowest quartile of adherence, 1.46; 95% CI, 1.02–2.10; P _trend =0.06). Conclusions: In REGARDS participants, we identified trends toward an inverse association of the Mediterranean diet score and a positive association of adherence to the Southern dietary pattern with risk of SCD.