Tené T. Lewis

Background: Young and middle‐aged women with ischemic heart disease have a higher burden of psychosocial factors compared with male counterparts. They also have worse morbidity and mortality, despite less atherosclerotic burden. Data on daily life stress and autonomic physiology could help guide targeted interventions. Methods: We studied 302 individuals ≤61 years of age recently hospitalized for a myocardial infarction. All underwent a 7‐day home monitoring of mood and stress using ecological momentary assessments, with concomitant Holter monitoring for autonomic physiology. Deceleration capacity, a prognostic marker of parasympathetic activity, was the primary autonomic outcome; heart rate variability was also examined. Results: The sample was 43% women with mean age of 51 years (SD, 7 years). Across the week of monitoring, women reported higher levels of negative mood and stress than men. Women also exhibited significantly lower parasympathetic activity (daily average of deceleration capacity) than men; heart rate variability was also lower. Among women, daily negative mood was inversely associated with lower deceleration capacity: for each 1‐log unit higher daily negative mood score, deceleration capacity declined 4.5% in women, but among men, the difference was close to zero: 0.5% ( P =0.02 for interaction). Adjustment for other risk factors did not materially affect the associations. A similar pattern of results was observed for heart rate variability metrics. Conclusions: Young and middle‐aged women who recently survived a myocardial infarction have more parasympathetic withdrawal than men in daily life, especially during moments of negative mood. These results underscore the need for greater attention to psychosocial management in women after myocardial infarction.

Background: Women with premature myocardial infarction (MI) have worse outcomes than similarly aged men despite less severe disease, and stress-related factors have been implicated. We examined sex differences in the association of mental stress-induced myocardial ischemia (MSIMI) with cardiovascular outcomes after premature MI and explored vascular and inflammatory mechanisms. Methods: We studied 602 individuals (mean age 51 years; 46% women) within 8 months of MI who underwent 99mTc-sestamibi myocardial perfusion imaging at rest and after mental stress. MSIMI was defined as a summed difference score ≥3. We measured reactive hyperemia index (RHI) as peripheral microvascular reactivity to stress and interleukin-6 (IL-6) as inflammatory response to stress. The primary endpoint was cardiovascular death or nonfatal MI; the secondary endpoint added heart failure hospitalization. Cox proportional hazards models adjusted for sociodemographic factors, clinical, and psychiatric history. Results: MSIMI was more common in women than men (19.2% vs. 13.2%, p=0.04). Over a median follow-up of 34.2 months, 51 primary and 91 secondary endpoint events occurred. The hazard ratio (HR) of MSIMI for the primary endpoint was 3.2 (95% CI, 1.3, 7.6) in women and 1.9 (95% CI, 0.8, 4.5) in men (p for interaction=0.41), which remained similar after multivariable adjustment. The adjusted population attributable fraction was 27.6% (99% CI, 3.9%, 36.9%) in women and 11.1% (95% CI, −5.8%, 18.4%) in men. In exploratory analyses, all MSIMI-related primary endpoint events among women occurred in Black women (HR, 4.3; 95% CI, 1.7–11.1). Associations with the secondary endpoint were weaker and attenuated after adjustment. IL-6 and RHI responses did not attenuate associations. Conclusions: Among women, MSIMI was associated with about threefold increased risk and over one quarter attributable fraction for cardiovascular death or nonfatal MI. Black women were at especially high risk. While larger studies are warranted to confirm sex differences and explore mechanisms, these data underscore the impact of emotional factors on morbidity and mortality in post-MI women.

Background: Information is lacking about everyday psychological states of individuals with a recent myocardial infarction (MI) and whether they influence outcomes. We investigated real world psychological experiences and their association with subsequent cardiovascular events in survivors of an MI. Methods: We studied 287 individuals ≤ 60 years of age within 8 months from an MI. At the baseline visit, we assessed sociodemographic and clinical factors, and administered a battery of psychological scales of depression, anxiety, anger, perceived stress and social support. Participants underwent a 7-day home monitoring of mood and stress using ecological momentary assessments, and a momentary negative affect (MNA) score, integrating daily mean ratings of sadness, anxiety, anger, distress and loneliness, was calculated. Participants were followed for a median time of 28 months. The study endpoint was a composite index of major adverse cardiovascular events (MACE), including cardiovascular death, nonfatal MI, stroke or hospitalizations for heart failure. Cox proportional hazards models adjusted for sociodemographic and clinical factors. Results: The mean age of the sample was 51 years, and 43% of participants were women. Each standard deviation increase in MNA was significantly associated with a 60% increased risk of MACE (95% confidence interval (CI), 20% to 100%), irrespective of adjustment for sociodemographic factors and clinical characteristics. The association was similar in women and men. Momentary positive mood and momentary perceived stress were not associated with MACE. The MNA score showed a larger independent contribution to MACE compared to the combined battery of baseline psychological assessments and the association was independent of baseline history of depression. Conclusion: Among individuals after MI, moment-to-moment negative affect during one week of monitoring in daily life is a powerful predictor of subsequent cardiovascular events. A prospective evaluation of negative mood during everyday living could represent a novel strategy to uncover residual risk after MI.

Background: Rates of atrial fibrillation (AF) are lower in Black compared to White Americans. Socioeconomic disadvantage and reduced healthcare access may contribute to lower observed AF incidence in Black populations due to underdiagnosis and underascertainment. Therefore, we evaluated the association of socioeconomic status and healthcare access with AF incidence in a cohort of Black Americans. Methods: 3,240 participants from the Jackson Heart Study, which recruited Black adults from the Jackson metropolitan area in 2000-2004, were followed up through 2016 for incident AF. Socioeconomic position (education and income) and healthcare access (insurance status, difficulty obtaining care, trust in providers, and satisfaction with care) were assessed at baseline. AF was ascertained from study electrocardiograms at baseline and exam 3 and self-reported physician diagnosis at annual follow-up surveys. Multivariable Cox regression was used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the association between exposure variables and AF incidence adjusting for potential confounders. Results: During a mean follow-up of 11.5 years, 817 incident AF cases were identified. Higher educational attainment and income were associated with a reduced risk of AF. Compared with participants who had less than a high school education, those who attended trade or vocational school or college had an 18% lower estimated hazard of AF (HR 0.82, 95% CI 0.67, 1.02). Likewise, participants in the highest income category had a 39% lower estimated hazard of AF (HR 0.61, 95% CI 0.47, 0.78) compared with those in the lowest. Easier access to healthcare and greater satisfaction with received healthcare were also associated with lower AF risk. Conclusion: Higher socioeconomic status and better healthcare access were associated with lower risk of AF in a cohort of Black Americans. These findings do not support a simple explanation in which socioeconomic disadvantage and poorer healthcare access lead to lower observed AF incidence through underascertainment within Black adults.

BACKGROUND: Historical redlining may contribute to racial inequities in cardiovascular health. Longitudinal studies are needed to investigate the influence of historical redlining on blood pressure (BP) and its changes over time, and to understand the role contemporary residential segregation plays in this relationship. METHODS: Using the MESA (Multi-Ethnic Study of Atherosclerosis), this study examined associations between redlining, measured using 1930s Home Owners’ Loan Corporation grades, and repeated BP measures. We used race/ethnicity-stratified 3-level mixed-effects models to assess associations between redlining and average BP, as well as changes in BP, across 6 follow-up examinations from 2000 to 2018, accounting for time-varying sociodemographic and health factors. RESULTS: The sample included 4774 adults with a mean baseline age of 61.9 years; the racial/ethnic composition was 26.7% Black, 23.9% Hispanic, 13.3% Chinese, and 36.1% White. Independent of sociodemographic factors, Black participants in redlined neighborhoods graded D had 7.26 mm Hg higher average systolic BP (95% CI, 0.99–13.54) and 3.62 mm Hg higher average diastolic BP (95% CI, 0.64–6.60), compared with those in non-redlined tracts graded A . Contemporary residential segregation modified this association such that the increase was larger in currently segregated Black neighborhoods. When assessing BP changes, we found that the difference in systolic BP for participants in D -graded neighborhoods decreased among Black participants over follow-up. There was no statistically significant association with average BP or BP changes in other racial/ethnic groups. CONCLUSIONS: These findings demonstrated that historical discriminatory policies may have a harmful impact on BP outcomes among Black adults in the United States.

Objective: African American women experience disproportionate cardiovascular disease risk, and altered central hemodynamics signal early vascular aging. For African American mothers, concern about their children’s exposure to racism represents a salient psychosocial stressor, but its vascular consequences are unclear. We examined whether greater racism‑related Concern for Children (CFC) was associated with adverse longitudinal changes in central hemodynamics. Methods: African American mothers aged 30-46 years ( n =236) underwent assessments of central systolic blood pressure (cSBP), augmentation index (AIx), pulse pressure amplification (PPA), and pulse wave velocity (PWV; n =205) at baseline and 4±1 years later. CFC was measured continuously (range 0-24) and categorically (high vs. low). Multivariable linear regression models examined associations between CFC and changes in central hemodynamics, adjusting for baseline values and sociodemographic, clinical, and psychosocial covariates. Logistic regression evaluated CFC and odds of newly developed high‑risk PPA (PPAP =0.002). At follow‑up, women with high CFC had AIx values 3.9 percentage points higher than those with low CFC ( P =0.005). CFC was also associated with declining PPA (b=‑0.003, 95% CI [‑0.005, ‑0.001]; P =0.024) and greater odds of newly developed high‑risk PPA (OR=1.08, 95% CI [1.01, 1.15]; P =0.033). No associations were observed for cSBP or PWV. Conclusions: Greater racism‑related concern for children is associated with signs of early vascular aging in African American mothers, highlighting the cardiovascular consequences of racism‑related maternal stress.

Background: Stark disparities in the outcome of myocardial infarction (MI) persist, with large unexplained variations affecting younger Black women. Mental stress–induced myocardial ischemia (MSIMI) is an emerging mechanistic pathway that may help explain excess risks in this group. We sought to determine whether MSIMI is more common in Black women with recent premature MI than other demographic groups. Methods: We cross‐sectionally studied 602 individuals 61 years and younger who were hospitalized for MI in the previous 8 months. Participants underwent 99mTc‐sestamibi myocardial perfusion imaging at rest and after mental stress (speech task). A summed difference score was used to quantify ischemia. Clinically significant MSIMI was defined as a summed difference score ≥3. Log‐binomial and robust Poisson regression were used to adjust for sociodemographic, lifestyle, clinical, and psychosocial factors. Results: The mean age of patients was 51 years (range, 25–61 years), 46% were women, and 59% self‐identified as Black. Black women had a more adverse psychosocial profile and higher rates of obesity and diabetes but a less severe index MI. The incidence of MSIMI was approximately doubled in Black women than the other groups ( P <0.001 for interaction). Clinical and psychosocial risk factors did not explain these differences. In a fully adjusted model, the risk ratio of MSIMI for Black women was 2.2 (95% CI, 2.0–2.5) compared with Black men, 2.3 (95% CI, 1.8–2.9) compared with non‐Black women, and 1.8 (95% CI, 1.4–2.2) compared with non‐Black men. Conclusions: Among midlife individuals with a recent MI, Black women have a disproportionately higher risk of MSIMI. Targeted interventions for this high‐risk group are needed.

Background: Previous research has shown an association between neighbourhood context and adverse birth outcomes, but with high heterogeneity. Objective: To examine the degree to which social support buffers against the adverse effects of neighbourhood deprivation on preterm birth and small for gestational age (SGA). Methods: This study is a secondary analysis of data from the nuMoM2b (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers‐To‐Be) longitudinal cohort study, which recruited participants between 2010 and 2013. We estimated prevalence differences (PD) for area deprivation index (ADI) and for social support with each adverse birth outcome, and we evaluated whether the effect of ADI was modified by perceived social support; we additionally stratified by race/ethnicity. All models were adjusted for maternal age and education. Results: Our analytic sample included n = 8377 participants. Among the birth outcomes we investigated, high social support had the strongest association with preterm birth. Participants reporting high social support had three fewer cases of preterm birth per 100 pregnancies (PD = −0.03, 95% CI −0.05, 0.00), compared to participants reporting low or moderate social support. The only evidence of high social support buffering against the harmful effects of neighbourhood deprivation was seen with SGA. Among participants with low or moderate social support, a 25‐percentile increase in ADI was associated with two excess cases of SGA per 100 pregnancies (PD = 0.02, 95% CI −0.01, 0.04); whereas among participants with high social support, there was a null effect (PD = 0.00, 95% CI −0.01, 0.01). This effect modification was seen mostly among non‐Hispanic White individuals. Conclusion: Social support might offer some protection against the effects of neighbourhood deprivation on SGA, perhaps more so for non‐Hispanic White people. However, we did not find evidence of social support buffering against the effects of neighbourhood deprivation on preterm birth.