The American Heart Association (AHA) recently developed the Cardiovascular Health Index (CVHI), a health metric consisting of 7 modifiable risk factors. The relationship of the CVHI with preclinical markers, such as carotid intima-media thickness (CIMT) has not been assessed. We examined 490 male monozygotic and dizygotic twins without overt cardiovascular disease. CIMT was measured using B-mode ultrasonography. Each of the 7 CVHI components (blood pressure, fasting glucose, total cholesterol, body mass index, physical activity, healthy diet, and smoking) was given a point score of 0, 1, or 2 to represent poor, intermediate, or ideal health, respectively. A CVHI summation score was computed (range 0 to 14) and categorized as inadequate (0 to 4), average (5 to 9), or optimum (10 to 14) cardiovascular health. Mixed-model regression was used to examine the association of the CVHI with CIMT. The mean age of the twins was 55.4 years, and 61% were monozygotic. The mean CIMT was 0.75 (± 0.11) mm and the mean CVHI score was 7.7 (± 2.1). There was an inverse correlation between CVHI and CIMT (Spearman r=-0.22, P<0.01). For every 5-unit increase in overall CVHI score (indicating better cardiovascular health category), CIMT decreased by 0.045 mm (P<0.001) after adjusting for demographic variables and other confounders. Within monozygotic twin pairs, a 5-unit increment in CVHI score was associated with a 0.05 mm lower CIMT (P<0.001). The CVHI is independently associated with CIMT and the association is not confounded by shared genetic and other familial factors.

Background This study describes the patterns and socioeconomic influences of tobacco use among adults in tobacco-cultivating regions of rural southwest China. Methods A cross-sectional survey was conducted in 8681 adults aged ≥18 years in rural areas of Yunnan Province, China from 2010 to 2011. A standardized questionnaire was administered to obtain data about participants’ demographic characteristics, individual socioeconomic status, ethnicity, self-reported smoking habits, and exposure to secondhand smoke (SHS). The socioeconomic predictors of current smoking, nicotine addiction, and SHS exposure were analyzed using multivariate logistic regression. Results The prevalence rates of tobacco use were much higher in men compared with women (current smoking 68.5% vs. 1.3%; and nicotine dependence 85.2% vs. 72.7%). However, the rate of SHS exposure was higher in women compared with men (76.6% vs. 70.5%). Tobacco farmers had higher prevalence rates of current smoking, nicotine dependence, and SHS exposure compared with participants not engaged in tobacco farming (P<0.01). Most tobacco users (84.5%) reported initiating smoking during adolescence. A total of 81.1% of smokers smoked in public places, and 77.6% smoked in workplaces. Individuals belonging to an ethnic minority had a lower probability of SHS exposure and nicotine dependence. Individual educational level was found to be inversely associated with the prevalence of current smoking, exposure to SHS, and nicotine dependence. Higher annual household income was associated with a greater risk of nicotine dependence. Conclusions This study suggests that tobacco control efforts in rural southwest China must be tailored to address tobacco-cultivating status and socioeconomic factors.

Background-Previous studies suggest that among patients with stable coronary artery disease, patients with diabetes mellitus (DM) have less angina and more silent ischemia when compared with those without DM. However, the burden of angina in diabetic versus nondiabetic patients after elective percutaneous coronary intervention (PCI) has not been recently examined. Methods and Results-In a 10-site US PCI registry, we assessed angina before and at 1, 6, and 12 months after elective PCI with the Seattle Angina Questionnaire angina frequency score (range, 0-100, higher=better). We also examined the rates of antianginal medication prescriptions at discharge. A multivariable, repeated-measures Poisson model was used to examine the independent association of DM with angina over the year after treatment. Among 1080 elective PCI patients (mean age, 65 years; 74.7% men), 34.0% had DM. At baseline and at each follow-up, patients with DM had similar angina prevalence and severity as those without DM. Patients with DM were more commonly prescribed calcium channel blockers and long-Acting nitrates at discharge (DM versus not: 27.9% versus 20.9% [P=0.01] and 32.8% versus 25.5% [P=0.01], respectively), whereas β-blockers and ranolazine were prescribed at similar rates. In the multivariable, repeated-measures model, the risk of angina was similar over the year after PCI in patients with versus without DM (relative risk, 1.04; range, 0.80-1.36). Conclusions-Patients with stable coronary artery disease and DM exhibit a burden of angina that is at least as high as those without DM despite more antianginal prescriptions at discharge. These findings contradict the conventional teachings that patients with DM experience less angina because of silent ischemia.

BACKGROUND: Patients with obstructive (≥50% stenosis) left main (LM) coronary artery disease (CAD) are at high risk for adverse events; prior studies have also documented worse outcomes among women than men with severe multivessel/LM CAD. However, the prognostic significance of nonobstructive (1%-49% stenosis) LM CAD, including sex-specific differences, has not been previously examined.METHODS AND RESULTS: In the long-term CONFIRM (Coronary CT Angiography Evaluation For Clinical Outcomes: An International Multicenter) registry, patients underwent elective coronary computed tomographic angiography for suspected CAD and were followed for 5 years. After excluding those with obstructive LM CAD, 5166 patients were categorized as having normal LM or nonobstructive LM (18% of cohort). Cumulative 5-year incidence of death, myocardial infarction, or revascularization was higher among patients with nonobstructive LM than normal LM in both women and men: women (34.3% versus 15.4%; P<0.0001); men (24.6% versus 18.2%; P<0.0001). A significant interaction existed between sex and LM status for the composite outcome (P=0.001). In multivariable Cox regression, the presence of nonobstructive LM plaque increased the risk for the composite outcome in women (adjusted hazard ratio, 1.48; P=0.005) but not in men (adjusted hazard ratio, 0.98, P=0.806). In subgroup analysis, women with nonobstructive LM CAD had a nearly 80% higher risk for events than men with nonobstructive LM CAD (adjusted hazard ratio, 1.78; P=0.017); sex-specific interactions were not observed across other patterns (eg, location or extent) of nonobstructive plaque.CONCLUSION: Nonobstructive LM CAD was frequently detected on coronary computed tomographic angiography and strongly associated with adverse events among women. Recognizing the sex-specific prognostic significance of nonobstructive LM plaque may augment risk stratification efforts.

Background--With the recent implementation of the Medicare Quality Payment Program, providers face increasing accountability for delivering high-quality care. Such pay-for-performance programs aim to leverage systematic data captured by electronic health record (EHR) systems to measure performance; however, the fidelity of EHR query for assessing performance has not been validated compared with manual chart review. We sought to determine whether our institution's methodology of EHR query could accurately identify cases in which providers failed to prescribe statins for eligible patients with coronary artery disease. Methods and Results--A total of 9459 patients with coronary artery disease were seen at least twice at the Emory Clinic between July 2014 and June 2015, of whom 1338 (14.1%, 95% confidence interval 13.5-14.9%) had no statin prescription or exemption per EHR query. A total of 120 patient cases were randomly selected and reviewed by 2 physicians for further adjudication. Of the 120 cases initially classified as statin prescription failures, only 21 (17.5%; 95% confidence interval, 11.7-25.3%) represented true failure following physician review. Conclusions--Sole reliance on EHR data query to measure quality metrics may lead to significant errors in assessing provider performance. Institutions should be cognizant of these potential sources of error, provide support to medical providers, and form collaborative data management teams to promote and improve meaningful use of EHRs. We propose actionable steps to improve the accuracy of EHR data query that require hypothesis testing and prospective validation in future studies.

The efficacy of implantable cardioverter-defibrillators (ICD) for primary prevention of sudden cardiac death (SCD) has not been studied in patients with end-stage renal disease (ESRD) and left ventricular dysfunction. We sought to identify predictors of long-term survival among ICD recipients with and without ESRD. Methods Patients implanted with an ICD at our institution from January 2006 to March 2014 were retrospectively identified. Clinical and demographic characteristics were collected. Patients were stratified by the presence of ESRD at the time of ICD implant. Mortality data were collected from the Social Security Death Index (SSDI). Results A total of 3453 patients received an ICD at our institution in the pre-specified time period, 184 (5.3%) of whom had ESRD. In general, ESRD patients were sicker and had more comorbidities. Kaplan Meier survival curve showed that ESRD patients had worse survival as compared with non-dialysis patients (p < 0.001). Following adjustment for differences in baseline characteristics, patients with ESRD remained at increased long-term mortality in the Cox model. The one-year mortality in the ESRD patients was 18.1%, as compared with 7.7% in the non-dialysis cohort (p < 0.001). The three-year mortality in ESRD patients was 43%, as compared with 21% in the non-dialysis cohort (p < 0.001). Conclusion ESRD patients are at significantly increased risk of mortality as compared with a non-dialysis cohort. While the majority of these patients survive more than one year post-diagnosis, the three-year mortality is high (43%). Randomized studies addressing the benefits of ICDs in ESRD patients are needed to better define their value for primary prevention of SCD.

OBJECTIVE - Elevated glucose levels are common after an acute myocardial infarction (AMI) and increase the risk of death. Prior trials of glucose control after AMI have been inconsistent in thei r ability to lower glucose levels and have reportedmixed effects on mortality. We developed a paper-based glucose-lowering algorithm and assessed its feasibility and safety in the setting of AMI. RESEARCH DESIGN AND METHODS - A total of 287 participants with an acute ST segment elevation myocardial infarction (STEMI) and a capillary glucose level ≥8.0 mmol/L were randomly allocated to glucose management with intravenous glulisine insulin using this algorithmin the coronary care unit (CCU), followed by once-daily subcutaneous insulin glargine for 30 days versus standard glycemic approaches. The primary outcome was a difference inmean glucose levels at 24 h. Participants were followed for clinical outcomes through 90 days. RESULTS - At 24 h, themean glucose level was 1.41mmol/L (95%CI 0.69-2.13) lower in the insulin (6.53 vs. 7.94mmol/L). Differences in glucose levels weremaintained at 72 h and 30 days. A total of 22.7% of the insulin group versus 4.4% of the standard group had biochemical hypoglycemia (with neither signs nor symptoms) in the CCU because of lower glycemic goals. However, there were no differences in symptomatic hypoglycemia or clinical outcomes between the groups. CONCLUSIONS - A paper-based insulin algorithm targeting glucose levels of 5.0-6.5 mmol/L (90-117 mg/dL) can be feasibly implemented in the CCU. A cardiovascular outcomes trial using this approach can determine whether targeted glucose lowering improves patient outcomes.

Objective: To estimate the prevalence and social, psychological and environmental-structural determinants of tobacco experimentation among adolescents in Shanghai, China. Methods: We conducted a cross-sectional study based on a two-stage cluster sample design by using the Chinese version of the Global Youth Tobacco Survey (GYTS) to investigate smoking behavior among 19,117 students from 41 junior and senior high schools in Shanghai, China. The associ ation between potential factors and tobacco experimentation were assessed using complex samples procedure logistic regression. Results: Of the 19,117 respondents, 10.5% (15.3% boys and 6.2% girls) reported the tobacco experimentation. The main social, psychological, and environmental-structural factors associated with tobacco experimentation were having close friends who smoke (AOR = 8.21; 95% CI: 6.49-10.39); one or both parents smoking (AOR 1.57; CI: 1.39-1.77); a poor school tobacco control environment (AOR 1.53; CI: 1.37-1.83); a high acceptance level of tobacco use (AOR 1.44; CI: 1.28-1.82); and a high level of media tobacco exposure (AOR 1.23; CI: 1.10-1.37). Peer smoking might contribute to smoking experimentation among girls (AOR 8.93; CI: 5.84-13.66) more so than among boys (AOR 7.79; CI: 5.97-9.94) and media tobacco exposure had no association with tobacco experimentation among female students. Conclusions: Social, psychological, and environmental factors are closely associated with tobacco experimentation among adolescents. Prevention programs aimed at reducing teen tobacco experimentation should be conducted at home and school with support by parents, peers and teachers. Our findings should prove useful for future development of intervention strategies among adolescents in Shanghai, China.

BACKGROUND: Although guidelines and performance measures exist for patients with diabetes mellitus, achievement of these metrics is not well known. The Diabetes Collaborative Registry(®) (DCR) was formed to understand the quality of diabetes mellitus care across the primary and specialty care continuum in the United States. METHODS AND RESULTS: We assessed the frequency of achievement of 7 diabetes mellitus-related quality metrics and variability across the Diabetes Collaborative Registry(®) sites. Among 574 972 patients with diabetes mellitus from 259 US practices, median (interquartile range) achievement of the quality metrics across the practices was the following: (1) glycemic control: 19% (5-47); (2) blood pressure control: 80% (67-88); (3) angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers in patients with coronary artery disease: 62% (51-69); (4) nephropathy screening: 62% (53-71); (5) eye examination: 0.7% (0.0-79); (6) foot examination: 0.0% (0.0-2.3); and (7) tobacco screening/cessation counseling: 86% (80-94). In hierarchical, modified Poisson regression models, there was substantial variability in meeting these metrics across sites, particularly with documentation of glycemic control and eye and foot examinations. There was also notable variation across specialties, with endocrinology practices performing better on glycemic control and diabetes mellitus foot examinations and cardiology practices succeeding more in blood pressure control and use of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers. CONCLUSIONS: The Diabetes Collaborative Registry(®) was established to document and improve the quality of outpatient diabetes mellitus care. While target achievement of some metrics of cardiovascular risk modification was high, achievement of others was suboptimal and highly variable. This may be attributable to fragmentation of care, lack of ownership among various specialists concerning certain domains of care, incomplete documentation, true gaps in care, or a combination of these factors.

China is one of the fastest developing countries in the world. Rapid economic progress has resulted in changes to both diet and physical activity. New found prosperity, increased urban migration, and the adoption of sedentary lifestyles by an aging Chinese population have resulted in a dramatic shift in disease burden—from infectious to chronic. Modern Chinese find themselves increasingly afflicted with the same noncommunicable chronic diseases typical of industrialized nations. Today, cardiovascular disease is the number one cause of both morbidity and mortality, affecting both rural and urban Chinese. The rising incidence of cardiovascular disease has been fueled by an epidemic of cardiometabolic risk factors. While hypertension and smoking have received considerable spotlight, little attention has been given to obesity, diabetes, and metabolic syndrome. Their increasing prevalence is the focus of this paper.