The Association Between the Use of Cholinesterase Inhibitors and Cardiovascular Events Among Older Patients With Alzheimer Disease

ObjectiveTo evaluate the association between the use of cholinesterase inhibitors (ChEIs) and incident cardiovascular events (CVEs) among older patients with Alzheimer disease (AD).Patients and MethodsThis retrospective cohort study was conducted with a new-user design and active-comparator design. The data source was the 2005–2014 Full Population file from the Health and Welfare Database in Taiwan. Patients were included if they were aged 50 years or older and had been diagnosed with AD between January 1, 2006, and December 31, 2010. The association between ChEI use and the risk of CVEs was investigated in patients with AD. Among the ChEI users, the risk of CVEs was further compared between patients with different cumulative doses and different ChEI treatment strategies. The propensity score method, which included matching and inverse probability of treatment weighting, was used to balance the potential confounders. A Cox proportional hazards model with competing risks was used to estimate the hazard ratio of CVEs.ResultsThe study included 6070 patients with AD. After covariate adjustment, ChEI users had a significantly lower risk of CVEs than nonusers (hazard ratio, 0.57; 95% CI, 0.51 to 0.62). Among ChEI users, patients with a high cumulative dose had a significantly lower risk of CVEs than those with a low cumulative dose (hazard ratio, 0.82; 95% CI, 0.70 to 0.96).ConclusionThe use of ChEIs was associated with a decreased risk of incident CVEs among patients with AD. The cardioprotective effect of ChEIs showed a dose-response relationship.     

Changes in Burnout and Satisfaction With Work-Life Integration in Physicians and the General US Working Population Between 2011 and 2020

ObjectiveTo evaluate the prevalence of burnout and satisfaction with work-life integration (WLI) among physicians and US workers in 2020 relative to 2011, 2014, and 2017.MethodsBetween November 20, 2020, and March 23, 2021, we surveyed US physicians and a probability-based sample of the US working population using methods similar to our prior studies. Burnout and WLI were measured using standard tools. Information about specific work-related COVID-19 experiences was collected.ResultsThere were 7510 physicians who participated in the survey. Nonresponder analysis suggested that participants were representative of US physicians. Mean emotional exhaustion and depersonalization scores were lower in 2020 than in 2017, 2014, and 2011 (all P<.001). However, emotional exhaustion and depersonalization scores did not improve in specialties most heavily affected by COVID-19. Overall, 38.2% of physicians reported 1 or more symptoms of burnout in 2020 compared with 43.9% in 2017, 54.4% in 2014, and 45.5% in 2011 (all P<.001). Providing care without adequate personal protective equipment (odds ratio [OR], 1.53; 95% CI, 1.35 to 1.72) and having suffered disruptive economic consequences due to COVID-19 (OR, 1.49; 95% CI, 1.32 to 1.69) were independently associated with risk of burnout. On multivariable analysis, physicians were at increased risk for burnout (OR, 1.41; 95% CI, 1.25 to 1.58) and were less likely to be satisfied with WLI (OR, 0.71; 95% CI, 0.64 to 0.79) than other working US adults.ConclusionBurnout and satisfaction with WLI among US physicians improved between 2017 and 2020. The impact of the COVID-19 pandemic on physicians varies on the basis of professional characteristics and experiences. Physicians remain at increased risk for burnout relative to workers in other fields.     

Health Care Provider Characteristics Associated With Colorectal Cancer Screening Preferences and Use

ObjectiveTo assess health care provider (HCP) preferences related to colorectal cancer (CRC) screening overall, and by HCP and patient characteristics.Participants and MethodsWe developed a survey based on the Theoretical Domains Framework to assess factors associated with CRC screening preferences in clinical practice. The survey was administered online November 6 through December 6, 2019, to a validated panel of HCPs drawn from US national databases and professional organizations. The final analysis sample included 779 primary care clinicians (PCCs) and 159 gastroenterologists (GIs).ResultsHCPs chose colonoscopy as their preferred screening method for average-risk patients (96.9% (154/159) for GIs, 75.7% (590/779) for PCCs). Among PCCs, 12.2% (95/779) preferred multi-target stool DNA (mt-sDNA), followed by fecal immunochemical test (FIT), (7.3%; 57/779) and guaiac-based fecal occult blood test (gFOBT) (4.8%; 37/779). Preference among PCCs and GIs generally shifted toward noninvasive screening options for patients who were unable to undergo invasive procedures; concerned about taking time from work; unconvinced about need for screening; and refusing other screening recommendations. Among PCCs, preference for mt-sDNA over FIT and gFOBT was less frequent in larger compared with smaller clinical practices. Additionally, preference for mt-sDNA over FIT was more likely among PCCs with more years of clinical experience, higher patient volumes (> 25/day), and practice locations in suburban and rural settings (compared to urban).ConclusionBoth PCCs and GIs preferred colonoscopy for CRC screening of average-risk patients, although PCCs did so less frequently and with approximately a quarter preferring stool-based tests (particularly mt-sDNA). PCCs’ preference varied by provider and patient characteristics. Our findings underscore the importance of informed choice and shared decision-making about CRC screening options.     

Association of Gestational Age at Birth With Left Cardiac Dimensions at Near-Term Corrected Age Among Extremely Preterm Infants

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U-Shaped Association Between Duration of Sports Activities and Mortality: Copenhagen City Heart Study

ObjectiveTo investigate the association between the duration of weekly leisure-time sports activity and all-cause mortality.MethodsAs part of the prospective Copenhagen City Heart Study, 8697 healthy adults completed a comprehensive questionnaire about leisure-time sports activities. Duration (minutes per week) of leisure-time sports activities was recorded for tennis, badminton, soccer, handball, cycling, swimming, jogging, calisthenics, health club activities, weightlifting, and other sports. The primary end point was all-cause mortality, and the median follow-up was 25.6 years. The association between duration of leisure-time sports activities and all-cause mortality was studied using multivariable Cox proportional hazards regression analysis.ResultsCompared with the reference group of 2.6 to 4.5 hours of weekly leisure-time sports activities, we found an increased risk for all-cause mortality for those with 0 hours (hazard ratio [HR], 1.51; 95% CI, 1.29 to 1.76), for those with 0.1 to 2.5 hours (HR, 1.24; 95% CI, 1.05 to 1.46), and for those with more than 10 hours (HR, 1.18; 95% CI, 1.00 to 1.39) of weekly leisure-time sports activities. These relationships were generally consistent with additional adjustments for potential confounders among subgroups of age, sex, education, smoking, alcohol intake, and body mass index, when the first 5 years of follow-up were excluded, and for cardiovascular disease mortality.ConclusionWe observed a U-shaped association between weekly duration of leisure sports activities and cardiovascular and all-cause mortality, with lowest risk for those participating in 2.6 to 4.5 weekly hours, being consistent across subgroups. Participation in sport activities should be promoted, but the potential risk of very high weekly hours of sport participation should be considered for inclusion in guidelines and recommendations.     

The Association of Sleep Apnea and Cardiorespiratory Fitness With Long-Term Major Cardiovascular Events

ObjectiveTo determine the risk of long-term major adverse cardiovascular events (MACE) when sleep-disordered breathing (SDB) and decreased cardiorespiratory fitness (CRF) co-occur.MethodsWe included consecutive patients who underwent symptom-limited cardiopulmonary exercise tests between January 1, 2005, and January 1, 2010, followed by first-time diagnostic polysomnography within 6 months. Patients were stratified based on the presence of moderate-to-severe SDB (apnea/hypopnea index ≥15 per hour) and decreased CRF defined as <70% predicted peak oxygen consumption (VO₂). Long-term MACE was a composite outcome of myocardial infarction (MI), coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), stroke or transient ischemic attack (TIA), and death, assessed until May 21, 2018. Cox-proportional hazard models were adjusted for factors known to influence CRF and MACE.ResultsOf 498 included patients (60±13 years, 28.1% female), 175 (35%) had MACE (MI=17, PCI=14, CABG=13, stroke=20, TIA=12, deaths=99) at a median follow-up of 8.7 years (interquartile range=6.5 to 10.3 years). After adjusting for age, sex, beta blockers, systemic hypertension, diabetes mellitus, coronary artery disease, cardiac arrhythmia, chronic obstructive pulmonary disease, smoking, and use of positive airway pressure (PAP), decreased CRF alone (hazard ratio [HR]=1.91, 95% confidence interval [CI], 1.15 to 3.18; P=.01), but not SDB alone (HR=1.26, 95% CI, 0.75 to 2.13, P=.39) was associated with increased risk of MACE. Those with SDB and decreased CRF had greater risk of MACE compared with patients with decreased CRF alone (HR=1.85; 95% CI, 1.21 to 2.84; P<.005) after accounting for these confounders. The risk of MACE was attenuated in those with reduced CRF alone after additionally adjusting for adequate adherence to PAP (HR=1.59; 95% CI, 0.77 to 3.31; P=.21).ConclusionThe incidence of MACE, especially mortality, was high in this sample. Moderate-to-severe SDB with concurrent decreased CRF was associated with higher risk of MACE than decreased CRF alone. These results highlight the importance of possibly including CRF in the risk assessment of patients with SDB and, conversely, that of screening for SDB in patients with low peak VO₂.     

Association of Cardiovascular Disease Risk Factors With Sociodemographic Characteristics and Health Beliefs Among a Community-Based Sample of African American Adults in Minnesota

ObjectiveTo assess cardiovascular disease (CVD) and CVD risk factors and their association with sociodemographic characteristics and health beliefs among African American (AA) adults in Minnesota.MethodsA cross-sectional analysis was conducted of a community-based sample of AA adults enrolled in the Minnesota Heart Health Program Ask About Aspirin study from May 2019 to September 2019. Sociodemographic characteristics, health beliefs, and self-reported CVD and CVD risk factors were collected. Prevalence ratio (PR) estimates were calculated using Poisson regression modeling to assess the association between participants’ characteristics and age- and sex-adjusted CVD risk factors.ResultsThe sample included 644 individuals (64% [412] women) with a mean age of 61 years. Risk factors for CVD were common: hypertension (67% [434]), hyperlipidemia (47% [301]), diabetes (34% [219]), and current cigarette smoking (25% [163]); 19% (119) had CVD. Those with greater perceived CVD risk had a higher likelihood of prevalent hyperlipidemia (PR, 1.34; 95% CI, 1.14 to 1.57), diabetes (PR, 1.61; 95% CI, 1.30 to 1.98), and CVD (PR 1.61; 95% CI, 1.16 to 2.23) compared with those with lower perceived risk. Trust in health care provider was high (83% [535]) but was not associated with CVD or CVD risk factors.ConclusionIn this community sample of AAs in Minnesota, CVD risk factors were high, as was trust in health care providers. Those with greater CVD risk perceptions had higher CVD prevalence. Consideration of sociodemographic and psychosocial influences on CVD and CVD risk factors could inform development of effective cardiovascular health promotion interventions in the AA Minnesota community.     

Submaximal Angiotensin-Converting Enzyme Inhibitor and Angiotensin Receptor Blocker Dosing Among Persons With Proteinuria

For persons with proteinuria, angiotensin-converting enzyme inhibitors (ACEis) and angiotensin II receptor blockers (ARBs) are treatment mainstays for reducing kidney disease progression. Guidelines for managing hypertension and chronic kidney disease recommend titrating to the maximum ACEi/ARB dose tolerated. Using deidentified national electronic health record data from the Optum Labs Data Warehouse, we examined ACEi/ARB dosing among adults with proteinuria—defined as either a urine albumin to creatinine ratio of 30 mg/g or greater or a protein to creatinine ratio of 150 mg/g or greater—who were prescribed an ACEi/ARB medication between January 1, 2017, and December 31, 2018. Among 100,238 included patients (mean age, 65.1 years; 49,523 [49.4%] female), 29,883 (29.8%) were taking maximal ACEi/ARB doses. Among 74,287 patients without potential contraindications to dose escalation (systolic blood pressure <120 mm Hg, estimated glomerular filtration rate <15 mL/min per 1.73 m², serum potassium level greater than 5.0 mEq/L, or acute kidney injury within the prior year), the frequency of maximal ACEi/ARB dosing was 32.3% (24,025 patients). In adjusted analyses, age less than 40 years, female sex, Hispanic ethnicity, lower urine albumin to creatinine ratio, lack of diabetes, heart failure, lower blood pressure, higher serum potassium level, and prior acute kidney injury were associated with lower odds of maximal ACEi/ARB dosing. Having a prior nephrologist visit was not associated with maximal dosing. Our results suggest that greater attention toward optimizing the dose of ACEi/ARB therapy may represent an opportunity to improve chronic kidney disease care and reduce excess morbidity and mortality associated with disease progression.     

Cost-Related Nonadherence to Medications Among US Adults With Chronic Liver Diseases

ObjectiveTo estimate the prevalence, risk factors, and consequences of cost-related medication nonadherence (CRN) in individuals with chronic liver diseases (CLDs) in the United States.Patients and MethodsUsing the National Health Interview Survey from January 1, 2014, to December 31, 2018, we identified individuals with CLDs. Using complex weighted survey analysis, we obtained national estimates and risk factors for CRN and its association with cost-reducing behaviors and measures of financial toxicity. We evaluated the association of CRN with unplanned health care use, adjusting for age, sex, race/ethnicity, insurance, income, education, and comorbid conditions.ResultsOf 3237 respondents (representing 4.6 million) US adults with CLDs, 813 (representing 1.2 million adults, or 25%; 95% CI, 23% to 27%) reported CRN, of whom 68% (n=554/813) reported maladaptive cost-reducing behaviors. Younger age, female sex, low income, and multimorbidity were associated with a higher prevalence of CRN. Compared with patients without CRN, patients experiencing CRN had 5.1 times higher odds of financial hardship from medical bills (adjusted odds ratio [aOR], 5.05; 95% CI, 3.73 to 6.83) and 2.9 times higher odds of food insecurity (aOR, 2.85; 95% CI, 2.02 to 4.01). The CRN was also associated with 1.5 times higher odds of emergency department visits (aOR, 1.46; 95% CI, 1.11 to 1.94).ConclusionWe observed a high prevalence of CRN and associated consequences such as high financial distress, financial hardship from medical bills, food insecurity, engagement in maladaptive cost-reducing strategies, increased health care use, and work absenteeism among patients with CLD. These financial determinants of health have important implications in the context of value-based care.     

Potentially Preventable Hospitalizations Among Adults With Pediatric-Onset Disabilities

ObjectiveTo examine the risk of any and specific potentially preventable hospitalizations (PPHs) for adults with cerebral palsy (CP) or spina bifida (SB). We hypothesize that PPH risk is greater among adults with CP/SB compared with the general population.Patients and MethodsUsing January 1, 2007, to December 31, 2017, national private administrative claims data (OptumInsight) in the United States, we identified adults with CP/SB (n=10,617). Adults without CP/SB were included as controls (n=1,443,716). To ensure a similar proportion in basic demographics, we propensity-matched our controls with cases in age and sex (n=10,617). Generalized estimating equation models were applied to examine the risk of CP/SB on PPHs. All models were adjusted for age, sex, race/ethnicity, health indicators, US Census Division data, and socioeconomic variables. Adjusted odds ratios were compared within a 4-year follow-up.ResultsAdults with CP/SB had higher risk for any PPH (odds ratio [OR], 4.10; 95% CI, 2.31 to 7.31), and PPHs due to chronic obstructive pulmonary disease/asthma (OR, 1.85; CI, 1.23 to 2.76), pneumonia (OR, 3.01; 95% CI, 2.06 to 4.39), and urinary tract infection (OR, 6.48; 95% CI, 3.91 to 10.75). Cases and controls who had an annual wellness visit had lower PPH risk (OR, 0.52; 95% CI, 0.41 to 0.67); similarly, adults with CP/SB who had an annual wellness visit compared with adults with CP/SB who did not had lower odds of PPH (OR, 0.75; 95% CI, 0.60 to 0.94).ConclusionAdults with pediatric-onset disabilities are at a greater risk for PPHs. Providing better access to preventive care and health-promoting services, especially for respiratory and urinary outcomes, may reduce PPH risk among this patient population.     

Comparison of Transcatheter and Open Mitral Valve Repair Among Patients With Mitral Regurgitation

In 2013, the Food and Drug Administration approved the first transcatheter mitral valve repair (TMVr) device for degenerative mitral regurgitation for patients at prohibitive surgical risk. To better understand contemporary utilization trends and outcomes, we reviewed hospitalizations, identified using International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes, in which the patient underwent TMVr or mitral valve repair (MVr) with a diagnosis of mitral regurgitation, without stenosis, from the National (Nationwide) Inpatient Sample from 2014 to 2017. We included 10,020 hospitalizations in which the patient underwent TMVr and 5845 in which the patient underwent MVr and assessed trends in demographic characteristics, patient comorbidities, total hospital charges, and outcomes. Transcatheter mitral valve repair experienced exponential growth, increasing from 150 to 5115 over the study period (P<.001 for trend), whereas MVr grew to a lesser degree. The median length of stay for TMVr decreased from 4 to 2 days; mortality declined from 3.3% to 1.6% (P<.001 for both). Both TMVr and MVr rates of discharge home increased over the study period. Total charges for TMVr increased from $149,582 to $178,109, whereas those for MVr increased to a lesser degree, from $149,426 to $157,146 (P<.001 for both). Discharge disposition, length of stay, and in-hospital mortality all exhibited favorable trends for both procedures. Caution must be exercised in direct comparisons between procedures as they target somewhat different populations. With expanded indications for TMVr, we anticipate further increases in procedural volume, although the effect on MVr remains unclear.     

Changes in Burnout and Satisfaction With Work-Life Integration in Physicians During the First 2 Years of the COVID-19 Pandemic

ObjectiveTo evaluate the prevalence of burnout and satisfaction with work-life integration (WLI) in US physicians at the end of 2021, roughly 21 months into the COVID-19 pandemic, with comparison to 2020, 2017, 2014, and 2011.MethodsBetween December 9, 2021, and January 24, 2022, we surveyed US physicians using methods similar to those of our prior studies. Burnout, WLI, depression, and professional fulfillment were assessed with standard instruments.ResultsThere were 2440 physicians who participated in the 2021 survey. Mean emotional exhaustion and depersonalization scores were higher in 2021 than those observed in 2020, 2017, 2014, and 2011 (all P<.001). Mean emotional exhaustion scores increased 38.6% (2020 mean, 21.0; 2021 mean, 29.1; P<.001), whereas mean depersonalization scores increased 60.7% (2020 mean, 6.1; 2021 mean, 9.8; P<.001). Overall, 62.8% of physicians had at least 1 manifestation of burnout in 2021 compared with 38.2% in 2020, 43.9% in 2017, 54.4% in 2014, and 45.5% in 2011 (all P<.001). Although these trends were consistent across nearly all specialties, substantial variability by specialty was observed. Satisfaction with WLI declined from 46.1% in 2020 to 30.2% in 2021 (P<.001). Mean scores for depression increased 6.1% (2020 mean, 49.54; 2021 mean, 52.59; P<.001).ConclusionA dramatic increase in burnout and decrease in satisfaction with WLI occurred in US physicians between 2020 and 2021. Differences in mean depression scores were modest, suggesting that the increase in physician distress was overwhelmingly work related. Given the association of physician burnout with quality of care, turnover, and reductions in work effort, these findings have profound implications for the US health care system.     

Relationship Between Etiology of Cirrhosis and Survival Among Patients Hospitalized in Intensive Care Units

ObjectiveTo determine short-term outcomes of patients with alcohol-associated cirrhosis (ALC) admitted to the intensive care unit (ICU) compared with other etiologies of liver disease. In addition, we investigate whether quick sequential organ failure assessment accurately predicts presence of sepsis and in-hospital mortality in critically ill patients with various etiologies of cirrhosis.MethodsA retrospective cohort of 1174 consecutive patients with cirrhosis admitted to the ICU between January of 2006 and December of 2015 was analyzed. Outcomes of interest included survival rates within the ICU, post-ICU in-hospital, or at 30 days post-ICU discharge.ResultsFive hundred seventy-eight patients were found to have ALC with 596 in the non-ALC group. There was no significant difference in ICU mortality rates in ALC versus non-ALC cohorts (10.2% vs 11.7%, P=.40). However, patients with ALC had significantly higher post-ICU in-hospital death (10.0% vs 6.5%, P=.04) as well as higher mortality at 30-day post-ICU discharge (18.7% vs 11.2%, P<.001). Sustained alcohol abstinence did not offer survival advantage over nonabstinence. The predictive power for quick sequential organ failure assessment for sepsis and in-hospital mortality for patients with cirrhosis was limited.ConclusionCritically ill patients with ALC have decreased survival after ICU discharge compared with patients with other etiologies of cirrhosis, independent of alcohol abstinence.     

Association Between Performance on an Interdisciplinary Stroke Assessment Battery and Falls in Patients With Acute Stroke in an Inpatient Rehabilitation Facility: A Retrospective Cohort Study

ObjectiveTo explore the association between demographic factors and functional performance measures of patients with acute stroke in an inpatient rehabilitation facility (IRF) and falls during the IRF stay and to quantify the diagnostic accuracy of functional outcome measures in identifying fallers.DesignRetrospective cohort study.SettingInpatient rehabilitation facility.ParticipantsIndividuals with acute stroke admitted to hospital-based IRF (N=139).InterventionsNot applicable.Main Outcome MeasuresOdds ratios were used to examine the relationship between fall frequency and functional outcome measures (National Institute of Stroke Scale, neglect [Item #11], Berg Balance Scale, Stroke Rehabilitation Assessment of Movement mobility and Stroke Rehabilitation Assessment of Movement lower extremity subscales [STREAM-LE], Montreal Cognitive Assessment, Dynamic Gait Index, and Stroke Impact Scale). Receiver operator characteristic analysis with area under the curve, sensitivity, specificity, and diagnostic odds ratio were used to assess the diagnostic accuracy of each functional outcome measure to distinguish patients who fell vs those who did not fall in the IRF.ResultsA total of 23 patients (16.2%) fell during the IRF hospitalization. Patients who did and did not fall did not differ in terms of age, sex, stroke type, or stroke location. Only the STREAM-LE was associated with falls (odds ratio, 0.93; 95% CI, 0.86-0.99). Area under the curve was 0.67 (95% CI, 0.51-0.82). With a positivity cutoff point of 12, sensitivity and specificity were 73.3% (95% CI, 54.6%-92.2%) and 50.0% (95% CI, 39.9%-59.2%), respectively. The diagnostic odds ratio was 3.4.ConclusionsThe STREAM-LE score at admission to IRF may identify patients with acute stroke who are more likely to fall during their stay. However, the search for measures with greater diagnostic accuracy should continue.     

Employment and Job Benefits Among Those With Spinal Cord Dysfunction: A Comparison of People With Spinal Cord Injury and Multiple Sclerosis

Objective(1) Identify the proportion of participants with spinal cord dysfunction (SCD) reporting each of 10 job benefits and compare the proportions between participants with spinal cord injury (SCI) and multiple sclerosis (MS); and (2) examine if diagnostic criteria, demographics, education level, and functional limitations are associated with the number of job benefits received.DesignEconometric modeling of cross-sectional data using a 2-step data analytic model of employment and job benefits.SettingMedical university in the southeastern United States.ParticipantsParticipants (N=2624) were identified from the southeastern United States. After eliminating those age 65 and older, there were 2624 adult participants with SCD; 1234 had MS and 1390 had SCI.InterventionsNot applicable.Main Outcome MeasuresCurrent employment status; number of benefits received and specific benefits received.ResultsA greater proportion of participants with MS received benefits, with significant differences observed on all but 1 type of benefit. Among those who were employed, a greater number of benefits was associated with having MS, greater education, younger age, married or in an unmarried couple, and not having functional restrictions with cognition, doing errands, or shopping alone in the community, and walking.ConclusionsEmployed participants with MS were more likely to receive job benefits, indicative of a higher quality of employment, compared to participants with SCI. Employment without benefits is a form of underemployment that disproportionately affects individuals with many of the same characteristics that initially lead to disparities in probability of gainful employment.     

Association Between Personal Activity Intelligence and Mortality: Population-Based China Kadoorie Biobank Study

ObjectiveTo prospectively investigate the association between personal activity intelligence (PAI) — a novel metabolic metric which translates heart rate during physical activity into a simple weekly score — and mortality in relatively healthy participants in China whose levels and patterns of physical activity in addition to other lifestyle factors are different from those in high-income countries.Patients and MethodsFrom the population-based China Kadoorie Biobank study, 443,792 healthy adults were recruited between June 2004 and July 2008. Participant’s weekly PAI score was estimated and divided into four groups (PAI scores of 0, ≤50, 51–99, or ≥100). Using Cox proportional hazard analyses, we calculated adjusted hazard ratios (AHRs) for cardiovascular disease (CVD) and all-cause mortality related to PAI scores.ResultsDuring a median follow-up of 8.2 (interquartile range, 7.3 to 9.1) years, there were 21,901 deaths, including 9466 CVD deaths. Compared with the inactive group (0 PAI score), a baseline weekly PAI score greater than or equal to 100 was associated with a lower risk of CVD mortality, an AHR of 0.87 (95% CI, 0.81 to 0.94) in men, and an AHR of 0.84 (95% CI, 0.78 to 0.92) in women, after adjusting for multiple confounders. Participants with a weekly PAI score greater than or equal to 100 also had a lower risk of all-cause mortality (AHR, 0.93; 95% CI, 0.89 to 0.97 in men, and AHR, 0.93; 95%, 0.88 to 0.98 in women). Moreover, this subgroup gained 2.7 (95% CI, 2.4 to 3.0) years of life, compared with the inactive cohort.ConclusionAmong relatively healthy Chinese adults, the PAI metric was inversely associated with CVD and all-cause mortality, highlighting the generalizability of the score in different races, ethnicities, and socioeconomic strata.     

Association of Combined Healthy Lifestyles With Cardiovascular Disease and Mortality of Patients With Diabetes: An International Multicohort Study

ObjectiveTo prospectively examine the associations of combined lifestyle factors with incident cardiovascular disease (CVD) and mortality in patients with diabetes.Patients and MethodsPatients with prevalent diabetes were included from 5 prospective, population-based cohorts in China (Dongfeng-Tongji cohort and Kailuan study), the United Kingdom (UK Biobank study), and the United States (National Health and Nutrition Examination Survey and National Institutes of Health–AARP Diet and Health Study). Healthy lifestyle scores were constructed according to non–current smoking, low to moderate alcohol drinking, regular physical activity, healthy diet, and optimal body weight; the healthy level of each lifestyle factor was assigned 1 point, or 0 for otherwise, and the range of the score was 0 to 5. Cox proportional hazards models were used to estimate hazard ratios for incident CVD, CVD mortality, and all-cause mortality adjusting for sociodemographic, medical, and diabetes-related factors, and outcomes were obtained by linkage to medical records and death registries. Data were collected from October 18, 1988, to September 30, 2020.ResultsA total of 6945 incident CVD cases were documented in 41,350 participants without CVD at baseline from the 2 Chinese cohorts and the UK Biobank during 389,330 person-years of follow-up, and 40,353 deaths were documented in 101,219 participants from all 5 cohorts during 1,238,391 person-years of follow-up. Adjusted hazard ratios (95% CIs) comparing patients with 4 or 5 vs 0 or 1 healthy lifestyle factors were 0.67 (0.60 to 0.74) for incident CVD, 0.58 (0.50 to 0.68) for CVD mortality, and 0.60 (0.53 to 0.68) for all-cause mortality. Findings remained consistent across different cohorts, subgroups, and sensitivity analyses.ConclusionThe international analyses document that adherence to multicomponent healthy lifestyles is associated with lower risk of CVD and premature death of patients with diabetes.