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DALLAS, Nov. 9, 2020 -- Increasing rates of food insecurity in counties across the U.S. are independently associated with an increase in cardiovascular death rates among adults between the ages of 20 and 64, according to preliminary research to be presented at the American Heart Association's Scientific Sessions 2020. The meeting will be held virtually, Friday, November 13 - Tuesday, November 17, 2020, and is a premier global exchange of the latest scientific advancements, research, evidence-based clinical practice updates in cardiovascular science for health care worldwide.

About 10% of adults in the U.S. are considered food insecure, meaning they lack immediate access to fresh, healthy and affordable food. In addition, the stress from not knowing where their next meal will come from or regularly consuming cheap, processed foods may have an adverse impact on cardiovascular health.

"Our study is one of the first national analyses to look at changes in both food insecurity and cardiovascular mortality over time, and to see if changes in food insecurity impact cardiovascular health," said study co-author Sameed Khatana, M.D., M.P.H., instructor of cardiovascular medicine at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. "This research shows food insecurity, which is a particular type of economic distress, is associated with cardiovascular disease. It illustrates that cardiovascular health is tied to many things. It's more than doctors' visits, screenings, medications and procedures; what is going on outside the clinic, in society, has a significant impact on patients' health, too."

Researchers accessed both the National Center for Health Statistics and the Map the Meal Gap study to analyze county-level data on cardiovascular death rates and food insecurity rates that occurred from 2011 to 2017, among adults age 20 to 64, and those 65 years old and older.

In their analysis, researchers examined cardiovascular mortality trends in the U.S. by average annual percent change in food insecurity. They assessed the relationship between changes in food insecurity and cardiovascular death rates, after adjusting for variables including changes in demographics, employment, poverty, income, health insurance and other factors already known to affect cardiovascular risk.

Among the key findings:

Overall, food insecurity rates for the entire country declined significantly (from 14.7% to 13.3%) between 2011 and 2017.

The level in which food insecurity changes was a significant predictor of death for people between the ages of 20 and 64. U.S. counties that had the most increase in food insecurity levels had cardiovascular death rates that increased from 82 to 87 per 100,000 population. Counties that had a decrease in food insecurity had a cardiovascular mortality rate that remained stable at 60 per 100,000 population.

Cardiovascular death rates remained much higher among the elderly (age ?65) than for people 64 and younger, yet the rate of deaths did decline at all levels: from 1,643 to 1,542 per 100,000 population among those who experienced the most change in food insecurity levels, and from 1,408 to 1,338 per 100,000 population among those who had the least change. The changes were not scientifically significant.

For every 1% increase in food insecurity, there was a similar increase in cardiovascular mortality among non-elderly adults (0.83%).

"Overall, food insecurity rates did go down. However, while economic levels have improved when the country is measured as a whole, there has been a growing disparity demonstrating that parts of the country are being left behind," said Khatana.

Mercedes R. Carnethon Ph.D., FAHA, a member of the American Heart Association's Council on Epidemiology and Prevention Leadership Committee, said the analysis is comprehensive with some concerning trends.

"We know food insecurity and other social determinants of health can adversely impact heart and stroke risk factors like high blood pressure and diabetes, and this impact is disproportionately higher among traditionally underrepresented racial and ethnic groups," said Carnethon, the Mary Harris Thompson Professor and Vice Chair of the Department of Preventive Medicine in the Feinberg School of Medicine at Northwestern University in Chicago. "Social determinants of health are likely to worsen against the backdrop of the COVID-19 pandemic. The effects will extend beyond this period of time and lead to future elevations in cardiovascular diseases among vulnerable populations. Unfortunately, the outlook is not favorable, and major societal infrastructure changes are necessary to improve this situation."

In the future, the authors intend to study whether interventions that improve food insecurity would, in fact, lead to better cardiovascular health.

"When policy makers are thinking about the cardiovascular health of communities, they need to consider things like food insecurity, as well as the overall social and economic well-being of the community," Khatana said. "Interventions that improve the economic well-being of a community could lead to improvements in cardiovascular health of the people living there."

Embargoed until 4 a.m. CT/5 a.m. ET Monday, Nov. 9, 2020

DALLAS, Nov. 9, 2020 -- Black women born in the United States have a higher risk of developing preeclampsia compared to Black women who immigrated to the country, according to preliminary research to be presented at the American Heart Association's Scientific Sessions 2020. The meeting will be held virtually, Friday, November 13-Tuesday, November 17, 2020, and is a premier global exchange of the latest scientific advancements, research and evidence-based clinical practice updates in cardiovascular science for health care worldwide.

Preeclampsia, a serious complication of pregnancy characterized by high blood pressure and kidney dysfunction, is one of the leading causes of maternal death worldwide. It is 60% more common in Black women and is a risk factor for cardiovascular disease.

"Improving the cardiovascular health among U.S.-born Black women can make a difference in the trajectory of their pregnancies. Race itself is not the only contributing factor," said Garima Sharma, M.D., assistant professor of medicine at Johns Hopkins University School of Medicine in Baltimore and co-first author of the study.

In a review of data on nearly 4,000 Black women in Boston - born in and outside of the U.S. - researchers analyzed the role of their birthplace to their risk of preeclampsia and whether the length of time in the U.S. also affected the risk among the women who were not born in the country. The analysis included women from a subset of the Boston Birth Cohort - reviewing data on urban, low-income Black women in Boston. Race and ethnicity were self-reported. Of the study group, 1,652 were born in the U.S. and 2,302 were born in the Caribbean, Sub-Saharan Africa or other regions.

The study noted a higher prevalence of preeclampisa risk factors among U.S.-born Black women: smoking, diabetes, obesity, stress and previous pregnancies. They were also younger, less educated and more often single compared to foreign-born Black women.

The analysis found:

foreign-born Black women had a 26% lower risk of preeclampsia, compared to native-born American black women; and

when categorized by how long they lived in the U.S., immigrants who had lived in the U.S. for less than 10 years had an 8.5% risk of preeclampsia, compared to a 9.3% risk for those who had lived in the U.S. more than 10 years.

"Our findings suggest the 'healthy immigrant effect' tends to wane the longer an immigrant lives in the U.S.," Sharma said. The healthy immigrant effect refers to the fact that immigrants are typically healthier when they arrive in the U.S.

"The fact that the prevalence of preeclampsia in the mothers who were not born in the U.S. increased over time and grew closer to matching the risk of the U.S.-born mothers stresses the importance of improving cardiovascular health," she said. "We know that preeclampsia is associated with increased cardiovascular risk in later life, due mostly to the same risk factors.

Future research should focus on why and what we can do to implement changes to prevent cardiovascular disease and improve heart health among Black women."

Embargoed until 4 a.m. CT/5 a.m. ET, Monday, Nov. 9, 2020

DALLAS, Nov. 9, 2020 -- Overweight, sedentary, postmenopausal Latinas participating in a 12-week intervention program that counseled them about how to stand more and sit less greatly reduced daily sitting time, according to preliminary research to be presented at the American Heart Association's Scientific Sessions 2020. The meeting will be held virtually, Friday, November 13 - Tuesday, November 17, 2020, and is a premier global exchange of the latest scientific advancements, research and evidence-based clinical practice updates in cardiovascular science for health care worldwide.

"There is more and more research that indicates people who spend a lot of time sitting, either at work or at home, are at increased risk for cardiovascular disease and circulation problems. However, there are not many studies that have explored ways to change this behavior, particularly among older women of diverse backgrounds," said study author Gregory Talavera, M.D., M.P.H., professor of psychology at San Diego State University in San Diego, California. "Our simple intervention can substitute for or complement other lifestyle changes aimed at decreasing cardiovascular disease risk in older people who are often the most sedentary compared to people in other age groups."

Talavera and colleagues studied 254 overweight, sedentary, postmenopausal Latinas (average age 64) from disadvantaged backgrounds in San Diego from 2017 to 2019. Researchers randomly assigned the women to take part in a 12-week standing intervention program or a comparison group that received an equal number of contacts to discuss topics on healthy aging.

Women in the intervention group interacted with counselors eight times during the 12 weeks. Three of those meetings were in-person including one in each participant's home. Five were telephone sessions. The women learned how to address barriers to standing in their daily lives. The most common barriers were time and lower extremity pain due to arthritis. Counselors talked with the women about social cues, personal habits and how to change them with the goal of sitting less. Interventions included: behavioral contracts; sharing what they had learned with their family members for social support; biofeedback from a thigh-worn inclinometer (measures sitting/standing/laying down time); a small portable standing desk; and a wrist-worn timer that vibrated reminding them to stand.

The control group received written information and 12 phone counseling sessions to promote healthy aging.

While tailoring the program, researchers considered the family-oriented aspects among this group because many of the women lived in multi-generational homes. It was also important to understand the traditional/conservative gender roles within Latino communities that could impact their ability to be more physically active (within a multi-generational home in Latino communities, older women are less likely to work outside the home and more likely to be a caretaker to other family members and handle a lot of household chores).

"We provided cultural tailoring for the program, adapting an English version of the protocol into Spanish with changes that reflect Latina lifestyles such as incorporating standing time while completing household chores," Talavera said. "This program can be done in the home and could benefit women who are unable to participate in traditional physical activity."

Using data from the thigh-worn inclinometer, researchers found:

At the start of the study, all participants spent an average of 540 minutes (9 hours) daily sitting.
By 12 weeks, women in the intervention group reduced their sitting time an average of 71 minutes daily. Women in the control group that received only heart-healthy information reduced sitting time an average of 7.5 minutes daily.

Average standing time increased nearly 50 minutes per day in the intervention group, compared to an increase of 2.5 minutes per day in the control group.

Average stepping time increased more than 13 minutes in the intervention group, compared to nearly 5 minutes in the control group.

"These were older women with a number of health conditions that affected their ability to participate in traditional physical activities, so we were very surprised by how large of an improvement the intervention group demonstrated after only 12 weeks," Talavera said. "Many older women of diverse backgrounds experience lower extremity problems such as arthritis. We believe this easy intervention may also benefit other groups of older women."

Eligible participants self-identified as Latina and Spanish- or English-speaking with no current use of insulin or severe health conditions that would prevent participation in the study.

Co-authors are Sheila Castaneda, Ph.D.; Maria Lopez-Gurrola, M.D.; Ana Rebeca Alvarez-Malo, M.D.; Johanne Hernandez, R.N., M.B.A.; Dorothy Sears, Ph.D.; Chase Reuter, B.S.; Loki Natarajan, Ph.D.; Michelle Takemoto, Ph.D.; Ya-Ju Chang, Ph.D.; Yesenia Avitia, B.S.; Areilia Haimovich, B.S.; Luis Ornales, B.S.; Andrea De La Torre, B.S.; and Matthew Allison, M.D., M.P.H. Author disclosures are in the abstract.

The American Heart Association's Strategically Focused Research Network on Women's Health funded the study.

This abstract will be presented in Cardiovascular Disease in Women: Special Topics.

DALLAS, Nov. 9, 2020 -- Lifestyle habits including eating a healthy diet, getting regular exercise and not smoking can reduce the risk of death, even for people taking multiple medications, according to preliminary research to be presented at the American Heart Association's Scientific Sessions 2020. The meeting will be held virtually, Friday, November 13 - Tuesday, November 17, 2020, and is a premier global exchange of the latest scientific advancements, research and evidence-based clinical practice updates in cardiovascular science for health care worldwide.

"We've long known about the benefits of leading a healthy lifestyle. The results from our study underscore the importance of each person's ability to improve their health through lifestyle changes even if they are dealing with multiple health issues and taking multiple prescription medications," said lead author Neil Kelly, Ph.D., a medical student at Weill Cornell Medicine of Cornell University in New York City.

The study analyzed data from more than 20,000 participants of the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study (average age of 64; 56% women). At the start of the study, 44% of participants were taking four or fewer prescription medications; 39% were taking five to nine prescription medicines; and 17% were taking 10 or more prescription medications.

Researchers evaluated the number of medications taken, level of participation in four healthy behaviors and all-cause death rates. The types of medications and the conditions they were used to treat (e.g. heart disease, diabetes, kidney disease, cognitive impairment, etc.), varied widely among study participants. The healthy lifestyle behaviors were physical activity; smoking abstinence; low sedentary time; and following a Mediterranean diet, which emphasizes legumes, fruits, vegetables, whole grains, fish and olive oil and moderation for dairy products and wine.

At follow-up roughly 10 years later, the analysis found:

a healthy lifestyle decreased the risk of death regardless of the number of medications a person was taking; and

the higher the number of healthy lifestyle habits a person had, the lower their risk of death.

"It's especially important for health care professionals to counsel patients and develop interventions that can maximize healthy lifestyle behaviors, even among patients with several prescription medications," Kelly added. "It's important for the public to understand that there is never a bad time to adopt healthy behaviors. These can range from eating a healthier diet to taking a daily walk in their neighborhood. A healthier lifestyle buys more time."

DALLAS, Nov. 9, 2020 -- One-third of people using e-cigarettes or related products reported symptoms associated with lung or respiratory tract impact or injury, according to an analysis of a 2016 national survey, to be presented at the American Heart Association's Scientific Sessions 2020. The meeting will be held virtually, Friday, November 13 - Tuesday, November 17, 2020, and is a premier global exchange of the latest scientific advancements, research and evidence-based clinical practice updates in cardiovascular science for health care worldwide.

"Although many people continue to view vaping or using e-cigarettes and related products as safe - or at least safer than smoking combustible cigarettes - the use of these products can be risky," said Thanh-Huyen T. Vu, M.D., Ph.D., senior author of the study and research associate professor of epidemiology in the department of preventive medicine at the Northwestern University Feinberg School of Medicine in Chicago. "Recent outbreaks of e-cigarette- or vaping-associated lung injury - known as EVALI - have raised significant public health concerns about the impact of vaping on lung health. However, information is limited about clinical symptoms related to the use of different types of e-cigarettes and related products, especially information on symptoms among otherwise healthy individuals."

To help fill that knowledge gap, researchers analyzed the survey responses of more than 1,400 current e-cigarette and related products users, ages 18 to 64, evenly divided among male and female, who took part in a national, online survey in 2016. Participants reported the specific electronic cigarette vaping devices and related products they used. Additionally, from a list of 13 specific symptoms they selected the ones they believed might be caused by their vaping and reported any other symptoms they thought they experienced as a result of vaping.

Researchers specifically focused on five symptoms that were among the list of those identified by the U.S. Centers for Disease Control and Prevention (CDC) as being associated with e-cigarette- or vaping-associated lung injury: cough, shortness of breath, nausea, stomach pain and chest pain. Researchers also analyzed whether specific product choices influenced the occurrence of these symptoms, after adjusting for demographic factors, cigarette smoking and the frequency and duration of e-cigarette and related products use.

The researchers found:

More than half (55%) of respondents had one or more of the symptoms.

One third (33%) reported having one or more of the five e-cigarette- or vaping-associated lung injury (EVALI)-like symptoms; cough and nausea were the most common.

The proportion of respondents reporting EVALI-like symptoms was higher among those who were younger than age 45, Hispanic, current cigarette smokers or current users of other tobacco products such as pipes or smokeless tobacco.

Compared with those using non-refillable devices, people were 70% more likely to report EVALI-like symptoms if they used devices refilled by pouring in more e-liquid, and 95% more likely to report these symptoms if they used devices with refillable cartridges.

People who reported mixing their own e-liquid were 40% more likely to report EVALI-like symptoms.

People who used flavored e-cigarettes were 71% more likely to report EVALI-like symptoms.

After vaping-related lung injuries and deaths spiked in 2019, investigators at the U.S. Centers for Disease Control and Prevention identified one possible cause of the lung damage to be vitamin E acetate, an additive used in some cannabis-containing e-liquids purchased from the Internet or from sources other than legal marijuana dispensaries.

"Our results indicate that e-cigarette- or vaping-associated lung injury symptoms were not an oddity, a brief occurrence or solely related to the use of THC (the psychoactive component of cannabis) or vitamin E acetate, both of which were pegged as possible contributors to EVALI outbreaks in the past year or so," Vu said. "Health care professionals need to assist patients in better understanding the full risks and potential harms of using e-cigarettes and related products."

Although the survey was conducted in 2016, the researchers believe that the findings are relevant and important today. Vu said use of e-cigarettes and related products has increased since 2016, despite increased public health concern, and new device options proliferate -- with an increasing numbers of product choices to tempt potential users and to attract current users to new products.

"While these findings are from an adult survey, they are also important for youth. We know from previous reports that youth and teens who vape are likely to experiment with altering their liquids and devices and to choose flavored products," said study co-author Rose Marie Robertson, M.D., FAHA, deputy chief science and medical officer of the American Heart Association and co-director of the Association's Tobacco Center of Regulatory Science which supported the study. "Public health messages should be designed for parents and guardians or other adults working closely with youth, such as teachers and coaches, to increase the understanding of the relation of e-cigarette use with serious health risks."

According to the 2020 National Youth Tobacco Survey, 3.6 million U.S. youths currently use e-cigarettes, and among current users, more than eight in 10 reported using flavored e-cigarettes. The American Heart Association supports an aggressive, three-pronged initiative involving research, policy advocacy and youth activation to combat the teen vaping epidemic in the U.S.

"We know that almost 90% of cigarette smokers are addicted before the age of 20 and nicotine has very profound effects on the developing brain," said Aruni Bhatnagar, Ph.D., FAHA, co-director with Dr. Robertson of the American Heart Association's Tobacco Center of Regulatory Science and a professor of medicine at the University of Louisville School of Medicine, in Louisville, Ky. "This study provides a clear message that despite the belief that e-cigarettes are less harmful or maybe some people even believe completely innocuous, that there is harm, which is even perceived by the people who use them."

Bhatnagar said a more rigorous evaluation is needed to better understand the subclinical changes in the lungs and the circulatory system and whether those changes are immediate or accrue over a lifetime or over an extended period of time to cause an actual cardiovascular or pulmonary event.

Recently, concerns have been raised about whether vaping-related lung damage might make people more likely to become infected with the COVID-19 virus and to become seriously ill if they do.

"Although further research is needed on the association of vaping with EVALI and the association of lung injury with COVID-19, the existing evidence indicates that there should be concern, and it is worth avoiding this risk by not vaping," Vu said.

Embargoed until 4 a.m. CT/5 a.m. ET Monday, Nov. 9, 2020

DALLAS, Nov. 9, 2020 -- Higher fitness levels reduced the risk of developing an irregular heart rhythm, known as atrial fibrillation, by 30% to 50% in a study of male, African American veterans, according to preliminary research to be presented at the American Heart Association's Scientific Sessions 2020. The meeting will be held virtually, Friday, November 13 -Tuesday, November 17, 2020, and is a premier global exchange of the latest scientific advancements, research and evidence-based clinical practice updates in cardiovascular science for health care worldwide.

Atrial fibrillation (also called AFib or AF) is an irregular heartbeat (arrhythmia) that can lead to blood clots, stroke, heart failure and other heart-related complications. According to the American Heart Association, at least 2.7 million Americans are living with AFib.

"Engaging in physical activity to increase fitness is an inexpensive and practical intervention that health care professionals can prescribe to patients to prevent and manage cardiovascular disease," said lead researcher Apostolos Tsimploulis, M.D., a cardiology fellow at the State University of New York at Stony Brook. "All of our evidence suggests the health benefits associated with increased cardiorespiratory fitness and reduced risk of atrial fibrillation are the same for all adults regardless of race."

To study the effects of exercise on the development of atrial fibrillation, researchers examined the medical records of more than 11,000 middle-aged, male African American veterans (average age 58) from 1985 to 2013. None exhibited evidence of heart disease during or prior to completing a symptom-limited treadmill stress test at two VA Medical Centers - in Washington, D.C., and Palo Alto, California.

Participants were categorized into four fitness groups based on their age-specific cardiorespiratory fitness (CRF). CRF was measured in metabolic equivalents, or METs, resting metabolic rate (1 MET=3.5 ml of O2/kg of body weight per minute). The groups were categorized as: least fit, moderately fit, fit and highly fit.

A search of medical records was conducted by two independent investigators to directly assess the association between CRF and atrial fibrillation. Models were adjusted for risk factors, including heart or blood pressure medications, age and body mass index.

During an average follow-up of 10.7 years, 1,423 veterans developed atrial fibrillation:

421 (16.6%) in the least fit group;

366(10.9%) in the moderately fit group;

323 (11.9%) in the fit group; and

313 (12%) in the high-fit group.

When compared to the least-fit group, the atrial fibrillation risk was:

29% lower in the moderately fit group;

37% lower in the fit group; and

51% lower in the high fit group.

Researchers noted the study results are strong based on the number of participants, and atrial fibrillation incidence was established during a follow-up period spanning roughly 17 years (median 10.7 years). Access to adjusted, longitudinal data, including medications and heart risk factors, along with equal access to care (care from the VA regardless of a patient's ability to pay) are significant factors. This permitted continuous follow-up and minimized the potential for disparities in medical care.

Tsimploulis noted the precise cause of atrial fibrillation was not determined. In addition, CRF was measured only once; the level or frequency of physical activity was not assessed; and follow-up data on changes in cardiorespiratory fitness or physical activity of the participants over time were not available.

"We cannot make associations between atrial fibrillation and frequency, intensity, duration or volume of physical activity. Future studies are needed to document the effects of cardiorespiratory fitness on the incidence of atrial fibrillation, and the studies must include women," Tsimploulis said.

The American Heart Association recommends adults participate in at least 150 minutes per week of moderate-intensity aerobic activity or 75 minutes per week of vigorous aerobic activity or a combination of both.

Embargoed until 4 a.m. CT/5 a.m. ET Monday, Nov. 9, 2020

DALLAS, Nov. 9, 2020 -- Many transgender people who receive gender-affirming hormone therapy already have unaddressed heart disease risk factors such as high blood pressure and high cholesterol, even during young adulthood, according to preliminary research to be presented at the American Heart Association's Scientific Sessions 2020. The meeting will be held virtually, Friday, November 13 - Tuesday, November 17, 2020, and is a premier global exchange of the latest scientific advancements, research, evidence-based clinical practice updates in cardiovascular science for health care worldwide.

"Previous research has shown that transgender individuals are less likely to have access to health care or to utilize health care for a variety of reasons, including stigma and fear of mistreatment," said Kara J. Denby, M.D., lead study author and a clinical fellow in cardiovascular medicine at the Cleveland Clinic Foundation in Cleveland, Ohio. "Since transgender individuals have frequent physician visits while taking hormone therapy, this seems an opportune time to screen for cardiovascular risk factors and treat previously undiagnosed cardiovascular disease that can lead to poor health outcomes in the future."

The researchers examined risk factors and medical history for more than 400 adults (56% assigned male sex at birth, mostly in their 20s and 30s) when they first sought care at the multidisciplinary transgender program at the Cleveland Clinic Foundation.

For participants without current heart disease, two scoring systems were used to estimate their risk of developing heart disease. The researchers found: 6.8% had undiagnosed high blood pressure; and 11.3% had undiagnosed high cholesterol.

Of those already diagnosed with high blood pressure, more than one-third had not been receiving recommended treatment. And, of those already diagnosed with high cholesterol, more than three-quarters had not been receiving recommended treatment.

"When we calculated the risk for developing a heart attack or stroke over 10 years, the risk for transgender men and women was higher than that reported for the average American of their age and gender. We also found that, even in the highest risk individuals, many were not receiving recommended treatment," said Denby.

In addition, the researchers found that more than half of the study participants (56.5%) had been previously diagnosed with a mental health disorder such as anxiety or depression, which is also associated with increased risk of heart disease.

"Transgender individuals face numerous barriers and biases to access the health care they need. We owe it to them to improve access and care so they can improve their CVD health and overall well-being. Policies and health care structures that are safe and supportive are critical for the transgender population to achieve health equity," Denby said.

The study, however, is limited by being a retrospective review of medical records. The results cannot be used to prove a cause-and-effect relationship between being transgender and the presence of heart disease risk factors.

DALLAS, Nov. 9, 2020 -- Remote or virtual cardiovascular or cardiac rehabilitation programs using tele-counseling with specialists, provided via telephone or mobile apps and web-based technology, were found to be as effective as on-site programs offered in hospitals, according to preliminary research to be presented at the American Heart Association's Scientific Sessions 2020. The meeting will be held virtually, Friday, November 13-Tuesday, November 17, 2020, and is a premier global exchange of the latest scientific advancements, research and evidence-based clinical practice updates in cardiovascular science for health care worldwide.

Cardiac rehabilitation is a standardized, outpatient program of exercise and education designed to help patients with established vascular disease or heart failure and patients after hospitalization for a heart attack, stroke, heart failure or surgery to treat heart disease. Research has shown that cardiac rehabilitation programs can reduce the risk of death from heart disease, hospital and emergency visits and the risk of future heart problems. However, many people have limited access to these services due to numerous factors including limited availability, transportation challenges and costs.

It has become challenging to provide on-site, outpatient cardiovascular rehab in hospitals or community sites in the advent of the COVID-19 public health emergency this year. Non-essential services closed in some countries as a result of COVID-19, and social distancing requirements prevented group activities, thereby, terminating in-person, on-site cardiac rehabilitation programs. Health care systems have adapted since the initial COVID-19 closures to provide remote delivery, also called telehealth, of rehabilitation services.

Two separate studies recently investigated the participation rates and effectiveness of remote, or virtual, rehabilitation programs for cardiac patients since the COVID-19 pandemic.

Health Care System Design and Virtual Delivery System: Cardiovascular Rehabilitation Access and Participation Rates During Covid19 Public Health Emergency (P2365)

Central East Cardiovascular Rehabilitation in the Eastern Greater Toronto area, Ontario, launched a region-wide, community-based cardiovascular rehabilitation service in 2011. The program includes region-wide referral criteria, centralized referral acceptance and standardized delivery of quality care by a regional workforce. The evidence-based, cardiac rehabilitation program serves patients at 17 community sites across a large region of Ontario and includes weekly visits for six months. More than 3,600 people participate in the program annually, with 70% acceptance rates and 60% completion rates.

When the Canadian and provincial governments implemented a nationwide lockdown on March 17 to limit the spread of COVID-19, the centrally managed, regional health care team of Central East Cardiac Rehabilitation Program rapidly transitioned from in-person, on-site to virtual content within one week. The virtual cardiovascular rehabilitation program included e-visits by telephone and email, as well as interactive technology such as web-based video support and mobile apps.

"We anticipated that the pandemic response would negatively impact referral, acceptance and completion rates," said Joseph A. Ricci, M.D., medical director of the Central East Cardiovascular Rehabilitation Program in Toronto, and lead author of this study. "Our centralized processes allowed uninterrupted referrals, and although office closures reduced community referrals, inpatient referrals increased."

In addition, patient acceptance and adherence were not significantly reduced compared to traditional cardiac rehabilitation services.

Compared to the same six-week period in 2019, after implementing the virtual rehab program since late March 2020:

Total referrals increased by 33%;

Patient acceptance exceeded 90%; and

Attendance rate vs. scheduled was 85%.

"We understood that virtual rehab may not be equivalent to the in-person, on-site community interaction patients were accustomed to, so we were pleasantly surprised that the virtual program was just as effective and that patient satisfaction did not decline," said Ricci. "The data confirm that virtual cardiac rehabilitation offers a viable solution as a result of the COVID pandemic, and also for patients in rural areas or those who have limited access to transportation."

However, one disadvantage of virtual cardiac rehab could be the higher cost in comparison to on-site delivery. In this study, the cost per patient was approximately double, due to staff costs related to more frequent one-on-one patient consultation and smaller group interactions.

Ricci added, "Based on this experience, modern technologies should be integrated into traditional delivery models beyond the pandemic period, including exploration of hybrid in-person, on-site and virtual rehabilitation programs. These programs are essential to improving outcomes for cardiovascular patients."

Co-authors are Riyad Akbarali, R. Kin., M.H.Sc.; Courtney Tsui, M.S.F.C., R.Kin.; Adam Pierce, B.A.Sc.; Stephanie Bennett, M.F.Sc., R.Kin.; Michael Wilson, B.Sc.; Kristen Doucette, B.H.Sc.; Thiru Appasamy, M.Com., Neville Suskin, M.B.Ch.B.; Trixie Williams, R.N., B.Sc.N., M.H.S.; and Stephanie Frisbee, Ph.D. Author disclosures are in the abstract.

The study was conducted by the program's CE Cardiovascular Rehabilitation Outcomes Research without funding from external sources.

Note: Session: EP.APS.18 - Role of Healthcare Systems and Care Delivery in Modifying CVD Epidemiology and Epidemiology of Atrial Fibrillation

Remote Cardiac Rehabilitation is a Good Alternative of Outpatient Cardiac Rehabilitation in the Covid-19 Era (P664)

In 2019, the University of Tokyo Hospital established a remote cardiovascular rehabilitation program for patients with heart failure. Patients who participated in the remote program received telephone support from cardiologists and nurses specializing in heart failure every two weeks for five months after hospital discharge. Each patient received a DVD of the cardiac rehab program, used their own medical devices at home and tracked their daily steps using a mobile app.

"Since our hospital has a large heart transplantation center in Japan, with many patients suffering from severe heart failure, we needed to perform remote cardiac rehabilitation before the COVID-19 era," said Atsuko Nakayama, M.D., Ph.D., a cardiologist at the University of Tokyo Hospital. "As the pandemic rapidly spread throughout the world, people needed to social distance, and on-site cardiac rehab services were temporarily suspended. During stressful times, the risk of cardiovascular events in patients with heart failure increases, and we wanted to evaluate if remote cardiac rehabilitation might be an effective alternative."

Researchers investigated patients hospitalized for heart failure from January 2019 to April 2020. This prospective study assessed patients' cardiac function including blood pressure, heart rate and shortness of breath. Emergency readmission rate within 30 days after hospital discharge was compared among groups receiving outpatient, remote or no cardiac rehabilitation. Quality of life scores were also compared between the outpatient and remote groups.

The results showed that remote cardiac rehabilitation is as effective as outpatient rehab for improvements in short-term prognosis after hospital discharge for patients hospitalized with heart failure. The emergency readmission rate within 30 days after discharge was lower in both the outpatient and remote groups as compared with patients who did not receive any rehabilitation services. In addition, patients' quality of life scores one month after discharge were higher in the remote group than the patients in the outpatient group.

"We were surprised by the better quality of life scores in the remote rehab group compared to the outpatient group," said Nakayama. "Our team speculated that talking to health care professionals on the phone instead of in person helped patients feel more comfortable discussing their medical problems, leading to better management of their heart problems. These findings suggest that remote rehab programs are a good alternative for in-person, outpatient programs."

The study also found that the participation rate in the remote cardiac rehabilitation program was higher during the COVID-19 pandemic:

Prior to COVID, more than 50% of patients did not complete any type of rehab after discharge, and 3% received remote rehab.

After in-person, outpatient programs closed, 69% of patients participated in a remote rehabilitation program.

During the COVID pandemic, only 20% of patients did not receive any cardiovascular rehabilitation services after discharge.

Nakayama added, "Most hospitals in the world can easily start a remote cardiac rehab service, which can help many cardiac patients during the COVID-19 pandemic. Our remote program required minimal expenses except for DVDs, booklets and phone costs, and patients did not need any special medical devices. In the future, remote cardiac rehabilitation may help resolve disadvantages due to regional disparities and access to medical specialists, which would especially benefit elderly patients and people living far away from a hospital."

DALLAS, Nov. 9, 2020 -- As the COVID-19 pandemic continues to affect people around the globe, research is ongoing to facilitate a greater understanding of the virus to improve patient care and outcomes. Heart health and medications and the potential role each have on patients with COVID-19 have been the focus of hundreds of studies. The American Heart Association will host experts presenting the latest COVID-19 research at its Scientific Sessions 2020; two studies are highlighted below. The meeting will be held virtually, Friday, November 13 - Tuesday, November 17, 2020, and is a premier global exchange of the latest scientific advancements, research and evidence-based clinical practice updates in cardiovascular science for health care worldwide.

Prevalence and Outcomes Among Hospitalized Patients With Covid-19 and Atrial Fibrillation or Flutter (Presentation P2355)

Previous studies have shown higher death rates in COVID-19 patients with evidence of heart damage. Heart damage can manifest as abnormal heart rhythms such as atrial fibrillation and atrial flutter. Atrial fibrillation is the most common form of heart arrhythmias and is an independent risk factor for death, especially in critically ill patients.

This study reviewed the prevalence and outcomes of hospitalized COVID-19 patients with atrial fibrillation and atrial flutter. Researchers reviewed medical records of 435* patients in the Yale Cardiovascular COVID Registry, who were adults, ages 18 and older (mean age 68.2 years; >50% were male) hospitalized between March and June 2020 in the Yale New Haven Health System. *Please note: This news release includes updated data compared to the abstract.

The data for the first 435 patients included in the registry revealed that 7.8% patients were diagnosed with atrial fibrillation/flutter for the first time in their lives, and 15.9% of the patients had a prior history of these types of arrhythmia. Overall, about one fifth of the patients had an episode of atrial fibrillation/flutter during hospitalization.

Additional analysis on the outcomes of the patients with atrial fibrillation/flutter showed that patients with a prior history of atrial fibrillation/flutter had a significantly higher risk of death or ICU mortality, independent of other health issues related to the heart, kidneys and lungs. Data also indicated in-hospital atrial arrhythmias were significantly associated with even higher risk of death and ICU mortality, as well as multi-organ failure, such as respiratory failure and renal failure.

"Our study suggests that the combination of COVID-19 and atrial arrhythmias may create a pathologic synergy that markedly increases the risk for major adverse cardiac events and death," said Zaniar Ghazizadeh, M.D., a lead author of the study and an internal medicine resident at Yale New Haven Hospital/Yale School of Medicine in New Haven, Connecticut. "COVID-19 places patients at a high risk for abnormal heart rhythms that are, in turn, associated with markedly worse outcomes including death and multi-organ failure. Patients and physicians need to monitor for these arrhythmias closely and treatments needs to be timely."

The researchers also cite the need for more investigation to understand the mechanisms of heart injury from COVID-19 infection and methods to prevent this complication.

Authors are Zaniar Ghazizadeh, M.D.; Chad Gier, M.D.; Avinainder Singh, M.D., M.M.Sc.; Lina Vadlamani, M.S., M.B.A.; Maxwell Eder, M.D.; Justin Pacor, M.D.; Jakob Park, M.D.; Manan Pareek, M.D., Ph.D.; Zain Ahmed, M.D., M.P.H., M.S.; Kim G. Smolderen, Ph.D.; Judith Lynne Meadows, M.D., M.P.H.; Tariq Ahmad, M.D., M.P.H.; Nihar R. Desai, M.D., M.P.H.; Rachel .J Lampert, M.D.; and James V. Freeman, M.D., M.P.H. The authors' disclosures are detailed in the abstract. No external funding sources were noted for this study.

Note: Session: EA.APS.25 - Atrial Fibrillation: Screening, Risk Factors, & Ablation Techniques and Outcomes

Meta-analyses for the Effect of Renin-angiotensin-aldosterone System Inhibitors on Mortality and Testing Positive of Covid-19 (Presentation 399)

There has been speculation that two types of medications used to treat high blood pressure and heart failure - angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) - may increase the risk of contracting COVID-19 .

The researchers examined MEDLINE and EMBASE databases for studies that detailed patients treated with ACE inhibitors and/or ARB medications. They conducted two meta-analyses to evaluate the results of 17 trials: 1) to investigate the rate of COVID-19 positive cases, and 2) to determine the death rate among those hospitalized with COVID-19.

Their analyses yielded these findings:

Patients taking ACE inhibitors or ARBs did not have an increased rate of COVID-19 infection; and

Hospitalized COVID-19 patients taking ACE inhibitors or ARBs did not have an increased rate of death.

A sub-analysis was also done, focused on the studies including patients treated for hypertension. The results indicate taking ACE inhibitors and ARBs was associated with a lower death rate among hospitalized COVID-19 patients with a history of hypertension.

"Our study results confirm that patients already taking ACE inhibitors and ARBs should not discontinue taking them due to COVID-19 infection," said lead study author Yujiro Yokoyama, M.D., surgeon at St. Luke's University Health Network's Easton Hospital in Pennsylvania. "Both medications have proven benefits for heart and kidney disease, and this further confirms previous findings that ACE inhibitors do not pose additional risk with COVID-19."

Early in the COVID-19 pandemic, the American Heart Association issued a joint statement with the Heart Failure Society of America and the American College of Cardiology to address the use of ACE inhibitors and ARB medications among patients at risk for developing COVID-19. The recommendations called for the continuation of ACE-i or ARB medications among patients already taking them for indications such as heart failure, hypertension or ischemic heart disease. Cardiovascular disease patients who are diagnosed with COVID-19 should be fully evaluated before adding or removing any treatments, and any changes to their treatment should be based on the latest scientific evidence and shared-decision making with their physician and health care team.

Embargoed until 4 a.m. CT/ 5 a.m. ET, Monday, Nov. 9, 2020

DALLAS, Nov. 9, 2020 -- Centhaquine, a new medication to treat patients who have severe blood or fluid loss, significantly improved outcomes and reduced death rate when added to standard of care, compared to standard care alone, according to preliminary research to be presented at the American Heart Association's Resuscitation Science Symposium 2020. The virtual meeting is November 14-16 and will feature the most recent advances related to treating cardiopulmonary arrest and life-threatening traumatic injury.

Severe loss of blood or fluids due to trauma, hemorrhage, gastrointestinal bleeding, excessive blood loss after surgery, diarrhea or vomiting can cause hypovolemic shock. About 60,000 people in the U.S. and 1.9 million people worldwide die each year due to hemorrhagic shock, with a large percentage of patients dying from blood loss within the first six hours.

"The primary goal when treating traumatic hemorrhage is to control blood loss and maintain cardiovascular function to prevent multi-organ failure and death," said Anil Gulati, M.D., Ph.D., lead author of the study and chairman and chief executive officer at Pharmazz, Inc., the company that produces centhaquine. "Despite advances in medical science, treatment for hypovolemic shock has changed little in the past 50 years, and there is an urgent need for an effective resuscitative agent for this serious and life-threatening condition. We investigated the safety and efficacy of centhaquine compared to standard care for the treatment of hypovolemic shock."

Centhaquine is a first-in-class resuscitative agent for treatment of hypovolemic shock with a unique mechanism of action. It increases pooled venous blood returning to the heart and redistributes that blood to vital organs, a critical process to preserve organ function and reduce mortality in patients with shock.

This multi-center, randomized, placebo-controlled phase III clinical study included 105 patients in India receiving standard of care for hypovolemic shock in a hospital or intensive care setting. Patients were randomized to receive either 1) standard of care and intravenous centhaquine, or 2) standard of care plus saline (control group).

Researchers found several markers of improvement in the group receiving centhaquine compared to those who received standard treatment alone:

At 24 hours of resuscitation, systolic blood pressure was raised from 90 mmHg or less to higher than 110 mmHg in 59% of patients in the control group and 81% of those in the centhaquine group.

Also, at 24 hours diastolic blood pressure was above 70 mmHg in 50% of the control group and 78% of those in the centhaquine group.

Reduction of blood lactate levels to 1.5 mmol/L or less occurred in 47% of the control group patients and 69% of the centhaquine patients. High levels of blood lactate are related to an increased risk of death for patients experiencing shock.

47% of patients in the standard treatment group had low base-deficit - a measure of oxygen imbalance - compared to 68% in the centhaquine group. Base-deficit is an indicator of low tissue blood perfusion and oxygenation. Lower numbers indicate better blood perfusion and tissue oxygenation.

The 28-day death rate was 12% in the control group and 3% in the centhaquine group.

Gulati added that the centhaquine group had improved acute respiratory distress syndrome and multiple organ dysfunction scores compared with the control group.

"Time is of the essence for hypovolemic shock patients, and these results suggest faster recovery towards normalization of blood pressure with centhaquine," Gulati said. "Centhaquine added to standard shock treatment also showed compelling mortality improvement over standard shock treatment, with a 9% absolute reduction in mortality compared to the control group."

Centhaquine is currently available to health care professionals in India and is advancing towards late stage clinical trials in the United States.

Embargoed until 4 a.m. CT/5 a.m. ET, Monday, Nov. 9, 2020

DALLAS, Nov. 9, 2020 -- Exposure to higher ozone concentrations in the air is significantly associated with a higher risk of out-of-hospital cardiac arrest (OHCA), according to preliminary research to be presented at the American Heart Association's Resuscitation Science Symposium 2020. The virtual meeting is November 14-16, 2020 and will feature the most recent advances related to treating cardiopulmonary arrest and life-threatening traumatic injury.

Previous studies have shown acute exposure to ozone and particulate matter in the air is associated with the development of chronic diseases. A 2010 scientific statement from the American Heart Association deemed ambient air pollutants a "modifiable factor that contributes to cardiovascular morbidity and mortality."

"Air pollutants have been associated with increased mortality in the U.S., however, it is unknown whether ozone and particulate matter in the air on any given day are associated with a higher risk of an individual experiencing cardiac arrest outside of the hospital," said Ali Malik, M.D., M.Sc., a clinical cardiology and cardiovascular outcomes research fellow at Saint Luke's Mid America Heart Institute in Gladstone, Missouri, and lead author of the study.

Researchers used data from the Cardiac Arrest Registry to Enhance Survival to examine if higher concentrations of ozone and particulate matter were associated with incidents of cardiac arrest. This study included 187,000 individuals with non-traumatic OHCA during 2013-2016. Participants were age 63 years on average, 61% were men and 53% were non-white. Individual exposures to particulate matter and ozone were estimated using data from the U.S. Environmental Protection Agency's atmospheric models that predict daily ozone levels by census tract.

The results of the analysis found that for every 12 parts per billion (ppb) increase in the ozone level, the odds of a OHCA increased by 1%, which is statistically significant. However, there was no association between particulate matter concentration and OHCA, and no difference in risk for air-quality-related OHCA tied to age, sex or race.

"We found that a higher concentration of ozone on the day the out of hospital cardiac arrest occurred was significantly associated with a higher risk," Malik said. "Importantly, we found that the relationship between ozone and risk of OHCA was present even at concentrations below the EPA air quality standard. These findings may have important public health implications."

Malik added, "Mechanisms by which acute ozone exposure increases the risk of cardiac arrest need to be better defined. It is important to limit exposure to high ozone levels, and we need more aggressive measures to decrease ambient air ozone concentrations."

Malik noted that this is an observational study and exposure to air pollutants was derived from outdoor estimates. Further study is needed to determine the exact relationship between air pollution and cardiac arrest.

Embargoed until 4 a.m. CT / 5 a.m. ET Nov. 9, 2020

DALLAS, Nov. 9, 2020 - Adults from underrepresented racial groups who have acute heart blockages and cardiac arrests received fewer early interventions, had longer hospital stays and higher death rates than their white counterparts, according to preliminary research to be presented at the American Heart Association's Resuscitation Science Symposium 2020. The 2020 meeting will be held virtually, November 14-16 and will feature the most recent advances related to treating cardiopulmonary arrest and life-threatening traumatic injury.

Researchers set out to investigate whether health inequities exist for racial and ethnic minorities with heart problems that could increase their risk for hospitalization or poorer outcomes after a heart event.

"As medical professionals, we need to continue to evaluate our own practice and perceptions. Race is a powerful determinant of a patient's health, along with their sex, age, insurance status and socio-economic status, and these factors work additively from a risk standpoint. For example, an older Black woman from a low-income household without medical insurance will likely have worse health outcomes than a middle-aged white man from an affluent home with good health insurance," said Saraschandra Vallabhajosyula, M.D., M.Sc., the study's senior author and a fellow of interventional cardiology at Emory University School of Medicine in Atlanta. "The complex interplay of these important non-clinical risk factors, also called social determinants of health, need careful evaluation. Only when we eliminate these disparities can we say health care is truly equitable."

Using data from the National Inpatient Sample, researchers examined more than 3 million hospital admissions across the U.S. between 2012 and 2017, 182,000 of which had cardiac arrest complications, making it the largest study of its kind.

The analysis found:

Racial and ethnic minority patients received fewer early treatment methods including coronary angiographies (uses contrast dyes and x-ray pictures to detect heart blockages) and percutaneous coronary interventions (PCI, formerly known as an angioplasty with a stent). (Rates for coronary angiography were 61.9% for Black patients; 70.2% for other groups; and 73.1% among white patients. PCI rates were 44.6%; 53.0%; and 58.1%, respectively).

Black patients experienced longer hospital stays, higher rates of palliative care consultation, less frequent use of a do not resuscitate (DNR) order and fewer discharges to home (they more frequently discharged to another type of care facility).

Asian, Pacific Islanders, Hispanics and Native Americans all had higher in-hospital death rates than white patients.
These findings are suggestive of a higher disease burden and a lower level of social support for patients from an underrepresented racial or ethnic group.

Further research into equitable care is required to address the disparities in care and outcomes for people from racial subgroups. This study is a retrospective analysis, so authors suggest careful validation is needed in future research. Additionally, patients self-reported race, and the information was not independently verified.

Embargoed until 4 a.m. CT, 5 a.m. ET Monday, Nov. 9, 2020

DALLAS, Nov. 9, 2019 - Due to the COVID-19 pandemic, safety precautions were initiated for health care professionals who are administering CPR, and the new protocols have not had a negative effect on patient outcomes or survival, according to preliminary research presented at the American Heart Association's Resuscitation Science Symposium 2020. The 2020 meeting will be held virtually, November 14-16, and will feature the most recent advances related to treating cardiopulmonary arrest and life-threatening traumatic injury.

"The increased precautions taken by health care professionals are for their own safety and for the safety of other patients in the hospital, and help the greater community," said Priyanka Sheth, lead author of the study and a master's candidate at the University of Louisville in Kentucky. "Based upon this analysis, the use of equipment such as N-95 face masks, face shields and protective gowns do not appear to be degrading the quality of patient care, at least specifically during CPR procedures."

Due to the COVID-19 pandemic, new interim CPR guidance was introduced by the American Heart Association and the Centers for Disease Control and Prevention (CDC) encouraging health care professionals to increase precautions with respect to personal protective equipment (PPE) and protocols used when administering cardiopulmonary resuscitation (CPR). The interim guidance has been widely adopted during emergency situations involving patients with known COVID-19, as well as for patients suspected to have COVID-19. There has, however, been debate about possible strain the new guidance places on health care professionals and whether or not the additional protective equipment is impacting the quality of CPR administered, potentially leading to poor patient outcomes.

To assess the safety and effectiveness of the updated CPR practices during the pandemic, this study analyzed the outcomes for patients at one medical center in Kentucky who were treated with in-hospital CPR. Researchers compared patient outcomes from March to June 2020 to outcomes of patients treated from March to May 2019.

Researchers examined the patients' demographics, comorbidities and body mass index (BMI) measurements, as well as the characteristics of CPR performed and patient outcomes. The patient groups were matched by patient characteristics, although the patients who were COVID-19 positive had significantly higher BMI than the patients without COVID-19.

A total of 94 hospital codes (codes indicating that CPR was performed) identified 80 patients for the study. In 2019, in-hospital CPR was performed 41 times, and none of the patients had COVID-19. Of the 2020 in-hospital CPR treatment codes analyzed, 43 patients did not have COVID-19, and 10 patients were COVID-19 positive.

The average amount of time of the CPR event was significantly greater for the patients with COVID-19. The year-to-year comparison did indicate, however, there was no significant difference in the percentage of patients who survived. Of the patients who were COVID-19 positive, 50% survived the code event, compared to 64% of the patients without COVID-19. Data also indicated that only one of the patients with COVID-19 (10%) survived to hospital discharge, compared to 25% of patients without COVID-19.

Study researchers concluded patient outcomes were similar for the patients in 2019 and 2020, indicating that additional precautions taken by health care professionals because of the COVID-19 outbreak are not degrading the quality of CPR administered.

"The safest practice for both health care professionals and for patients is to continue following the American Heart Association and CDC guidance when it comes to extra precautions during CPR administration," said Sheth. "Future research could potentially replicate this study on a national scale to assess if the same trends can be observed across multiple medical centers."

PHILADELPHIA--Food insecurity is one of the nation's leading health and nutrition issues--about 13.7 million (10.5 percent) of households in the United States were food insecure at some time during 2019, a trend likely to increase in light of the COVID-19 pandemic. According to preliminary research conducted by researchers at Penn Medicine, increasing rates of food insecurity in counties across the United States are independently associated with an increase in cardiovascular death rates among adults between the ages of 20 and 64.

The large-scale, national study, which will be presented at the American Heart Association's Scientific Sessions 2020, provides evidence of the link between food insecurity and increased risk of cardiovascular death. This is one of the first national analyses to evaluate changes in both food security and cardiovascular mortality over time, and to see if changes in food insecurity impact cardiovascular health. The findings were also published today in Circulation: Cardiovascular Quality and Outcomes.

"This research gives us a better understanding of the connection between economic distress and cardiovascular disease," said Sameed Khatana, MD, MPH, senior author of the study and instructor of Cardiovascular Medicine in the Perelman School of Medicine at the University of Pennsylvania. "What's going on outside the clinic has significant impact on patients' health. There are many factors beyond the medications we may be prescribing that can influence their wellbeing, food insecurity being one of them."

Researchers analyzed data from the National Center for Health Statistics and the Map the Meal Gap study, to examine county-level cardiovascular death rates and food insecurity rates from 2011 to 2017, among adults age 20 to 64, and those 65 years and older.

The researchers found that while the overall food insecurity rates for the entire country declined between 2011 and 2017, the counties that had the most increase in food insecurity levels had cardiovascular death rates that increased from 82 to 87 per 100,000 individuals. Additionally, for every 1 percent increase in food insecurity, there was a similar increase in cardiovascular mortality among non-elderly adults (0.83 percent).

"There has been a growing disparity when it comes to food insecurity, and this data demonstrates that parts of the country are being left behind. Unfortunately, this may only get worse as the country grapples with the ramifications of the COVID-19 pandemic," Khatana said. "However, interventions that improve a community's economic wellbeing could potentially lead to improved community cardiovascular health."

The authors intend to study whether interventions that improve food insecurity can lead to better cardiovascular health.

Researchers from Western University and University of Houston published a new paper in the Journal of Marketing that examines whether spoiler movie reviews harm box office revenue.

The study, forthcoming in the Journal of Marketing, is titled "Do Spoilers Really Spoil? Using Topic Modeling to Measure the Effect of Spoiler Reviews on Box Office Revenue" and is authored by Jun Hyun (Joseph) Ryoo, Xin (Shane) Wang and Shijie Lu.

"No spoilers!" say many directors. Their concern is that if publications or moviegoers reveal plotlines and surprises, the public won't want to pay for the movie. But is that concern well-founded?

To examine this question, the research team examined daily box office revenues for movies released between January 2013 and December 2017 in the United States. These movies were then matched with their respective reviews collected from Internet Movie Database (IMDb), the most popular movie review platform in the United States. The researchers also developed a measurement of spoiler intensity, or the degree of plot uncertainty resolved by reading spoilers in movie reviews. The study results indicate that spoiler intensity has a positive and significant relationship with box office revenue.

Ryoo explains that "We postulate that uncertainty reduction is the driving mechanism behind this positive spoiling effect. If potential moviegoers are unsure about the quality of a movie, they are likely to benefit from the plot-related content of spoiler reviews when making their purchase decisions." Consistent with this, the research reveals an inverted-U relationship between average ratings and spoiler intensity, which suggests that the positive spoiling effect is stronger for movies that receive moderate or mixed ratings compared to movies that receive either very high or very low ratings. The positive spoiling effect is also stronger for movies that receive less advertising. Advertising can serve an informative function for consumers and is seen as a credible signal of quality in the movie industry. Less advertising should therefore lead to greater uncertainty about movie quality for potential moviegoers. Wang adds "The positive spoiling effect is also stronger for movies with limited release, which is a strategy often employed by independent and arthouse studios associated with greater uncertainty in terms of artistic quality. And the positive spoiling effect declines over time, likely because consumers have greater uncertainty in the earlier periods of a movie's life cycle."

This leads to several implications for stakeholders in the movie industry. Foremost among these is that online review platforms can potentially increase consumer welfare by using spoiler reviews. "The uncertainty-reduction mechanism suggests a spoiler-friendly review platform can help consumers make appropriate purchase decisions. We recommend that review platforms keep the warning labels on spoiler reviews because of the benefit of allowing consumers to self-select into the exposure to spoilers," says Lu.