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According to the World Health Organization, preeclampsia affects between 2% to 8% of pregnancies. It can cause serious, sometimes fatal, complications in the mother and child. Among other risk factors, such as obesity and diabetes, vitamin D deficiency during pregnancy has been associated with an increased risk of preeclampsia.

In an article in Pregnancy Hypertension, a team of researchers at the Medical University of South Carolina (MUSC) found that expression of a set of genes previously studied in the setting of early onset and severe preeclampsia is significantly affected by vitamin D status during late-stage pregnancy.

Exactly how preeclampsia develops is unclear. Recent evidence points to poor development of blood vessels in the placenta - the organ that nourishes the fetus throughout pregnancy. This leads to hypertension and several other complications in the mother. The only cure for preeclampsia is to deliver the fetus, which can be dangerous if done too early.

In a previous study that was supported by pilot funding from the South Carolina Clinical & Translational Research Institute (SCTR), the research team led by Kyu-Ho Lee, M.D., Ph.D., assistant professor in the departments of Pediatrics and Obstetrics and Gynecology at MUSC found that the expression of three genes - NKX2-5, SAM68, and sFLT1 - are highly correlated in the setting of early-onset and severe preeclampsia (EOSPE), with sFLT1 being an identified marker for preeclampsia risk. In the current study, which also received SCTR support, the authors examined the expression of these genes in healthy pregnant women.

"Having observed the correlated expression of these genes in preeclampsia, we wanted to see the pattern of expression of these genes in normal pregnancy," said Lee. "We had a secondary goal of seeing whether vitamin D status affected the expression of these genes."

The sFLT1 protein interferes with the activity of vascular endothelial growth factor (VEGF), which is an important regulator of blood vessel development. This reduces vascular growth in the placenta. The amount of sFLT1 in the placenta is regulated in part by SAM68 and NKX2-5, also known as the tinman gene. This hypothesized NKX2-5/SAM68/sFLT1 gene "axis" may contribute to the development of preeclampsia.

"NKX2-5 might be controlling the regulation of sFLT1 and SAM68 in such a way that in preeclampsia, the expression levels of those genes go awry and tilt the vascular development in a direction that might trigger preeclampsia," said Lee.

Vitamin D affects many aspects of the mother's health during pregnancy. To investigate how the gene axis is affected by maternal vitamin D status, Lee's team studied placental samples from 43 pregnant women enrolled in a clinical trial at MUSC organized by their collaborator, MUSC Health neonatologist Carol L. Wagner, M.D., a professor in the Department of Pediatrics. Half of the women received a high dose of vitamin D3 (4,000 IU/day), and the other half received a placebo. The study group included African American, Hispanic American and Caucasian American women.

In contrast to their previous study, the team did not detect significant levels of NKX2-5 in placental tissue samples before a healthy delivery. This finding suggests that NKX2-5 expression is important in early at-risk pregnancies but not healthy pregnancies. However, the team did observe a strong positive correlation between SAM68 and sFLT1 in all study participants.

"The tight correlation between SAM68 and sFLT1 makes us think that there's a functional relationship between these genes," said Lee.

Interestingly, when assessed at the last visit before delivery, women who were vitamin D deficient (

This study provides novel insight into the activity of the NKX2-5/SAM68/sFLT1 gene axis during healthy pregnancies in a diverse group of women and how it may be affected by the vitamin D status of the mother.

"These results raise the possibility that vitamin D somehow directly regulates sFLT1 and/or SAM68 expression at some level," said Lee. "However, at this point, we haven't addressed the exact molecular relationship."

Future studies might investigate the relationship between vitamin D status and the expression of sFLT1 and SAM68 in mothers diagnosed with preeclampsia.

"Ideally, you would want a study with an equal number of diseased versus control pregnancies that had differential levels of vitamin D," said Lee. "Then we could look at the incidence of disease in correlation to the levels of vitamin D they achieved and the amount of gene expression that we had observed."

The team's current findings contribute to a basic biological understanding of the development of pregnancy and preeclampsia. Lee believes that this understanding will improve the standard of care for treating preeclampsia.

"We can begin to develop clinical markers that would help us gauge the health of a pregnancy during its course," said Lee. "This could provide warning signs for an increasing risk of pregnancy complication."

Bats excel in acoustic perception and detect objects as tiny as mosquitoes using sound waves. Echolocation permits them to calculate the three-dimensional location of both small and large objects, perceiving their shape, size and texture. To this end, a bat's brain processes various acoustic dimensions from the echoes returning from the object such as frequency, spectrum and intensity.

But sometimes bats collide with large walls even though they detect these walls with their sonar system. Researchers from Tel Aviv University (TAU) have concluded that these collisions do not result from a sensory limitation but rather from an error in acoustic perception.

The study was led by Dr. Sasha Danilovich, a former PhD student in the lab of Prof. Yossi Yovel, Head of the Sagol School for Neuroscience and faculty member at the School of Zoology at the George S. Wise Faculty of Life Sciences. Other participants included Dr. Arian Bonman and students Gal Shalev and Aya Goldstein of the Sensory Perception and Cognition Laboratory at the School of Zoology and the Sagol School of Neuroscience. The paper was published on October 26, 2020, in PNAS.

The TAU researchers released dozens of bats in a corridor blocked by objects of different sizes and made of different materials. To their surprise, the researchers discovered that the bats collided with large sponge walls that produce a weak echo as if they did not exist. The bats' behavior suggested that they did this even though they had detected the wall with their sonar system, indicating that the collision did not result from a sensory limitation, but rather from an acoustic misperception.

The researchers hypothesize that the unnatural combination of a large object and a weak echo disrupts the bats' sensory perception and causes them to ignore the obstacle, much like people who bump into transparent walls.

The researchers then methodically changed the features of the objects along the corridor, varying their size, texture and echo intensity. They concluded that the bats' acoustic perception depends on a coherent, typical correlation of the dimensions with objects in nature -- that a large object should produce a strong echo and a small object a weak echo.

"By presenting the bats with objects whose acoustic dimensions are not coherent, we were able to mislead them, creating a misconception that caused them to repeatedly try to fly into a wall even though they had identified it with their sonar," Danilovich explains. "The experiment gives us a peek into how the world is perceived by these creatures, whose senses are so unique and different from ours."

At any given moment in time, our brain is involved in various activities. For example, when typing on a keyboard, our brain not only dictates our finger movements but also how thirsty we feel at that time. As a result, brain signals contain dynamic neural patterns that reflect a combination of these activities simultaneously. A standing challenge has been isolating those patterns in brain signals that relate to a specific behavior, such as finger movements. Further, developing brain-machine interfaces (BMIs) that help people with neurological and mental disorders requires the translation of brain signals into a specific behavior, a problem called decoding. This decoding also depends on our ability to isolate neural patterns related to specific behaviors. These neural patterns can be masked by patterns related to other activities and can be missed by standard algorithms.

Led by Maryam Shanechi, Assistant Professor and Viterbi Early Career Chair in Electrical and Computer Engineering at the USC Viterbi School of Engineering, researchers have developed a machine learning algorithm that resolved the above challenge. The algorithm published in Nature Neuroscience uncovered neural patterns missed by other methods and enhanced the decoding of behaviors that originated from signals in the brain. This algorithm is a significant advance in modeling and decoding of complex brain activity which could both enable new neuroscience discoveries and enhance future brain-machine interfaces.

Standard algorithms, says Shanechi, can miss some neural patterns related to a given behavior that are masked by patterns related to other functions happening simultaneously. Shanechi and her PhD student Omid Sani developed a machine learning algorithm to resolve this challenge.

Shanechi, the paper's lead senior author says, "We have developed an algorithm that, for the first time, can dissociate the dynamic patterns in brain signals that relate to specific behaviors one is interested in. Our algorithm was also much better at decoding these behaviors from the brain signals."

The researchers showed that their machine learning algorithm can find neural patterns that are missed by other methods. This was because unlike prior methods which only consider brain signals when searching for neural patterns, the new algorithm has the ability to consider both brain signals and the behavioral signals such as the speed of arm movements. Doing so, says Sani, the study's first author, the algorithm discovered the common patterns between the brain and behavioral signals and was also much better able to decode the behavior represented by brain signals. More generally, he adds, the algorithm can model common dynamic patterns between any signals for example, between the signals from different brain regions or signals in other fields beyond neuroscience.

To test the new algorithm, the study's authors, which include Shanechi's PhD students Omid Sani and Hamidreza Abbaspourazad, as well as Bijan Pesaran, Professor of Neural Science at NYU and Yan Wong, a former Post-Doc at NYU, relied on four existing datasets collected in the Pesaran Lab. The datasets were based on recorded changes in the neural activity during the performance of different arm and eye movement tasks.

In the future, this new algorithm could be used to develop enhanced brain-machine interfaces that help paralyzed patients by significantly improving the decoding of movement or speech generated by brain signals and thus translating these signals into a specific, desired behavior such as body movements. This could allow a paralyzed patient to move a robotic arm by merely thinking about the movement or generate speech by just thinking about it. In addition, this algorithm could help patients with intractable mental health conditions such as major depression by separating brain signals related to mood symptoms and allowing for real-time tracking of these symptoms (which is outlined in previous studies Shanechi completed). The tracked symptom could then be used as feedback to tailor a therapy to a patient's needs.

Shanechi adds, "By isolating dynamic neural patterns relevant to different brain functions, this machine learning algorithm can help us investigate basic questions about brain's functions and develop enhanced brain-machine interfaces to restore lost function in neurological and mental disorders."

As the holiday season nears, thoughts of pumpkin pies, roasted chestnuts and turkey dinners fill our dreams and our grocery shopping lists. While visions of holiday food may be pleasing to the eyes and tantalizing to the palate, it would be a mistake to conclude that pretty food is healthier than other food.

Yet consumers often fail to make the distinction, a mistake that the food industry, advertisers and restaurants count on to promote products.

So says USC research recently published in the Journal of Marketing. The study employed social science and psychology to unravel the complexity of how perceptions of beauty drive our appetite and spending decisions. And the researcher suggested measures that industry and policymakers can take to protect public health.

"Marketers frequently style food to look pretty," said Linda Hagen, the study's lead author and an assistant professor of marketing at the USC Marshall School of Business. "In our minds, people associate aesthetic beauty with nature and natural things, which transfers to perceptions that pretty food is healthy food, but people are often misled by the prettiness of food that's not very good for you."

Consumers see almost 7,000 food and restaurant ads annually -- about 19 per day -- and nearly three-quarters of the messages promote fast food. Advertisers employ teams of food stylists and digital tools to render food irresistible. The images include the artful architecture of a hamburger, a perfect circumference of cheesy pizza or cascading colorful nachos or French fries.

Hagen examined how classical aesthetics used in food presentation skews perception. Features such as symmetry, patterns, order and balance are hallmarks of classical beauty because they mimic nature. Think spider webs or honeycombs, a starfish or sunsets, butterfly wings or fish scales. Food looks pretty when it copies naturelike features. Moreover, previous neuroscience research suggests viewing delectable food images activates the brain's gustatory cortex, essentially simulating the food's pleasurable taste.

USC research shows a perceived link between pretty and healthy food

This study goes a step further to determine if pretty aesthetics have other, less obvious effects on food choices, assessing if attractive food appears healthier to consumers and thus influences their decisions.

In a series of experiments involving 4,300 subjects, the researcher asked people to examine photos of food as well as actual samples of food, then evaluate the displays as healthy or unhealthy and processed or unprocessed.

In the first study, 800 people were asked to search the internet and pick out samples of pretty or ugly food. The subjects returned with images of ice cream, lasagna, omelets and sandwiches, among other items. Next, subjects were asked to determine if the food was nutritious and healthy or not. Overwhelmingly, both men and women reported that pretty food was healthier.

In another experiment, 400 subjects evaluated two renderings of avocado toast: one image that showed neatly sliced crescents of delicate avocado arrayed on the toast and the other that depicted the fruit as a chunky green glop smeared on the bread. The participants were asked to rate the images by healthiness, naturalness and tastiness.

For each criterion, the subjects reported the pretty version of avocado toast as healthier and more natural, but the foods were viewed as equally expensive and tasty, the study shows.

The same outcome occurred with another group of 800 study participants who viewed pictures of foods such as cupcakes, almond bread with bananas and a plate of spaghetti marinara -- but with a caveat. Before they saw the images, the researcher had advised the subjects that the image they were about to see was aesthetically either flawed or beautiful, even though the image was the exact same photo. Biased by their expectation, the subjects considered the "ugly" food less natural and nutritious than the "pretty" food, though there was no real difference.

And the pattern continued in another experiment at a curbside produce stand that Hagen set up during move-in day at USC several years ago. She gave students $1, led them to a booth and showed them one of two green bell peppers: either a cosmetically perfect one or a somewhat odd-shaped one. When asked how much money they would maximally pay to purchase the bell pepper, the subjects were willing to spend roughly 56% more for the flawless fruit, a boost that was explained by a simultaneous increase in perceived healthiness.

"Time and again, in each of these experiments, people perceived the same food as more natural when it looks prettier and believe that this naturalness implies healthiness," Hagen said. "Consumers expect food to be more nutritious, less fatty and contain fewer calories when it looks pretty based on classical aesthetic principles, and that bias can affect consumer choices and willingness to pay for food."

Advertisements for pleasing-looking food may have more influence than you realize

In daily life, the effect holds true at the grocery store, where people consider natural things -- organic food, natural remedies or garden crops -- to be healthier than unnatural things such as processed food or synthetic chemicals.

Given that stylized food advertisements can mislead consumers into making unhealthy choices, the study suggests that companies or regulators consider measures such as disclaimers on food images in ads to disclose that the product has been modified to enhance its healthy appearance.

"Many food advertisements and restaurant menus may be suggesting greater levels of healthiness in food than is true," Hagen said. "The use of aesthetics that misleads people warrants close consideration by policymakers. A statement that explicitly reminds people that pretty food was modified for depiction helped mitigate the effect in the lab, so disclaimers may be an effective way to protect consumers."

Researchers at North Carolina State University have identified a new species of Rickettsia bacteria that may cause significant disease in dogs and humans. This new yet unnamed species, initially identified in three dogs, is part of the spotted-fever group Rickettsia which includes Rickettsia rickettsii, the bacteria that cause Rocky Mountain Spotted Fever (RMSF).

Rickettsia pathogens are categorized into four groups; of those, spotted-fever group Rickettsia (which are transmitted by ticks) is the most commonly known and contains the most identified species. There are more than 25 species of tick-borne, spotted-fever group Rickettsia species worldwide, with R. rickettsii being one of the most virulent and dangerous.

For dogs, R. rickettsii is the only known spotted fever group Rickettsia that causes clinical disease in North America. Symptoms of RMSF in dogs and people are similar, including fever, lethargy, weight loss and symptoms related to vascular inflammation, like swelling, rash and pain.

In 2018 and 2019, three dogs from three different states (Tennessee, Illinois and Oklahoma) with exposure to ticks and RMSF-associated symptoms had blood samples taken, to test them for R. rickettsii. While the samples reacted positively to antibody tests for R. rickettsii, when researchers at NC State utilized polymerase chain reaction (PCR) to amplify the pathogen's DNA from the samples, the DNA they retrieved was only 95% similar to R. rickettsii.

"Often, antibodies from other spotted fever group Rickettsia will cross-react in antibody tests for RMSF," says Barbara Qurollo, associate research professor at NC State and corresponding author of a paper describing the work. "So to be sure what we're dealing with, we also look at the genetic information via PCR and that's how we found that this is a new organism."

The initial PCR work led Qurollo and James Wilson, a PCR technician at NC State and first author of the study, to pursue the new bacteria further. They performed additional PCRs to amplify different genes and examined five different regions of the bacteria's DNA, comparing it to the sequenced DNA from other spotted fever group Rickettsia. They also performed a phylogenetic tree analysis, which allowed them to place the new Rickettsia firmly within the spotted fever group.

Before naming this new Rickettsia species, Qurollo and colleagues want to culture the organism, which would allow for better characterization of the new species. Culturing Rickettsia species from small amounts of a clinical sample has been difficult to do thus far.

"We're going to continue looking for this Rickettsia species, determine its geographical range and try to better characterize it - it's a slow process, but high on our radar," Qurollo says. "So far in 2020 we've detected this new Rickettsia species in four more dogs residing in the southeastern and midwestern U.S. We're also asking veterinarians to collect the ticks associated with dogs who show symptoms when possible, and we're collaborating with researchers in Oklahoma to collect ticks in the environment for testing. This will help us determine what tick species may be transmitting this particular bacteria.

"Another question we would like to answer is whether this new Rickettsia species also infects people. Dogs are great sentinels for tick-borne diseases - they have high rates of exposure to ticks and the ability to become infected with many of the same tick-borne pathogens that infect people. We hope to take a 'One Health' approach to this new pathogen and collaborate with scientists in human medicine as well."

Measures to reduce the spread of COVID-19 through non-pharmaceutical interventions (NPIs) such as mask wearing and social distancing are a key tool in combatting the impact of the ongoing coronavirus pandemic. These actions also have greatly reduced incidence of many other diseases, including influenza and respiratory syncytial virus (RSV).

Current reductions in these common respiratory infections, however, may merely postpone the incidence of future outbreaks, according to a study by Princeton University researchers published Nov. 9 in the Proceedings of the National Academy of Sciences.

"Declines in case numbers of several respiratory pathogens have been observed recently in many global locations," said first author Rachel Baker, an associate research scholar at the High Meadows Environmental Institute (HMEI) at Princeton University.

"While this reduction in cases could be interpreted as a positive side effect of COVID-19 prevention, the reality is much more complex," Baker said. "Our results suggest that susceptibility to these other diseases, such as RSV and flu, could increase while NPIs are in place, resulting in large outbreaks when they begin circulating again."

Baker and her co-authors found that NPIs could lead to a future uptick in RSV -- an endemic viral infection in the United States and a leading cause of lower respiratory-tract infections in young infants -- but that the same effect was not as pronounced for influenza.

"Although the detailed trajectory of both RSV and influenza in the coming years will be complex, there are clear and overarching trends that emerge when one focuses on some essential effects of NPIs and seasonality on disease dynamics," said co-author Gabriel Vecchi, Princeton professor of geosciences and the High Meadows Environmental Institute.

The researchers used an epidemiological model based on historic RSV data and observations of the recent decline in RSV cases to examine the possible impact of COVID-19 NPIs on future RSV outbreaks in the United States and Mexico.

They found that even relatively short periods of NPI measures could lead to large future RSV outbreaks. These outbreaks were often delayed following the end of the NPI period, with peak cases projected to occur in many locations in winter 2021-22. "It is very important to prepare for this possible future outbreak risk and to pay attention to the full gamut of infections impacted by COVID-19 NPIs," Baker said.

The authors also considered the implications of COVID-19 NPIs for seasonal influenza outbreaks and found results qualitatively similar to RSV. The dynamics of influenza are much harder to project due to viral evolution, however, which drives uncertainty over future circulating strains and the efficacy of available vaccines.

"For influenza, vaccines could make a big difference," Baker said. "In addition, the impact of NPIs on influenza evolution is unclear but potentially very important."

"The decrease in cases of influenza and RSV -- as well as the possible future increase we project -- is arguably the broadest global impact of NPIs across a variety of human diseases that we've seen," said co-author Bryan Grenfell, the Kathryn Briger and Sarah Fenton Professor of Ecology and Evolutionary Biology and Public Affairs, who is associated faculty in HMEI.

"NPIs could have unintended longer-term impacts on the dynamics of other diseases that are similar to the impact on susceptibility we projected for RSV," he said.

A similar effect of pandemic-related NPIs on other pathogens was observed following the 1918 influenza pandemic. Historic measles data from London show a shift from annual cycles to biennial outbreaks following a period of control measures implemented at that time.

Co-author C. Jessica Metcalf, associate professor of ecology and evolutionary biology and public affairs and an associated faculty member in HMEI, said that directly evaluating the associated risks of NPIs by developing and deploying tools such as serology that would better measure susceptibility is an important public health and policy direction. "The future repercussions of NPIs revealed by this paper hinge on how these measures change the landscape of immunity and susceptibility," Metcalf said.

DALLAS, Nov. 9, 2020 -- Nearly one-third of racial disparities in treating high blood pressure may stem from inequities in treatment intensification, 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.

Treatment intensification is critical for optimal blood pressure control and includes either prescribing a new medication in a different class or increasing the dose of an existing medication when a patient's blood pressure is higher than the goal. In this study, the goal levels were 140 mm Hg for the top number (systolic) and 90 mm Hg for the bottom number (diastolic). According to the current American Heart Association/American College of Cardiology Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults, hypertension is defined as 130/80 mm Hg or higher.

"Missed opportunities for increasing therapy may be one of the most significant contributors to racial disparities in blood pressure outcomes that may, in turn, contribute to poor health for Black Americans," said Valy Fontil, M.D., M.A.S., assistant professor of medicine at the University of California San Francisco (UCSF) and first author of the study.

"Achieving blood pressure control in the U.S. still relies on decisions made by clinicians and patients during the clinical encounter," said Kirsten Bibbins-Domingo, Ph.D., M.D., M.A.S., chair of the department of epidemiology and biostatistics at UCSF and senior author of the study. "More research is necessary to explain why there are such variations in these decisions to intensify therapy."

Researchers examined data from 2015 to 2017 for more than 15,000 patients treated for hypertension at 12 San Francisco safety-net clinics, which typically provide care to low-income patients. Patients were diagnosed with hypertension and had at least one clinic visit with uncontrolled blood pressure. The average age of patients was 58; 50% were women; and included patients from diverse racial ethnic groups: 29% Asian, 23% Black, 24% Hispanic, and 17% white adults.

The study authors analyzed racial differences in achieving normal blood pressure control and whether those differences could be explained by increasing medication therapy for high blood pressure or patients missing clinic appointments. Missed visits were counted as the number of "no shows" in the four weeks following high blood pressure diagnosis.

The study found:

Black participants had more missed opportunities for treatment intensification and missed more clinic appointments, compared to other racial groups.

Lower treatment intensification accounted for 28% and missed clinic visits for 14% of the total effect of Black patients' blood pressure control, which surprised researchers.

Additional or intensified treatment for blood pressure control was lower in Black patients and higher in Asian Americans than in the other racial groups.

"Previous studies have shown that Black patients with hypertension are the least likely to achieve normal blood pressure and Asian Americans are the most likely to achieve normal blood pressure, and our results confirmed this. The most surprising finding is that this racial difference appears to be explained by whether patients received additional or intensified therapy for high blood pressure," said co-author Lucia Pacca, Ph.D., a research associate at UCSF.

"We were completely surprised that Asian Americans' higher performance in achieving normal blood pressure was almost entirely explained by prescribing behavior," said Fontil. "Although other investigators have shown that treatment decisions for some conditions such as pain can vary based on the patient's race and physician bias, this phenomenon has not been widely reported for hypertension treatment. So, we were surprised that doctors were less likely to increase treatment for Black patients, and even more surprised that Asian American patients' higher likelihood in achieving normal blood pressure was largely related to doctors providing treatment intensification to more patients."

In addition, the researchers used a statistical model to estimate the likelihood of blood pressure control (lower than 140/90 mm Hg) to compare Black and white patients with hypertension. After accounting for gender, age, first recorded blood pressure during the two years of the study, clinic visit frequency and diabetes diagnosis, Black patients remained 15% less likely than whites to achieve blood pressure control.

"Our findings should prompt further investigation to determine why Black patients are less likely to have blood pressure therapy increased and why Asian Americans are more likely to be receive more aggressive treatment," Fontil said. "These findings also reemphasize the call for adopting treatment protocols and clinical decision supports that can help standardize quality of care for hypertension and perhaps other chronic diseases."

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."