Elizabeth A Jackson

University of Pittsburgh, Pittsburgh, Pennsylvania, United States

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Publications (79)575.13 Total impact

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    ABSTRACT: Background: Studies have reported associations between long-term air pollution exposures and cardiovascular mortality. The biological mechanisms connecting them remain uncertain. Methods: We examined associations of fine particles (PM2.5) and ozone with serum markers of cardiovascular disease risk in a cohort of midlife women. We obtained information from women enrolled at six sites in the multi-ethnic, longitudinal Study of Women's Health Across the Nation, including repeated measurements of high-sensitivity C-reactive protein (hs-CRP), fibrinogen, tissue-type plasminogen activator antigen (tPA-ag), plasminogen activator inhibitor Type 1 (PAI-1), and Factor VIIc (Factor VII coagulant activity). We obtained residence-proximate PM2.5 and ozone monitoring data for a maximum five annual visits, calculating prior year, six-month, one-month, and one-day exposures and their relations to serum markers using longitudinal mixed models. Results: For the 2,086 women studied from 1999 through 2004,PM2.5 exposures were associated with all blood markers except Factor VIIc after adjusting for age, race/ethnicity, education, site, body mass index, smoking, and recent alcohol use. Adjusted associations were of the strongest for prior year exposures for hs-CRP (21% increase per 10 µg/m PM2.5, 95% CI: 6.6, 37), tPA-ag (8.6%, 95% CI: 1.8, 16), and PAI-1 (35%, 95% CI: 19, 53). An association was also observed between year prior ozone exposure and Factor VIIc (5.7% increase per 10 ppb ozone, 95% CI: 2.9, 8.5). Conclusions: Our findings suggest that prior year exposures to PM2.5 and ozone are associated with adverse effects on inflammatory and hemostatic pathways for cardiovascular outcomes in midlife women.
    No preview · Article · Nov 2015 · Epidemiology (Cambridge, Mass.)
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    ABSTRACT: Background and purpose: Emerging work has linked menopausal vasomotor symptoms (VMS) to subclinical cardiovascular disease (CVD) among women. However, VMS are dynamic over time. No studies have considered how temporal patterns of VMS may relate to subclinical CVD. We tested how temporal patterns of VMS assessed over 13 years were related to carotid intima media thickness (IMT) among midlife women. Methods: The Study of Women's Health Across the Nation is a longitudinal cohort study of midlife women. Eight hundred and eleven white, black, Hispanic, and Chinese participants with a well-characterized final menstrual period completed measures of VMS, a blood draw, and physical measures approximately annually for 13 years. Women underwent a carotid artery ultrasound at study visit 12. Results: Four trajectories of VMS were identified by trajectory analysis (consistently high, early-onset, late-onset, persistently low VMS) and tested in relation to carotid indices in linear regression models. Results indicated that women with early-onset VMS had both greater mean IMT (beta, b [standard error, SE]=0.03 [0.01], P=0.03) and greater maximal IMT (b [SE]=0.04 [0.01], P=0.008) than women with consistently low VMS, adjusting for demographics and CVD risk factors. Conclusions: This is the first study to test trajectories of VMS in relation to subclinical CVD. Women with VMS early in the menopause transition had higher mean IMT and maximal IMT than those with consistently low VMS across the transition. Associations were not accounted for by demographic factors nor by CVD risk factors. Results can signal to women in need of early CVD risk reduction.
    No preview · Article · Nov 2015 · Stroke
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    ABSTRACT: Background: Previous studies have shown race/ethnicity, particularly African American and/or Hispanic status, to be a predictor of overweight/obese status in children. However, these studies have failed to adjust for low socioeconomic status (SES). This study assessed whether race/ethnicity remained an independent predictor of childhood obesity when accounting for variations in SES (low-income) among communities in Massachusetts. Methods: This study was based on 2009 summarized data from 68 Massachusetts school districts with 111,799 students in grades 1, 4, 7, and 10. We studied the relationship between the rate of overweight/obese students (mean = 0.32; range = 0.10-0.46), the rate of African American and Hispanic students (mean = 0.17; range = 0.00-0.90), and the rate of low-income students (mean = 0.27; range = 0.02-0.87) in two and three dimensions. The main effect of the race/ethnicity rate, the low-income rate, and their interaction on the overweight and obese rate was investigated by multiple regression modeling. Results: Low-income was highly associated with overweight/obese status (p < 0.0001), whereas the effect of race/ethnicity (p = 0.27) and its interaction (p = 0.23) with low-income were not statistically significant. For every 1% increase in low-income, there was a 1.17% increase in overweight/obese status. This pattern was observed across all African American and Hispanic rates in the communities studied. Conclusions: Overweight/obese status was highly prevalent among Massachusetts students, varying from 10% to 46% across communities. Although there were higher rates of overweight/obese status among African American and Hispanic students, the relationship disappeared when controlling for family income. Our findings suggest low SES plays a more significant role in the nation's childhood obesity epidemic than race/ethnicity.
    No preview · Article · Nov 2015 · Childhood Obesity
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    ABSTRACT: Despite the paucity of evidence, it is often presumed, and is physiologically plausible, that sudden, acute elevations in blood pressure may transiently increase the risk of recurrent aortic dissection (AD) or rupture in patients with a prior AD, because a post-dissection aorta is almost invariably dilated and may thus experience greater associated wall stress as compared with a nondilated aorta. Few data are available regarding the specific types and intensities of exercise that may be both safe and beneficial for this escalating patient population. The purpose of this editorial/commentary is to further explore this conundrum for clinicians caring for and counseling AD survivors. Moderate-intensity cardiovascular activity may be cardioprotective in this patient cohort. It is likely that severe physical activity restrictions may reduce functional capacity and quality of life in post-AD patients and thus be harmful, underscoring the importance of further exploring the role of physical activity and/or structured exercise in this at-risk patient population.
    Full-text · Article · Nov 2015 · Clinical Cardiology
  • Amanda Lyon · Elizabeth A. Jackson · Rita R. Kalyani · Dhananjay Vaidya · Catherine Kim
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    ABSTRACT: Reports from recent studies suggest that diabetes confers a higher risk of cardiovascular disease in women compared to men. Larger studies, including meta-analyses, report that women with diabetes have a 44 % greater risk of incident coronary heart disease and a 27 % greater risk of incident stroke compared to men with diabetes. In this article, we summarize results from longitudinal studies that examine sex differences in risk factors for and rates of macrovascular complications from diabetes. We also discuss possible mechanisms for increased cardiovascular risk associated with diabetes in women compared to men, including the clustering of hypertension, obesity, and elevated triglycerides, the possible contribution of hormonal differences, and sex differences in the prescription of and adherence to pharmacologic treatment. In conclusion, diabetes is associated with a slightly higher risk of cardiovascular disease in women compared to men. Future studies should further explore the reasons underlying imperfect use of medications that lower cardiovascular risk in both women and men with diabetes.
    No preview · Article · Nov 2015 · Current Diabetes Reports
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    ABSTRACT: Currently no research exists assessing lifestyle modifications and emotional state of acute aortic dissection (AAD) survivors. We sought to assess activity, mental health, and sexual function in AAD survivors. Physical and sexual activity will decrease in AAD survivors compared to pre-dissection. Incidence of anxiety and depression will be significant after AAD. A cross sectional survey was mailed to 197 subjects from a single academic medical center (part of larger IRAD database). Subjects were ≥18 years of age surviving a type A or B AAD between 1996 and 2011. 82 surveys were returned (overall response rate 42%). Mean age ± SD was 59.5 ± 13.7 years, with 54.9% type A and 43.9% type B patients. Walking remained the most prevalent form of physical activity (49 (60%) pre-dissection and 47 (57%) post-dissection). Physical inactivity increased from 14 (17%) before AAD to 20 (24%) after AAD; sexual activity decreased from 31 (38%) to 9 (11%) mostly due to fear. Most patients (66.7%) were not exerting themselves physically or emotionally at AAD onset. Systolic blood pressure (SBP) at 36 months post-discharge for patients engaging in ≥2 sessions of aerobic activity/week was 126.67 ± 10.30 vs. 141.10 ± 11.87 (p-value 0.012) in those who did not. Self-reported new-onset depression after AAD was 32% and also 32% for new-onset anxiety. Alterations in lifestyle and emotional state are frequent in AAD survivors. Clinicians should screen for unfounded fears or beliefs after dissection that may reduce function and/or quality of life for AAD survivors.
    Full-text · Article · Nov 2015 · Clinical Cardiology
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    ABSTRACT: Background: Physical functioning may be an important pre-clinical marker of chronic disease, used as a tool to identify patients at risk for future cardiometabolic abnormalities. This study evaluated if self-reported physical functioning was associated with the development of cardiometabolic abnormalities or their clustering (metabolic syndrome) over time. Methods: Participants (n=2,254) from the Study of Women's Health Across the Nation who reported physical functioning on the Short Form health survey and had a metabolic syndrome assessment (elevated fasting glucose, blood pressure, triglycerides, and waist circumference; reduced HDL cholesterol) in 2000 were included. Discrete survival analysis was used to assess the 10 year risk of developing metabolic syndrome or a syndrome component through 2010. Results: At baseline, the prevalence of metabolic syndrome was 22.0%. Women with substantial limitations (OR=1.60; 95% CI: 1.12, 2.29) in physical functioning were significantly more likely to develop the metabolic syndrome compared to women reporting no limitations. Self-reported physical functioning was significantly associated with incident hypertension and increased waist circumference. Conclusions: Simple screening tools for cardiometabolic risk in clinical settings are needed. Self-reported physical functioning assessments are simple tools that may allow health care providers to more accurately predict the course of chronic conditions.
    No preview · Article · Oct 2015 · Diabetes/Metabolism Research and Reviews
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    ABSTRACT: Nurturing the development of cardiovascular physician-scientist investigators is critical for sustained progress in cardiovascular science and improving human health. The transition from an inexperienced trainee to an independent physician-scientist is a multifaceted process requiring a sustained commitment from the trainee, mentors, and institution. A cornerstone of this training process is a career development (K) award from the National Institutes of Health (NIH). These awards generally require 75% of the awardee's professional effort devoted to research aims and diverse career development activities carried out in a mentored environment over a 5-year period. We report on recent success rates for obtaining NIH K awards, provide strategies for preparing a successful application and navigating the early career period for aspiring cardiovascular investigators, and offer cardiovascular division leadership perspectives regarding K awards in the current era. Our objective is to offer practical advice that will equip trainees considering an investigator path for success.
    No preview · Article · Oct 2015 · Journal of the American College of Cardiology
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    ABSTRACT: Objectives: We determined the sustainability of effects of a school-based intervention to improve health behaviors and cardiovascular risk factors among middle school children. Methods: We administered a questionnaire and health screenings to 5 schools in Ann Arbor and 2 schools in Ypsilanti, Michigan. We assessed demographics, physiological factors, diet, physical activity, and sedentary behaviors from 1126 students who received a health curriculum (Project Healthy Schools) in the fall of sixth grade in 2005, 2006, and 2007. We administered the questionnaire and screening again in the spring and each subsequent spring through ninth grade to all available, consenting students. Results: In the 4 years following the school-based intervention, total cholesterol, low-density lipoprotein cholesterol, and triglycerides improved, and for most years systolic and diastolic blood pressure improved. Serum glucose and body mass index did not change. Physical activity increased and sedentary behaviors diminished. Conclusions: Project Healthy Schools is associated with sustainable improvements in both cardiovascular parameters and healthy behaviors. (Am J Public Health. Published online ahead of print October 15, 2015: e1-e7. doi:10.2105/AJPH.2015.302835).
    No preview · Article · Oct 2015 · American Journal of Public Health
  • Geoffrey D. Barnes · Elizabeth A. Jackson

    No preview · Article · Oct 2015 · Journal of the American College of Cardiology
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    ABSTRACT: Aim: The purpose of this study was to assess associations between distinct patterns of circulating estradiol (E2) and follicle-stimulating hormone (FSH) over the menopause transition (MT) and subclinical measures of atherosclerosis after menopause. Methods and results: Four temporal patterns of E2 decline (Low: low before and after final menstrual period (FMP); Medium: medium before and high after FMP; High-early decline: high prior to FMP and early decline thereafter; High-late decline: high prior to FMP and late decline thereafter) and three of FSH rise (Low, Medium, High) over 9.6 years across FMP were identified and linked to carotid intima-media-thickness (IMT), adventitial diameter (AD), and presence of carotid plaque (cPlaque) measured after menopause at the 12th annual visit (visit 12). Participants were 856 women (age at visit 12 = 59.5 ± 2.7 years) from the Study of Women's Health Across the Nation (SWAN), who never reported a stroke or a heart attack. In models adjusted for visit 12 or baseline cardiovascular disease (CVD) risk factors, odds of having any cPlaque were ∼43% lower among women with the High-early decline E2 trajectory compared to women with the Low E2 trajectory. In contrast, women with the Medium E2 trajectory had significantly higher IMT than those with the Low E2 trajectory adjusting for visit 12 CVD risk factors. Interestingly, adjusting for baseline CVD risk factors attenuated this association. The Low FSH group had lower IMT than the Medium and High FSH groups (p ≤ 0.05) in all models. Conclusion: During MT, women are subjected to hormonal alterations that could potentially increase their risk of developing CVD after menopause.
    No preview · Article · Sep 2015 · European Journal of Preventive Cardiology
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    ABSTRACT: Although regular aerobic exercise improves overall health, increased physical activity can lead to heightened exposures to a variety of air pollutants. As such, the cardiovascular health benefits of exercise may be abrogated to some degree by the harmful actions of inhaled pollutants. This review aims to provide an up-to-date summary for health professionals of the cardiovascular responses as well as the risks of exercising in air pollution. Aerobic exercise augments the overall inhaled air pollution dose, potentiates the diffusion of pollutants into circulating blood, and augments oxidative stress and inflammation. The inhalation of particulate matter during exercise can raise blood pressure, impair vascular function, and unfavorably affect autonomic balance. Several studies suggest that air pollutants can increase ischemic symptoms and signs during exercise and can even be capable of impairing exercise performance in some scenarios. The overall evidence supports that the risk-to-benefit ratio generally favors that health care providers continue to strongly encourage their patients to perform regular aerobic exercise. Nevertheless, a greater effort should be made to educate patients about the risks of air pollutant exposures during exercise, particularly those at heightened cardiovascular risk. Although no strategy has been directly tested to reduce morbidity and mortality rate, several prudent actions can be taken to lessen the degree of exposures during exercise which may thereby help mitigate the adverse effects of air pollutants on exercise performance and cardiovascular risk.
    No preview · Article · Sep 2015 · Journal of cardiopulmonary rehabilitation and prevention
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    ABSTRACT: Fine particulate matter air pollution (PM2.5) and extreme temperatures have both been associated with alterations in blood pressure (BP). However, few studies have evaluated their joint haemodynamic actions among individuals at high risk for cardiovascular events. We assessed the effects of short-term exposures during the prior week to ambient PM2.5 and outdoor temperature levels on resting seated BP among 2078 patients enrolling into a cardiac rehabilitation programme at the University of Michigan (from 2003 to 2011) using multiple linear regression analyses adjusting for age, sex, BMI, ozone and the same-day alternate environmental factor (i.e. PM2.5 or temperature). Mean PM2.5 and temperature levels were 12.6 ± 8.2 μg/m and 10.3 ± 10.4°C, respectively. Each standard deviation elevation in PM2.5 concentration during lag days 4-6 was associated with significant increases in SBP (2.1-3.5 mmHg) and DBP (1.7-1.8 mmHg). Conversely, higher temperature levels (per 10.4°C) during lag days 4-6 were associated with reductions in both SBP (-3.6 to -2.3 mmHg) and DBP (-2.5 to -1.8 mmHg). There was little evidence for consistent effect modification by other covariates (e.g. demographics, seasons, medication usage). Short-term exposures to PM2.5, even at low concentrations within current air quality standards, are associated with significant increases in BP. Contrarily, higher ambient temperatures prompt the opposite haemodynamic effect. These findings demonstrate that both ubiquitous environmental exposures have clinically meaningful effects on resting BP among high-risk cardiac patients.
    No preview · Article · Jul 2015 · Journal of Hypertension
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    ABSTRACT: Fine particulate matter (PM2.5) air pollution and variations in ambient temperature have been linked to increased cardiovascular morbidity and mortality. However, no large-scale study has assessed their effects on directly measured aerobic functional capacity among high-risk patients. Using a cross-sectional observational design, we evaluated the effects of ambient PM2.5 and temperature levels over 7 days on cardiopulmonary exercise test results performed among 2078 patients enrolling into a cardiac rehabilitation programme at the University of Michigan (from January 2003 to August 2011) using multiple linear regression analyses (controlling for age, sex, body mass index). Peak exercise oxygen consumption was significantly decreased by approximately 14.9% per 10 μg/m(3) increase in ambient PM2.5 levels (median 10.7 μg/m(3), IQR 10.1 μg/m(3)) (lag days 6-7). Elevations in PM2.5 were also related to decreases in ventilatory threshold (lag days 5-7) and peak heart rate (lag days 2-3) and increases in peak systolic blood pressure (lag days 4-5). A 10°C increase in temperature (median 10.5°C, IQR 17.5°C) was associated with reductions in peak exercise oxygen consumption (20.6-27.3%) and ventilatory threshold (22.9-29.2%) during all 7 lag days. In models including both factors, the outcome associations with PM2.5 were attenuated whereas the effects of temperature remained significant. Short-term elevations in ambient PM2.5, even at low concentrations within current air quality standards, and/or higher temperatures were associated with detrimental changes in aerobic exercise capacity, which can be linked to a worse quality of life and cardiovascular prognosis among cardiac rehabilitation patients. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
    No preview · Article · Jun 2015 · Heart (British Cardiac Society)
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    ABSTRACT: Background: Physical performance measures have been shown to predict mortality and incident cardiovascular disease (CVD) mainly in elderly populations. We evaluated whether physical performance measures are associated with vascular health indices (carotid intima-media thickness (cIMT), adventitial diameter (cAD) and carotid plaque) in a large sample of multi-ethnic, late midlife women. Methods: Participants from the Study of Women's Health Across the Nation free of CVD and who had carotid ultrasound assessed at the 12th annual visit were evaluated. Physical function (PF) measures at visit 12 included: average 40-foot walking speed and average time needed for sit-to-stand assessment. Results: A total of 1103 women (53.7% White, 30.5% Black, 15.9% Chinese) aged 59.6±2.7years at visit 12, were included. In models adjusted for study site, race, current age, menopausal status and systolic blood pressure, slower walking speed and longer time needed for sit-to-stand were significantly associated with wider cAD, thicker cIMT and a higher probability of a high level of carotid plaque burden (all P-values<0.05). Associations between walking speed and cAD, and between time needed for sit-to-stand and cAD, remained significant (P=0.04) or marginally significant (P=0.07), respectively, after additional adjustment for CVD risk factors, medications and physical activity. However, the associations between PF measures and cIMT and plaque burden were largely explained by traditional CVD risk factors. Conclusions: The current study suggests that worse performance in simple objective PF tests may be an early indicator of vascular structural changes that precede vascular disease among women at late midlife.
    No preview · Article · Mar 2015 · International Journal of Cardiology
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    ABSTRACT: Young women with acute coronary syndrome (ACS) may represent a high risk group, but little is known about specific age and sex differences in clinical characteristics, treatment, outcomes, and trends over time. Data from 3237 men and women admitted with an ACS event from 1999 to 2006 were analyzed. Patients were grouped by sex and age less than 55 years. Demographics, presentation, treatment, and outcomes at 6 months were analyzed. Primary outcomes included mortality, recurrent myocardial infarction, rehospitalization, and stroke at 6 months. Secondary analyses assessed risk factors, management, and trends over time. Women under 55 years represented 8 % of the entire cohort, and 26 % of patients under age 55 years. Compared to older women, young women were more likely to be smokers (51 vs. 14 %, p < 0.001) and obese (44 vs. 34 %, p = 0.006). Young women had more diabetes and hypertension than young men. Mortality was lowest among young women and did not change over time. Young women received less treatment with aspirin, beta blockers, lipid-lowering agents, and ACE inhibitors, and underwent less coronary angiography and stenting than young men (44 vs. 59 %, p < 0.001). Rehospitalization was higher among young women than young men (37 vs. 27 %, p < 0.001), with no change over time. Modifiable risk factors such as smoking, obesity, diabetes, and hypertension should be addressed in young women. Following ACS, young women received fewer evidence-based medications, were treated less invasively, and had higher readmission rates within 6 months compared to young men.
    No preview · Article · Feb 2015 · Clinical Research in Cardiology
  • Robert D Brook · Elizabeth A Jackson · Paolo Giorgini · Cheri L McGowan
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    ABSTRACT: Several non-pharmacological therapies, such as sodium restriction and weight loss, have been promoted by hypertension guidelines based upon the trial evidence supporting their capacity to lower blood pressure. However, many patients may not respond nor be able to adhere to these non-pharmacological treatments. Despite numerous formal diet-lifestyle recommendations the prevalence of hypertension continues to grow worldwide. As such, additional approaches are needed to help combat this public health epidemic. In this review, we outline the evidence supporting the efficacy of a number of alternative approaches for blood pressure-lowering. Based upon the recommendations by a recent American Heart Association scientific statement, we also provide guidance on when and how to implement these methods in clinical practice. The available evidence supports several approaches including Transcendental Meditation, device-guided slow breathing, as well as aerobic, resistance, and isometric exercises. Nonetheless, many questions remain and future recommendations for employing alternative approaches will need to be updated as new trials are published. Copyright © 2015 Elsevier Inc. All rights reserved.
    No preview · Article · Jan 2015 · The American Journal of Medicine
  • Paolo Giorgini · Alan B. Weder · Elizabeth A. Jackson · Robert D. Brook
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    ABSTRACT: Background Hypertension guidelines recommend following published standardized protocols to obtain accurate blood pressure (BP) readings in clinical practice. However, the various measurement techniques among clinical trials that provide the basis for evidence-based management have not been evaluted or compared to guideline recommendations. Methods We reviewed published information regarding BP measurement in clinical trials (n=64) from 1990-2014 by searching PubMed and Google Scholar databases. Results Every trial failed to provide published information regarding at least one of the 10 methodological aspects we evaluated. Details regarding the healthcare provider(s) performing measurement(s), temporal-relation to last medication dosage, number of readings, resting time before (and between recordings), and the device(s) employed varied amongst the trials and often differed from clinical recommendations. Most studies did evaluate ≥2 BP readings in a seated position, presumably from the upper arm (though explicit acknowledgement of this latter detail was rare). When indicated, “trough” BP levels were most commonly obtained (15/16 trials), while the usage of automated devices increased over time. Conclusions Numerous aspects of BP measurement varied considerably across trials and often from most recent guideline recommendations. The lack of uniform methodologies in outcome studies that form the foundation of evidence-based guidelines may have significant clinical implications.
    No preview · Article · Sep 2014 · Journal of the American Society of Hypertension

  • No preview · Article · Aug 2014 · The American journal of medicine
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    ABSTRACT: Objectives: Inflammation has been implicated as a risk variable for cardiovascular disease (CVD). One source of inflammation is oral periapical disease, so elimination of periapical inflammation should affect CVD survival. We have investigated the relationship between radiographic evidence of endodontic treatment (endoTx) and CVD mortality. Methods: The Kuopio Oral Health and Heart study was a case-control study (256 CAD cases and 250 controls, mean age=60) with data collection in 1995. We have linked subsequent CVD mortality status to these baseline data to achieve a 15-year longitudinal follow-up. The relationship between radiographic evidence of endoTx on cardiovascular mortality was examined by proportional hazard regression analyses adjusting for age, sex and smoking, diabetes, hypertension, total/HDL cholesterol ratio and education. As endoTx may be dependent on the number of teeth present (NT), we also adjusted for this confounding variable. We also undertook subgroup analyses stratified by Coronary Artery Disease (CAD) or dentate status. Results: In the fully adjusted multivariate model, those who received at least 1 endoTx demonstrated a 67% improvement in CVD survival compared with those who did not. [Hazard ratio (HR) 0.33, 95% confidence interval (CI): 0.14 - 0.75 P=0.009. With additional adjustment for NT, endoTx was still protective against cardiovascular mortality [HR 0.45 CI 0.22 - 0.93 P=0.03. Subgroups who had CAD at baseline or the dentate group also demonstrated beneficial trends of endoTx with HR =0.48 CI: 0.18 - 1.30 P=0.15 and HR 0.49 CI:0.22 - 1.03 P=0.06, respectively. Conclusions: In this age 60 and older population, those who had had endodontic treatment that had eliminated periapical inflammation at baseline had a 67% improvement in cardiovascular survival at 15- years follow-up. There was also a non-significant trend for those who had both CAD at baseline and endodontic treatment for improved CVD survival. Future larger studies are warranted.
    No preview · Conference Paper · Jun 2014

Publication Stats

473 Citations
575.13 Total Impact Points

Institutions

  • 2015
    • University of Pittsburgh
      Pittsburgh, Pennsylvania, United States
  • 2008-2015
    • University of Michigan
      • • Division of Cardiovascular Medicine
      • • Department of Internal Medicine
      • • Medical School
      Ann Arbor, Michigan, United States
    • Concordia University–Ann Arbor
      Ann Arbor, Michigan, United States
  • 2012
    • Wayne State University
      Detroit, Michigan, United States