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1.  Stroke Location and Association With Fatal Cardiac Outcomes 
Background and Purpose
Cardiac mortality after stroke is common, and small studies have suggested an association of short-term cardiac mortality with insular location of cerebral infarction. Few population-based studies with long-term follow-up have evaluated the effect of stroke location on the long-term risk of cardiac death or myocardial infarction (MI) after first ischemic stroke. We sought to determine the association between stroke location and cardiac death or MI in a multiethnic community-based cohort.
Methods
The Northern Manhattan Study is a population-based study designed to determine stroke incidence, risk factors, and prognosis in a multiethnic urban population. First ischemic stroke patients age 40 or older were prospectively followed up for cardiac death defined as fatal MI, fatal congestive heart failure, or sudden death/arrhythmia and for nonfatal MI. Primary brain anatomic site was determined by consensus of research neurologists. Hazard ratios (HRs) and 95% CIs were calculated by Cox proportional-hazards models and adjusted for vascular risk factors (age, sex, history of coronary disease, hypertension, diabetes, cholesterol, and smoking), stroke severity, infarct size, and stroke etiology.
Results
The study population consisted of 655 patients whose mean age was 69.7 ± 12.7 years; 44.6% were men and 51.3% were Hispanic. During a median follow-up of 4.0 years, 44 patients (6.7%) had fatal cardiac events. Of these, fatal MI occurred in 38.6%, fatal congestive heart failure in 18.2%, and sudden death in 43.2%. In multivariate models, clinical diagnosis of left parietal lobe infarction was associated with cardiac death (adjusted HR = 4.45; 95% CI, 1.83 to 10.83) and cardiac death or MI (adjusted HR = 3.30; 95% CI, 1.45 to 7.51). When analysis of anatomic location was restricted to neuroimaging (computed tomography, magnetic resonance imaging, or both [n = 447]), left parietal lobe infarction was associated with cardiac death (adjusted HR = 3.37; 95% CI, 1.26 to 8.97), and both left (adjusted HR = 3.49; 95% CI, 1.38 to 8.80) and right (adjusted HR = 3.13; 95% CI, 1.04 to 9.45) parietal lobe infarctions were associated with cardiac death or MI. We did not find an association between frontal, temporal, or insular stroke and fatal cardiac events, although the number of purely insular strokes was small.
Conclusions
Parietal lobe infarction is an independent predictor of long-term cardiac death or MI in this population. Further studies are needed to confirm whether parietal lobe infarction is an independent predictor of cardiac events and death. Surveillance for cardiac disease and implementation of cardioprotective therapies may reduce cardiac mortality in patients with parietal stroke.
doi:10.1161/STROKEAHA.107.506055
PMCID: PMC4112463  PMID: 18635863
acute stroke; cardiac arrhythmia; epidemiology; sudden death
2.  Online Health Information Seeking Behaviors of Hispanics in New York City: A Community-Based Cross-Sectional Study 
Background
The emergence of the Internet has increased access to health information and can facilitate active individual engagement in health care decision making. Hispanics are the fastest-growing minority group in the United States and are also the most underserved in terms of access to online health information. A growing body of literature has examined correlates of online health information seeking behaviors (HISBs), but few studies have included Hispanics.
Objective
The specific aim of this descriptive, correlational study was to examine factors associated with HISBs of Hispanics.
Methods
The study sample (N=4070) was recruited from five postal zip codes in northern Manhattan for the Washington Heights Inwood Informatics Infrastructure for Comparative Effectiveness Research project. Survey data were collected via interview by bilingual community health workers in a community center, households, and other community settings. Data were analyzed using bivariate analyses and logistic regression.
Results
Among individual respondents, online HISBs were significantly associated with higher education (OR 3.03, 95% CI 2.15-4.29, P<.001), worse health status (OR 0.42, 95% CI 0.31-0.57, P<.001), and having no hypertension (OR 0.60, 95% CI 0.43-0.84, P=.003). Online HISBs of other household members were significantly associated with respondent factors: female gender (OR 1.60, 95% CI 1.22-2.10, P=.001), being younger (OR 0.75, 95% CI 0.62-0.90, P=.002), being married (OR 1.36, 95% CI 1.09-1.71, P=.007), having higher education (OR 1.80, 95% CI 1.404-2.316, P<.001), being in worse health (OR 0.59, 95% CI 0.46-0.77, P<.001), and having serious health problems increased the odds of their household members’ online HISBs (OR 1.83, 95% CI 1.29-2.60, P=.001).
Conclusions
This large-scale community survey identified factors associated with online HISBs among Hispanics that merit closer examination. To enhance online HISBs among Hispanics, health care providers and policy makers need to understand the cultural context of the Hispanic population. Results of this study can provide a foundation for the development of informatics-based interventions to improve the health of Hispanics in the United States.
doi:10.2196/jmir.3499
PMCID: PMC4129127  PMID: 25092120
Internet; information seeking behavior; health behavior; consumer health information; hispanic Americans
3.  Poor Long-Term Blood Pressure Control after Intracerebral Hemorrhage 
Background and Purpose
Hypertension is the most important risk factor associated with intracerebral hemorrhage (ICH). We explored racial differences in blood pressure (BP) control after ICH and assessed predictors of BP control at presentation, 30 days, and 1 year in a prospective cohort study.
Methods
Subjects with spontaneous ICH were identified from the DiffErenCes in the Imaging of Primary Hemorrhage based on Ethnicity or Race (DECIPHER) Project. Blood pressure was compared by race at each time point. Multivariable linear regression was used to determine predictors of presenting mean arterial pressure (MAP), and longitudinal linear regression was used to assess predictors of MAP at follow-up.
Results
A total of 162 patients were included (mean age 59, 53% male, 77% black). MAP at presentation was 9.6 mmHg higher in blacks than whites despite adjustment for confounders (p=0.065). Fewer than 20% of patients had normal blood pressure (<120/80 mmHg) at 30 days or 1 year. While there was no difference at 30 days (p=0.331), blacks were more likely than whites to have Stage I/II hypertension at one year (p=0.036). Factors associated with lower MAP at follow-up in multivariable analysis were being married at baseline (p=0.032) and living in a facility (versus personal residence) at the time of BP measurement (p=0.023).
Conclusions
Long-term blood pressure control is inadequate in patients following ICH, particularly in blacks. Further studies are needed to understand the role of social support and barriers to control to identify optimal approaches to improve blood pressure in this high-risk population.
doi:10.1161/STROKEAHA.112.663047
PMCID: PMC3458127  PMID: 22903494
Intracerebral hemorrhage; hypertension; secondary prevention; racial differences
4.  Daytime Sleepiness and Risk of Stroke and Vascular Disease: Findings from the Northern Manhattan Study (NOMAS) 
Background
Recent studies have suggested poor quality and diminished quantity of sleep may be independently linked to vascular events, though prospective and multiethnic studies are limited. This study aimed to explore the relationship between daytime sleepiness and the risk of ischemic stroke and vascular events in an elderly, multi-ethnic prospective cohort.
Methods and Results
As part of the Northern Manhattan Study, the Epworth Sleepiness Scale (ESS) was collected during the 2004 annual follow-up. Daytime sleepiness was trichotomized using previously reported cut points of “no dozing,” “some dozing,” and “significant dozing”. Subjects were followed annually for a mean of 5.1 years. Cox proportional hazards models were used to calculate hazard ratios (HR) and 95% confidence intervals (95% CI) for stroke, MI and death outcomes. We obtained the ESS on 2088 community residents. The mean age was 73.5 ± 9.3 yrs; 64% were women; 17% white, 20% black, 60% Hispanic, and 3% other. Over 44% of the cohort reported no daytime dozing, 47% reported “some dozing” and 9% “significant daytime dozing.” Compared to those reporting no daytime dozing, individuals reporting significant dozing had an increased risk of ischemic stroke [HR=2.74 (95% CI 1.38-5.43)], all 6 stroke [3.00 (1.57-5.73)], the combination of ischemic stroke, MI and vascular death [2.38 (1.50-3.78)], and all vascular events [2.48 (1.57-3.91)], after adjusting for medical comorbidities.
Conclusions
Daytime sleepiness is an independent risk factor for stroke and other vascular events. These findings suggest the importance of screening for sleep problems at the primary care level.
doi:10.1161/CIRCOUTCOMES.111.963801
PMCID: PMC3723347  PMID: 22787063
Ischemic Stroke; Sleep; Epidemiology; Vascular Disease; race/ethnicity
5.  Identifying interdisciplinary research priorities to prevent and treat pediatric obesity in New York City 
It is well recognized that an interdisciplinary approach is essential in the development and implementation of solutions to address the current pediatric obesity epidemic. In two half-day meetings that included workshops and focus groups, faculty from diverse fields identified critically important research challenges and gaps to childhood obesity prevention. The purpose of this white paper is to describe the iterative, interdisciplinary process that unfolded in an academic health center setting with a specific focus on under-represented minority groups of Black and Hispanic communities, and to summarize the research challenges and gaps related to pediatric obesity which were identified in the process. Although the research challenges and gaps were developed in the context of an urban setting including high risk populations (the northern Manhattan communities of Washington Heights, Inwood, and Harlem), many of the issues raised are broadly applicable. The processes by which the group identified research gaps and methodological challenges that impede a better understanding of how to prevent and treat obesity in children has resulted in an increase in research and community outreach collaborations and interdisciplinary pursuit of funding opportunities across units within the academic health center and overall University.
doi:10.1111/j.1752-8062.2010.00210.x
PMCID: PMC3677023  PMID: 20718818
pediatric obesity prevention; interdisciplinary; research priorities
6.  Too good to treat? Outcomes in patients not receiving thrombolysis due to mild deficits or rapidly improving symptoms 
International Journal of Stroke  2011;7(3):202-206.
Introduction
Among ischemic stroke patients arriving within the treatment window, rapidly improving symptoms or having a mild deficit (i.e. too good to treat)is a common reason for exclusion. Several studies have reported poor outcomes in this group. We addressed the question of early neurological deterioration in too good to treat patients in a larger prospective cohort study.
Methods
Admission and discharge information were collected prospectively in acute stroke patients who presented to the emergency room within three-hours from onset. The primary outcome measure was change in the NIHSS from baseline to discharge. Secondary outcomes were discharge NIHSS>4, not being discharged home, and discharge modified Rankin scale.
Results
Of 355patients who presented within three-hours, 127 (35.8%) had too good to treat listed as the only reason for not receiving thrombolysis, with median admission NIHSS = 1 (range = 0 to 19). At discharge seven(5.5%) showed a worsening of NIHSS ≥1 and 9 (7.1 %) had an NIHSS > 4. When excluding prior stroke (remaining n= 97), discharge status was even more benign: only five (5.2%) had a discharge NIHSS > 4 and two (2.1%) patients were not discharged home.
Conclusion
We found that a small proportion of patients deemed too good to treat will have early neurological deterioration, in contrast to other studies. Decisions about whether to treat mild stroke patients depend on the outcome measure chosen, particularly when considering discharge disposition among patients who have had prior stroke. The decision to thrombolyze may ultimately rest on the nature of the presentation and deficit.
doi:10.1111/j.1747-4949.2011.00696.x
PMCID: PMC3296877  PMID: 22103880
7.  Safety of thrombolysis in patients over the age of 80 
The Neurologist  2012;18(2):99-101.
Background
The safety of intravenous thrombolysis (IVT) in patients with acute ischemic stroke over age 80 is unclear. We hypothesized that patients over age 80 can be safely treated with IVT.
Methods
Admission and discharge data were collected on all patients at a single tertiary care center presenting within 12 hours of onset. Collected data included treatment with IVT, demographics, pre-treatment National Institutes of Health Stroke Scale (NIHSS) score, length of stay (LOS), mortality and discharge disposition. Analyses were restricted to patients over age 80, and the primary outcome was in-hospital mortality. Logistic regression was used to examine whether IVT was associated with mortality.
Results
Between 1/1/05 and 6/30/10, 112 patients over age 80 presented within 3 hours of ischemic stroke onset, and 31 received IVT. There were 15 deaths. In multi-variable models adjusted for age, sex, race-ethnicity and NIHSS, treatment with IVT compared to no treatment, was not associated with in-hospital death (adjusted OR 1.2, 95% confidence interval 0.3 – 4.3).
Conclusions
Treating ischemic stroke patients over 80 with IVT was not associated with an increase in mortality in an urban tertiary care center.
doi:10.1097/NRL.0b013e318248ea3c
PMCID: PMC3292776  PMID: 22367841
8.  A Mediterranean-Style Diet and White Matter Hyperintensity Volume: the Northern Manhattan Study 
Archives of Neurology  2012;69(2):251-256.
Objective
To examine the association between a Mediterranean-style diet (MeDi) and brain MRI white matter hyperintensities (WMH). The MeDi has previously been associated with a reduced risk of cardiovascular morbidity, possibly including stroke. A greater understanding of modifiable risk factors for small vessel damage may facilitate the prevention of stroke and cognitive decline.
Design
A cross-sectional analysis within a longitudinal population-based cohort study. A semi-quantitative food frequency questionnaire was administered and a score (range 0-9) was calculated to reflect increasing similarity to the MeDi pattern.
Setting
The Northern Manhattan Study.
Participants
1,091 participants, of which 966 had dietary information (mean age 72, 59% women, 65% Hispanic, 16% White, 17% Black).
Main outcome measures
WMH volume was measured by quantitative brain MRI. Linear regression models were constructed to examine the relation between the MeDi score and the log-transformed WMH volume as a proportion of total cranial volume, controlling for sociodemographic and vascular risk factors.
Results
On the MeDi scale, 12% scored 0-2, 16 scored 3, 23% scored 4, 23% scored 5, 26% scored 6-9. Each 1-point increase in MeDi score was associated with a lower log WMH volume (β=-0.04, p=0.02). The only MeDi score component that was an independent predictor of WMH volume was the ratio of monounsaturated to saturated fat (β=-0.20, p=0.001).
Conclusions
A Mediterranean-style diet was associated with a lower WMH burden, a marker of small vessel damage in the brain. However, white matter hyperintensities are etiologically heterogenous and can include neurodegeneration. Replication by other population-based studies is needed.
doi:10.1001/archneurol.2011.548
PMCID: PMC3281550  PMID: 22332193
9.  The Metabolic Syndrome and Cognitive Performance: The Northern Manhattan Study 
Neuroepidemiology  2011;37(3-4):153-159.
Background
The metabolic syndrome (MetS) is a risk factor for diabetes, stroke, myocardial infarction, and increased mortality, and has been associated with cognition in some populations. We hypothesized that MetS would be associated with lower Mini-Mental State Examination (MMSE) scores in a multi-ethnic population, and that MetS is a better predictor of cognition than its individual components or diabetes.
Methods
We conducted a cross-sectional analysis among 3,150 stroke-free participants. MetS was defined by the modified National Cholesterol Education Program guidelines-Adult Treatment Panel III (NCEP-ATPIII) criteria. Linear regression and polytomous logistic regression estimated the association between MMSE score and MetS, its individual components, diabetes, and inflammatory biomarkers.
Results
MetS was inversely associated with MMSE score (unadjusted β = −0.67; 95% CI −0.92, −0.41). Adjusting for potential confounders, MetS was associated with lower MMSE score (adjusted β = −0.24; 95% CI −0.47, −0.01), but its individual components and diabetes were not. Those with MetS were more likely to have an MMSE score of <18 than a score of ≥24 (adjusted OR = 1.94; 95% CI 1.26, 3.01). There was an interaction between MetS and race-ethnicity, such that MetS was associated with lower MMSE score among non-Hispanic whites and Hispanics but not non-Hispanic blacks.
Conclusions
MetS was associated with lower cognition in a multi-ethnic population. Further studies of the effect of MetS on cognition are warranted, and should account for demographic differences.
doi:10.1159/000332208
PMCID: PMC3214939  PMID: 22005335
Cognitive performance; Cognitive impairment; Vascular dementia; Vascular cognitive impairment; Cerebrovascular disorders; Metabolic syndrome
10.  Race-Ethnic Differences of Sleep Symptoms in an Elderly Multi-Ethnic Cohort: The Northern Manhattan Study 
Neuroepidemiology  2011;37(3-4):210-215.
Background
Sleep disorders are associated with stroke and may vary among elderly Hispanics, Blacks and Whites. We evaluated differences in sleep symptoms by race-ethnicity in an elderly population-based urban community sample.
Methods
Snoring, daytime sleepiness and reported sleep duration were ascertained by standardized interviews as a part of the Northern Manhattan Study, a prospective cohort study of vascular risk factors and stroke risk in a multi-ethnic urban population. Sleep symptoms were compared amongst race-ethnic groups using logistic regression models.
Results
A total of 1,964 stroke-free participants completed sleep questionnaires. The mean age was 75 ± 9 years, with 37% men, with 60% Hispanics, 21% Blacks and 19% Whites. In models adjusted for demographic and vascular risk factors, Hispanics had increased odds of frequent snoring (odds ratio, OR: 3.6, 95% confidence interval, CI: 2.3–5.8) and daytime sleepiness (OR: 2.8, 95% CI: 1.7–4.5) compared to White participants. Hispanics were more likely to report long sleep (≥9 h of sleep, OR: 1.8, 95% CI: 1.1–3.1). There was no difference in sleep symptoms between Black and White participants.
Conclusion
In this cross-sectional analysis among an elderly community cohort, snoring, sleepiness and long sleep duration were more common in Hispanics. Sleep symptoms may be surrogate markers for an underlying sleep disorder which may be associated with an elevated risk of stroke and may be modified by clinical intervention.
doi:10.1159/000334315
PMCID: PMC3713549  PMID: 22123526
Sleep symptoms; Snoring; Sleepiness; Sleep duration; Race; Ethnicity
11.  Perception of Recurrent Stroke Risk among Black, White and Hispanic Ischemic Stroke and Transient Ischemic Attack Survivors: The SWIFT Study 
Neuroepidemiology  2011;37(2):83-87.
Objectives
Risk modification through behavior change is critical for primary and secondary stroke prevention. Theories of health behavior identify perceived risk as an important component to facilitate behavior change; however, little is known about perceived risk of vascular events among stroke survivors.
Methods
The SWIFT (Stroke Warning Information and Faster Treatment) study includes a prospective population-based ethnically diverse cohort of ischemic stroke and transient ischemic attack survivors. We investigate the baseline relationship between demographics, health beliefs, and knowledge on risk perception. Regression models examined predictors of inaccurate perception.
Results
Only 20% accurately estimated risk, 10% of the participants underestimated risk, and 70% of the 817 study participants significantly overestimated their risk for a recurrent stroke. The mean perceived likelihood of recurrent ischemic stroke in the next 10 years was 51 ± 7%. We found no significant differences by race-ethnicity with regard to accurate estimation of risk. Inaccurate estimation of risk was associated with attitudes and beliefs [worry (p < 0.04), fatalism (p < 0.07)] and memory problems (p < 0.01), but not history or knowledge of vascular risk factors.
Conclusion
This paper provides a unique perspective on how factors such as belief systems influence risk perception in a diverse population at high stroke risk. There is a need for future research on how risk perception can inform primary and secondary stroke prevention.
Copyright © 2011 S. Karger AG, Basel
doi:10.1159/000329522
PMCID: PMC3186718  PMID: 21894045
Risk perception; Stroke knowledge; Health beliefs
12.  PERIODONTAL BACTERIA AND HYPERTENSION: The Oral Infections and Vascular Disease Epidemiology Study (INVEST) 
Journal of Hypertension  2010;28(7):1413-1421.
Objective
Chronic infections, including periodontal infections, may predispose to cardiovascular disease. We investigated the relationship between periodontal microbiota and hypertension. Methods and Results: 653 dentate men and women with no history of stroke or myocardial infarction were enrolled in INVEST. We collected 4533 subgingival plaque samples (average of 7 samples/subject). These were quantitatively assessed for 11 periodontal bacteria using DNA-DNA checkerboard hybridization. Cardiovascular risk factor measurements were obtained. Blood pressure and hypertension (systolic blood pressure≥140 mmHg, diastolic blood pressure≥90 mmHg or taking antihypertensive medication, or self-reported history) were each regressed on the level of bacteria: (1) considered causative of periodontal disease (etiologic bacterial burden); (2) associated with periodontal disease (putative bacterial burden); (3) associated with periodontal health (health associated bacterial burden). All analyses were adjusted for age, race/ethnicity, gender, education, body mass index, smoking, diabetes, LDL and HDL cholesterol. Etiologic bacterial burden was positively associated with both blood pressure and prevalent hypertension. Comparing the highest vs. lowest tertiles of etiologic bacterial burden, SBP was 9 mmHg higher, DBP was 5 mmHg higher (p for linear trend <0.001 in each case), and the odds ratio for prevalent hypertension was 3.05 (95%CI:1.60,5.82) after multivariable adjustment.
Conclusions
Our data provide evidence of a direct relationship between the levels of subgingival periodontal bacteria and both systolic and diastolic blood pressure as well as hypertension prevalence.
doi:10.1097/HJH.0b013e328338cd36
PMCID: PMC3403746  PMID: 20453665
infection; inflammation; hypertension; blood pressure; epidemiology; periodontitis
13.  Predictors of Health Information-Seeking Behaviors in Hispanics 
The objective of this study was to examine factors predicting use of the Internet to seek health information among Hispanics in the Washington Heights and Inwood areas of New York City. Data were collected by community health workers through the Washington Heights/Inwood Informatics Infrastructure for Community-Centered Comparative Effectiveness Research (WICER) community survey and a random sample of 100 surveys was selected for analysis. Binary logistic regression (N=100) was used to examine predictors of online health information-seeking behaviors (HISBs) of respondent and household members (dependent variables). Younger age, better health status, and higher education level significantly predicted respondents’ HISBs. Respondents’ health status and education level also significantly predicted household members’ HISBs.
PMCID: PMC3799171  PMID: 24199094
14.  Using the LOINC Semantic Structure to Integrate Community-based Survey Items into a Concept-based Enterprise Data Dictionary to Support Comparative Effectiveness Research 
In designing informatics infrastructure to support comparative effectiveness research (CER), it is necessary to implement approaches for integrating heterogeneous data sources such as clinical data typically stored in clinical data warehouses and those that are normally stored in separate research databases. One strategy to support this integration is the use of a concept-oriented data dictionary with a set of semantic terminology models. The aim of this paper is to illustrate the use of the semantic structure of Clinical LOINC (Logical Observation Identifiers, Names, and Codes) in integrating community-based survey items into the Medical Entities Dictionary (MED) to support the integration of survey data with clinical data for CER studies.
PMCID: PMC3799173  PMID: 24199059
15.  Race-ethnic differences in the relationship between lipid profile components and risk of myocardial infarction: the Northern Manhattan Study 
American heart journal  2011;161(5):886-892.
Objective
To explore race-ethnic differences in the relationship between plasma lipid components and risk of incident myocardial infarction (MI).
Design/Methods
As part of the Northern Manhattan Study, 2738 community residents without cardiovascular disease were prospectively evaluated. Baseline fasting blood samples were collected and lipid panel components were analyzed as continuous and categorical variables. Cox proportional hazard models were used to calculate hazard ratios (HR) and 95% confidence intervals (CI) for incident MI after adjusting for demographic and cardiovascular risk factors.
Results
The mean age was 68.8±10.4 years; 36.7% men, 19.9% non-Hispanic white, 24.9% non-Hispanic black, and 52.8% Hispanic (over 80% from the Caribbean). Hispanics had lower mean HDL-C, and higher TG/HDL-C. During a mean 8.9 years of follow-up there were 163 incident MIs. In the whole cohort all lipid profile components were associated with risk of MI in the expected directions. However, HDL-C (adjusted HR per 10 mg/dl increase 0.93, 95%CI 0.76–1.12) and TG/HDL-C>2 (adjusted HR 0.89, 95%CI 0.51–1.55) were not predictive of MI among Hispanics, but were predictive among non-Hispanic blacks and whites. TG/HDL-C per unit increase was associated with an 8% higher risk of MI among Hispanics (adjusted HR 1.08, 95%CI 1.04–1.12).
Conclusions
In Hispanics, low HDL-C and TG/HDL-C>2 were not associated with MI risk. Our data suggests that a different TG/HDL ratio cutoff may be needed among Hispanics to predict MI risk.
doi:10.1016/j.ahj.2011.01.018
PMCID: PMC3095911  PMID: 21570518
16.  Association between Social Isolation and Left Ventricular Mass 
The American journal of medicine  2011;124(2):164-170.
Background
Social isolation is associated with progression of cardiovascular disease with the most socially isolated patients being at increased risk. Increased left ventricular mass is a predictor of cardiovascular morbidity and mortality. It is not yet clear whether social isolation is a determinant of increased left ventricular mass.
Methods
We performed a cross-sectional study of Northern Manhattan Study participants who were free of clinical cardiovascular disease, had obtained transthoracic echocardiograms (n=2021) and a baseline questionnaire on social habits. Social isolation was defined as the lack of friendship networks (knowing fewer than 3 people well enough to visit within their homes). Echocardiographic left ventricular mass was indexed to height2.7, analyzed as a continuous variable and compared between exposure groups.
Results
The prevalence of social isolation was 13.5%. The average left ventricular mass was significantly higher (50.2 gm/m2.7) in those who were, as compared to those who were not (47.6 gm/m2.7), socially isolated (p<0.05). Higher prevalence of social isolation was found among those less educated, uninsured or unemployed.There were no significant race-ethnic differences in the prevalence of social isolation. In multivariate analysis, there was a trend toward an association between social isolation and increased left ventricular mass in the total cohort (p=0.09). Among Hispanics, social isolation was significantly associated with greater left ventricular mass. Hispanics who were socially isolated averaged 3.9 gm/ht2.7 higher left ventricular mass compared to those not socially isolated (p=0.002). This relationship was not present among non-Hispanic blacks or whites.
Conclusion
In this urban tri-ethnic cohort, social isolation was prevalent and associated with indices of low socioeconomic status. Hispanics who were socially isolated had a greater risk for increased left ventricular mass.
doi:10.1016/j.amjmed.2010.09.011
PMCID: PMC3064505  PMID: 21295196
social isolation; left ventricular mass; Hispanics; psychosocial factors
17.  Social determinants of physical inactivity in the Northern Manhattan Study (NOMAS) 
Journal of community health  2010;35(6):602-608.
Background
Physical inactivity is an important and modifiable cardiovascular disease risk factor. Little is known about the social determinants of physical inactivity in older, urban-dwelling populations.
Methods
We collected socio-demographic and medical risk factor information and physical activity questionnaires in the Northern Manhattan Study. Logistic regression models were constructed to examine whether measures of social isolation, race-ethnicity, and sex were associated with physical inactivity.
Results
Physical inactivity was present in 40.5% of the cohort. In multivariable models adjusted for medical comorbidities, Hispanic race-ethnicity (compared to non-Hispanic white) was associated with higher odds of physical inactivity (OR 2.18, 95% CI 1.78, 2.67), while women were more likely to be inactive than men (OR 1.33, 95% CI 1.15, 1.54). Having Medicaid/being uninsured (OR 1.20, 95% CI 1.02, 1.42), and having fewer than 3 friends (1.41, 95% CI 1.15, 1.72) were also associated with physical inactivity.
Conclusions
Physical inactivity is common, particularly in Hispanics, women, and those who are socially isolated. Public health interventions aimed at increasing physical activity in these more sedentary groups are required.
doi:10.1007/s10900-010-9249-2
PMCID: PMC2946979  PMID: 20574777
18.  Endothelial Function in Individuals with Coronary Artery Disease with and without Type 2 Diabetes 
Aim and Hypothesis
The goal of this study was to determine if individuals with coronary artery disease (CAD) and type 2 diabetes mellitus (T2DM) had greater endothelial dysfunction (ED) than individuals with only CAD.
Methods
Flow mediated dilation (FMD), calculated as percentage increase in brachial artery diameter in response to post-ischemic blood flow, was measured after an overnight fast in two cohorts. The first cohort included 76 participants in the Northern Manhattan Study (NOMAS) with CAD; 25 also had T2DM. The second cohort was composed of 27 individuals with both T2DM and CAD who were participants in a study of postprandial lipemia. Combined, we analyzed 103 patients with CAD; 52 with T2DM (T2DM+) and 51 without T2DM (T2DM−).
Results
The 52 CAD T2DM+ subjects had a mean FMD of 3.9 ± 3.2%, while the 51 CAD T2DM− subjects had a greater mean FMD of 5.5 ± 4.0% (P<0.03). An investigating of various confounders known to affect FMD identified age and BMI as the only significant covariates in a multiple regression model. Adjusting for age and BMI, we found that FMD remained lower in T2DM+ subjects compared to T2DM− subjects (difference −1.99%, P<0.03).
Interpretation/Conclusion
In patients with CAD, the concomitant presence of T2DM is independently associated with greater ED, as measured by FMD. This finding may be relevant to the greater early and late morbidity and mortality observed in patients with both CAD and T2DM.
doi:10.1016/j.metabol.2009.12.023
PMCID: PMC2891205  PMID: 20102776
Diabetes; CAD; Endothelial Function; Flow-Mediated Dilation
19.  Early Depressed mood after stroke predicts long-term disability: the Northern Manhattan Stroke Study (NOMASS) 
Introduction
Depression is highly prevalent after stroke, and may influence recovery. We aimed to determine whether depressed mood acutely after stroke predicts subsequent disability and mortality.
Methods
As part of the Northern Manhattan Stroke Study, a population-based incident stroke case follow-up study performed in a multiethnic urban population, participants were asked about depressed mood within 7–10 days after stroke. Participants were followed every 6 months the first 2 years, and yearly thereafter for 5 years, for death and disability measured by the Barthel Index (BI). We fitted polytomous logistic regression models using canonical link to examine the association between depressed mood after stroke and disability, comparing moderate (BI 60–95) and severe (BI < 60) disability to no disability (BI ≥ 95). Cox-proportional hazards models were created to examine the association between depressed mood and mortality.
Results
A question about depressed mood within 7–10 days after stroke was asked in 340 of 655 ischemic stroke patients enrolled, and 139 reported that they felt depressed. In multivariate analyses controlling for socio-demographic factors, stroke severity, and medical conditions, depressed mood was associated with a greater odds of severe disability compared to no disability at one (OR 2.91, 95% CI 1.07–7.91) and two years (OR 3.72, 95% CI 1.29–10.71) after stroke. Depressed mood was not associated with all cause mortality or vascular death.
Conclusion
Depressed mood after stroke is associated with disability but not mortality after stroke. Early screening and intervention for mood disorders after stroke may improve outcomes and requires further research.
doi:10.1161/STROKEAHA.110.583997
PMCID: PMC2932858  PMID: 20671256
20.  Social Network Types and Acute Stroke Preparedness Behavior 
Objectives
Presence of informal social networks has been associated with favorable health and behaviors, but whether different types of social networks impact on different health outcomes remains largely unknown. We examined the associations of different social network types (marital dyad, household, friendship, and informal community networks) with acute stroke preparedness behavior. We hypothesized that marital dyad best matched the required tasks and is the most effective network type for this behavior.
Methods
We collected in-person interview and medical record data for 1,077 adults diagnosed with stroke and transient ischemic attack. We used logistic regression analyses to examine the association of each social network with arrival at the emergency department (ED) within 3 h of stroke symptoms.
Results
Adjusting for age, race-ethnicity, education, gender, transportation type to ED and vascular diagnosis, being married or living with a partner was significantly associated with early arrival at the ED (odds ratio = 2.0, 95% confidence interval: 1.2–3.1), but no significant univariate or multivariate associations were observed for household, friendship, and community networks.
Conclusions
The marital/partnership dyad is the most influential type of social network for stroke preparedness behavior.
doi:10.1159/000328726
PMCID: PMC3343744  PMID: 22566985
Acute stroke; Emergency department admission; Ischemic attack; Social networks; Stroke symptoms
21.  Snoring and Insomnia are Not Associated with Subclinical Atherosclerosis in the Northern Manhattan Study (NOMAS) 
Background and Aims
Sleep disordered breathing (SDB) is a risk factor for stroke, but its association with subclinical atherosclerosis remains controversial. Snoring and insomnia are frequently co-morbid with SDB and may contribute to stroke. Data on the relationship between snoring and insomnia with atherosclerotic disease is sparse. We investigated the relationship between insomnia, snoring and carotid intima-media thickness (IMT), a marker of subclinical atherosclerosis, in the Northern Manhattan Study (NOMAS).
Methods
A group of 1,605 participants (mean age 65 ± 8 years; 40% men; 61% Hispanic, 19% black, 20% white) who had carotid IMT measurements performed was assessed for self-reported sleep habits. Habitual snoring was defined as self-reported snoring > 4 times per week. Presence of insomnia was based on three items extracted from the Hamilton Rating Scale for Depression. Carotid IMT was expressed as a mean composite measure of IMT in the carotid bifurcation, common and internal carotid artery. Multivariate linear regression models were used to identify associations between snoring, insomnia and carotid IMT.
Results
Habitual snoring was present in 29% of the subjects and insomnia in 26%. There was a higher prevalence of self reported snoring (84%) and insomnia (66%) among Hispanics than non-Hispanics. The mean total carotid IMT was 0.95 ± 0.09 mm; among those with self reported snoring was 0.94 ± 0.09 mm; and among those with insomnia was 0.95 ± 0.08 mm. After controlling for age, sex, race-ethnicity, BMI and cardiovascular risk factors, snoring (p= 0.986) and insomnia (p= 0.829) were not significantly associated with increased carotid IMT.
Conclusion
Snoring and insomnia were not significantly associated with subclinical atherosclerosis in this population based community cohort.
doi:10.1111/j.1747-4949.2010.00438.x
PMCID: PMC2907549  PMID: 20636708
sleep; snoring; insomnia; African American; Hispanic; Intima-Media Thickness; Risk factors; Sonography; Ultrasound
22.  Increased Stroke Risk and Lipoprotein(a) in a Multiethnic Community: The Northern Manhattan Stroke Study 
Context
Elevated lipoprotein(a) [Lp(a)] is associated with ischemic stroke (IS) among Whites, but data is sparse for non-White populations.
Objective
Using a population-based case-control study design with subjects from the Northern Manhattan Stroke Study, we assessed whether Lp(a) levels were independently associated with IS risk among Whites, Blacks and Hispanics.
Design and Setting
Lp(a) levels were measured in 317 IS cases (mean age 69 ± 13 years; 56% women; 16% Whites, 31% Blacks and 52% Hispanics) and 413 community-based controls, matched by age, race/ethnicity and gender. In-person assessments included demographics, socioeconomic status, presence of vascular risk factors and fasting lipid levels. Logistic regression was used to determine the independent association of Lp(a) and IS. Stratified analyses investigated gender and race/ethnic differences.
Results
Mean Lp(a) levels were greater among cases than controls (46.3 ± 41.0 vs. 38.9 ± 38.2 mg/dl; p < 0.01). After adjusting for stroke risk factors (hypertension, diabetes mellitus, coronary artery disease, cigarette smoking), lipid levels, and socioeconomic status, Lp(a) levels ≥30 mg/dl were independently associated with an increased stroke risk in the overall cohort (adjusted odds ratio, OR, 1.8, 95% confidence interval, CI, 1.20–2.6; p = 0.004). There was a significant linear dose-response relationship between Lp(a) levels and IS risk. The association between IS risk and Lp(a) ≥30 mg/dl was more pronounced among men (adjusted OR 2.0, 95% CI 1.1–3.5; p = 0.02) and among Blacks (adjusted OR 2.7, 95% CI 1.2–6.2; p = 0.02).
Conclusion
Elevated Lp(a) levels were significantly and independently associated with increased stroke risk, suggesting that Lp(a) is a risk factor for IS across White, Black and Hispanic race/ethnic groups.
doi:10.1159/000319065
PMCID: PMC3064933  PMID: 20664256
Lipoprotein(a); Northern Manhattan Stroke Study; Ischemic stroke
23.  Impaired flow-mediated vasodilatation is associated with increased left ventricular mass in a multi-ethnic population. The Northern Manhattan Study 
American journal of hypertension  2010;23(4):413-419.
BACKGROUND
Increased left ventricular (LV) mass and endothelial dysfunction are important risk factors for cardiovascular mortality and morbidity. However, it is not clear whether endothelial dysfunction is associated with increased LV mass. We tested the hypothesis that impaired flow-mediated vasodilatation (FMD) is associated with increased LV mass in a population-based multi-ethnic cohort.
METHODS
As a part of the Northern Manhattan Study, we performed two-dimensional echocardiography and FMD assessment during reactive hyperemia by high-resolution ultrasonography in 867 stroke-free community participants. LV mass was calculated according to an established method. LV hypertrophy was defined as the 90th percentile of sex-specific LV mass indexed for body surface area among normal subjects. Multivariable models were used to test the association of FMD with LV mass.
RESULTS
In multiple linear regression analyses adjusting for age, sex, body mass index, systolic blood pressure, antihypertensive medications, low-density lipoprotein cholesterol, diabetes, smoking, hematocrit, and race-ethnicity, FMD was inversely associated with LV mass (β = −1.21 ± 0.56, P = 0.03). The association persisted after further adjustment for any component of blood pressure (systolic, mean, and pulse pressure). In univariate logistic regression analysis, each 1% decrease in FMD was associated with a 8% higher risk of LV hypertrophy [odds ratio (OR) 1.08, 95% confidence interval (CI) 1.03–1.13 per each FMD point P< 0.01].
CONCLUSIONS
Impaired FMD is associated with LV mass, independent of other factors associated with increased LV mass. Endothelial dysfunction might be a potential risk factor for LV hypertrophy.
doi:10.1038/ajh.2009.261
PMCID: PMC2847833  PMID: 20057361
24.  Ethnic differences in Aortic Valve Thickness and Related Clinical Factors 
American heart journal  2010;159(4):698-704.
Background
Prior studies suggest that the causes of calcific aortic valve (AV) disease involve chronic inflammation, lipoprotein levels, and calcium metabolism, all of which may differ among race-ethnic groups. We sought to determine whether AV thickness differs by race-ethnicity in a large multi-ethnic population-based cohort.
Methods
The Northern Manhattan Study (NOMAS) includes stroke-free community-based Hispanic (57%), non-Hispanic black (22%), and non-Hispanic white (21%) participants. The relation between AV thickness on transthoracic echocardiography and clinical risk factors for atherosclerosis was evaluated among 2085 participants using polytomous logistic regression models. AV thickness was graded in three categories (normal, mild, and moderate/severe) based on leaflet thickening and calcification.
Results
Mild AV thickness was present in 44.4% and moderate/severe thickness in 5.7% of the cohort, with the lowest frequency of moderate/severe thickness seen particularly among Hispanic females. In multivariate models adjusting for age, sex, race-ethnicity, body mass index, hypertension, coronary artery disease, blood glucose, and high-density lipoprotein cholesterol, Hispanics had significantly less moderate/severe AV thickness (odds ratio (OR) 0.43, 95% confidence interval (95% CI) 0.25 to 0.73) than non-Hispanic whites. Men were almost 2-fold as likely to have moderate/severe AV thickness compared to women (OR 1.96, 95% CI 1.24 to 3.10).
Conclusions
In this large multi-ethnic population-based cohort, there were ethnic differences in the degree of AV thickness. Hispanic ethnicity was strongly protective against AV thickness. This effect was not related to traditional risk factors, suggesting that unmeasured factors related to Hispanic ethnicity and AV thickness may be responsible.
doi:10.1016/j.ahj.2009.12.031
PMCID: PMC2852575  PMID: 20362732
25.  The Association Between Kidney Disease and Cardiovascular Risk in a Multiethnic Cohort 
Background and Purpose
The objective of this study was to determine the relationship between chronic kidney disease (CKD), race–ethnicity, and vascular outcomes.
Methods
A prospective, multiracial cohort of 3298 stroke-free subjects with 6.5 years of mean follow-up time for vascular outcomes (stroke, myocardial infarction, vascular death) was used. Kidney function was estimated using serum creatinine and Cockcroft-Gault formula. Cox proportional hazards models were fitted to evaluate the relationship between kidney function and vascular outcomes.
Results
In multivariate analysis, Cockcroft-Gault formula between 15 and 59 mL/min was associated with a significant 43% increased stroke risk in the overall cohort. Blacks with Cockcroft-Gault formula between 15 and 59 mL/min had significantly increased risk of both stroke (hazard ratio, 2.65; 95% CI, 1.47 to 4.77) and combined vascular outcomes (hazard ratio, 1.59; 95% CI, 1.10–2.92).
Conclusion
Chronic kidney disease is a significant risk factor for stroke and combined vascular events, especially in blacks.
doi:10.1161/STROKEAHA.107.513713
PMCID: PMC3035384  PMID: 18617655
cardiac; chronic kidney disease; epidemiology; outcome; risk factors; stroke

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