Association of Cardiovascular Health Level in Older Age With Cognitive Decline and Incident Dementia

Question  Is there an association between cardiovascular health level in older age and risk of incident dementia?

Findings  In this French population-based cohort study involving 6626 individuals, an increased number of optimal cardiovascular health metrics (defined using a 7-item tool from the American Heart Association) were significantly associated with lower risk of incident dementia (hazard ratio, 0.90 for each additional metric at recommended optimal level).

Meaning  These findings may support the promotion of cardiovascular health to prevent development of risk factors associated with dementia.

Reference: JAMA. 2018;320(7):657-664. 


Fixed Low-Dose Triple Combination Antihypertensive Medication vs Usual Care for Blood Pressure Control in Patients With Mild to Moderate Hypertension in Sri Lanka

Question  Does the use of a pill containing low doses of 3 antihypertensive medications provide improved blood pressure control compared with usual care among patients with mild or moderate hypertension?

Findings  In this randomized clinical trial of 700 patients with hypertension who were untreated or receiving monotherapy, 70% of patients in the triple combination pill therapy group achieved a systolic/diastolic blood pressure of less than 140/90 mm Hg (or <130/80 mm Hg in patients with diabetes or chronic kidney disease) at 6 months compared with 55% of patients in the usual care group (a significant difference).

Meaning  Use of a low-dose triple combination blood pressure–lowering pill for initiation of treatment or escalation from monotherapy increased the proportion of patients with hypertension reaching their blood pressure targets.

Reference: JAMA. 2018;320(6):566-579.

Effect of a Responsive Parenting Educational Intervention on Childhood Weight Outcomes at 3 Years of AgeThe INSIGHT Randomized Clinical Trial

Question  Does an educational intervention designed to inform primiparous mothers about responsive parenting behaviors affect weight outcomes of children at age 3 years?

Findings  In this randomized clinical trial that included 279 mother-child dyads, a responsive parenting intervention significantly reduced body mass index z scores compared with controls (−0.13 vs 0.15, respectively) at age 3 years.

Meaning  Among primiparous mother-child dyads, an educational intervention that provided instruction about responsive parenting behaviors improved body mass index z score at age 3 years compared with a control intervention.

Reference: JAMA. 2018;320(5):461-468.

Effect of a Behavioral Intervention for Underserved Preschool-Age Children on Change in Body Mass Index

Question  What is the effect of a 36-month multicomponent behavioral intervention for obesity prevention on body mass index (BMI) trajectories in underserved preschool-age children at risk for obesity but not yet obese?

Findings  In this randomized clinical trial that included 610 parent-child pairs from underserved communities, the mean BMI in both the intervention and control groups was 17.8 at 36 months, with no significant difference in BMI trajectories.

Meaning  The behavioral intervention was not effective in this low-income minority population.

Reference: JAMA. 2018;320(5):450-460.

A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest


Concern about the use of epinephrine as a treatment for out-of-hospital cardiac arrest led the International Liaison Committee on Resuscitation to call for a placebo-controlled trial to determine whether the use of epinephrine is safe and effective in such patients.


In a randomized, double-blind trial involving 8014 patients with out-of-hospital cardiac arrest in the United Kingdom, paramedics at five National Health Service ambulance services administered either parenteral epinephrine (4015 patients) or saline placebo (3999 patients), along with standard care. The primary outcome was the rate of survival at 30 days. Secondary outcomes included the rate of survival until hospital discharge with a favorable neurologic outcome, as indicated by a score of 3 or less on the modified Rankin scale (which ranges from 0 [no symptoms] to 6 [death]).


At 30 days, 130 patients (3.2%) in the epinephrine group and 94 (2.4%) in the placebo group were alive (unadjusted odds ratio for survival, 1.39; 95% confidence interval [CI], 1.06 to 1.82; P=0.02). There was no evidence of a significant difference in the proportion of patients who survived until hospital discharge with a favorable neurologic outcome (87 of 4007 patients [2.2%] vs. 74 of 3994 patients [1.9%]; unadjusted odds ratio, 1.18; 95% CI, 0.86 to 1.61). At the time of hospital discharge, severe neurologic impairment (a score of 4 or 5 on the modified Rankin scale) had occurred in more of the survivors in the epinephrine group than in the placebo group (39 of 126 patients [31.0%] vs. 16 of 90 patients [17.8%]).


In adults with out-of-hospital cardiac arrest, the use of epinephrine resulted in a significantly higher rate of 30-day survival than the use of placebo, but there was no significant between-group difference in the rate of a favorable neurologic outcome because more survivors had severe neurologic impairment in the epinephrine group. (Funded by the U.K. National Institute for Health Research and others; Current Controlled Trials number, ISRCTN73485024.)

Reference: N Engl J Med 2018; 379:711-721

Risk Factors, Mortality, and Cardiovascular Outcomes in Patients with Type 2 Diabetes


Patients with diabetes are at higher risk for death and cardiovascular outcomes than the general population. We investigated whether the excess risk of death and cardiovascular events among patients with type 2 diabetes could be reduced or eliminated.


In a cohort study, we included 271,174 patients with type 2 diabetes who were registered in the Swedish National Diabetes Register and matched them with 1,355,870 controls on the basis of age, sex, and county. We assessed patients with diabetes according to age categories and according to the presence of five risk factors (elevated glycated hemoglobin level, elevated low-density lipoprotein cholesterol level, albuminuria, smoking, and elevated blood pressure). Cox regression was used to study the excess risk of outcomes (death, acute myocardial infarction, stroke, and hospitalization for heart failure) associated with smoking and the number of variables outside target ranges. We also examined the relationship between various risk factors and cardiovascular outcomes.


The median follow-up among all the study participants was 5.7 years, during which 175,345 deaths occurred. Among patients with type 2 diabetes, the excess risk of outcomes decreased stepwise for each risk-factor variable within the target range. Among patients with diabetes who had all five variables within target ranges, the hazard ratio for death from any cause, as compared with controls, was 1.06 (95% confidence interval [CI], 1.00 to 1.12), the hazard ratio for acute myocardial infarction was 0.84 (95% CI, 0.75 to 0.93), and the hazard ratio for stroke was 0.95 (95% CI, 0.84 to 1.07). The risk of hospitalization for heart failure was consistently higher among patients with diabetes than among controls (hazard ratio, 1.45; 95% CI, 1.34 to 1.57). In patients with type 2 diabetes, a glycated hemoglobin level outside the target range was the strongest predictor of stroke and acute myocardial infarction; smoking was the strongest predictor of death.


Patients with type 2 diabetes who had five risk-factor variables within the target ranges appeared to have little or no excess risk of death, myocardial infarction, or stroke, as compared with the general population. (Funded by the Swedish Association of Local Authorities and Regions and others.)

Smoking Cessation, Weight Change, Type 2 Diabetes, and Mortality


Whether weight gain after smoking cessation attenuates the health benefits of quitting is unclear.


In three cohort studies involving men and women in the United States, we identified those who had reported quitting smoking and we prospectively assessed changes in smoking status and body weight. We estimated risks of type 2 diabetes, death from cardiovascular disease, and death from any cause among those who had reported quitting smoking, according to weight changes after smoking cessation.


The risk of type 2 diabetes was higher among recent quitters (2 to 6 years since smoking cessation) than among current smokers (hazard ratio, 1.22; 95% confidence interval [CI], 1.12 to 1.32). The risk peaked 5 to 7 years after quitting and then gradually decreased. The temporary increase in the risk of type 2 diabetes was directly proportional to weight gain, and the risk was not increased among quitters without weight gain (P<0.001 for interaction). In contrast, quitters did not have a temporary increase in mortality, regardless of weight change after quitting. As compared with current smokers, the hazard ratios for death from cardiovascular disease were 0.69 (95% CI, 0.54 to 0.88) among recent quitters without weight gain, 0.47 (95% CI, 0.35 to 0.63) among those with weight gain of 0.1 to 5.0 kg, 0.25 (95% CI, 0.15 to 0.42) among those with weight gain of 5.1 to 10.0 kg, 0.33 (95% CI, 0.18 to 0.60) among those with weight gain of more than 10.0 kg, and 0.50 (95% CI, 0.46 to 0.55) among longer-term quitters (>6 years since smoking cessation). Similar associations were observed for death from any cause.


Smoking cessation that was accompanied by substantial weight gain was associated with an increased short-term risk of type 2 diabetes but did not mitigate the benefits of quitting smoking on reducing cardiovascular and all-cause mortality. (Funded by the National Institutes of Health.)