ARIC Manuscript Proposal #817. PC Reviewed: 08/23/01 Status: A_ Priority: 1 SC Reviewed: 09/06/01 Status: A_ Priority: 1

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1 1 ARIC Manuscript Proposal #817 PC Reviewed: 08/23/01 Status: A_ Priority: 1 SC Reviewed: 09/06/01 Status: A_ Priority: 1 1.a. Full Title: Cardiovascular Events and Cognitive Changes. b. Abbreviated Title (Length 26 characters): CVD and Cognitive Changes 2. Writing Group (list individual with lead responsibility first): Lead: Suzana Alves de Moraes Address: Department of Epidemiology, School of Hygiene and Public Health- The Johns Phone: Fax: smoraes@jhsph.edu Writing group members Moyses Szklo: Department of Epidemiology, School of Hygiene and Public Health- The Johns Phone: mszklo@jhsph.edu Kate Tilling: Department of Public Health Sciences, King's College, London, U.K. Phone: kate.tilling@kcl.ac.uk Reiko Sato: Departament of Epidemiology, School of Hygiene and Public Health-The Johns Phone: e mail: rsato@jhsph.edu David Knopman: Department of Neurology, Mayo Clinic, Rochester, MN. Phone: knopman@mayo.edu 3. Timeline: The first manuscript is expected in 6 months. 4. Rationale: Some epidemiological studies have shown that cardiovascular events are related to a lower cognitive function, although most of these studies have been restricted to older populations in which comorbidities may confound the relationship (1-7). Only few epidemiological studies have focused on cognitive function or cognitive decline in middle-age populations (8,9). It is, in addition, unclear

2 2 whether the cognitive decline seen after a cardiovascular event is merely the continuation of a decline trend that started before the event (10,11), rather than a result from the event. Several clinical and epidemiological studies have suggested a relationship between coronary artery bypass and cognitive decline as well as the long-term persistence of such a relationship (12,13). Results from pooled analyses based on 12 cohort studies and 11 intervention studies have suggested that coronary artery bypass surgery can promote cognitive decline (14), with some authors hypothesizing that such decline could result from microembolization and/ or hypoperfusion following cardiopulmonary bypass (15,16). The role of life events such as marital status changes, vital exhaustion, occupation, or income has not been explored in relation to cognitive decline in younger cohorts; neither have these factors been evaluated as confounding variables pertaining to the relationship between cardiovascular disease and cognitive changes over time (17-22). The purpose of the present study is to explore whether cardiovascular events (MI and stroke), or procedures such as bypass surgery or angioplasty occurring between the ARIC visits 2 nd and 4 th may accelerate the age-related cognitive decline, after adjustment for known and potential confounders. 5. Main Hypothesis/Study Questions: The analyses aim at evaluating whether stroke, MI or specific procedures are associated with cognitive changes over time, taking in account, a) whether the event is an incident or a recurrent acute event; and b) the lag-time between the event and the cognitive tests. The data will be adjusted for confounding variables such as demographic characteristics, cardiovascular risk factors and behavioral correlates. 6. Data (variables, time window, source, inclusions/exclusions): ARIC visits 2 and 4 data are necessary to examine the cognitive changes (outcome). Data on procedures, stroke and MI will be based on the updated data-set available through 1997 (or through the end of V4, if available). Definite, probable and possible ischaemic or hemorrhagic strokes, and definite and probable MI will be considered. Covariates: Social demographic variables: Age, gender, education level, race-center, income, occupation, marital status and perceived health status. Marital status will take into account the possible loss of a partner between visits 2 and 4. Cardiovascular risk factors: Diabetes, hypertension, fasting plasma fibrinogen, cholesterol and triglycerides, Body Mass Index, Carotid intimal medial thickness and vital exhaustion. Previous myocardial infarction will be based on past medical history and/or ECG evidence. Previous stroke will be based on clinical history. Behavioral factors: Smoking, drinking and sports index. People with missing values for cognitive tests in either or both visits and those reporting CNS medications will be excluded. Statistical analysis: Linear regression modeling will be done using STATA software, Version 7.0 (23). Those diagnosed as an incident/recurrent cardiovascular event will be compared to event-free subjects. Dummy variables will be created for categorical variables. All variables that show associations with cognitive changes at a p value 0.25 will be considered for inclusion in the multivariate models. For the multivariate models, a variable will be kept in subsequent models if it changes the estimates by more than 10% (24). The predicted values for the

3 3 outcome (adjusted between-visit mean change) will be estimated from the final models for each cognitive function test. 7.a. Will the data be used for non-cvd analysis in this manuscript? Yes No b. If Yes, is the author aware that the file ICTDER02 must be used to exclude persons with a value RES_OTH = CVD Research for non-dna analysis, and for DNA analysis RES_DNA = CVD Research would be used? Yes No (This file ICTDER02 has been distributed to ARIC PIs, and contains the responses to consent updates related to stored sample use for research.) 8.a. Will the DNA data be used in this manuscript? Yes No 8.b. If yes, is the author aware that either DNA data distributed by the Coordinating Center must be used, or the file ICTDER02 must be used to exclude those with value RES_DNA = No use/storage DNA? Yes No 9. The lead author of this manuscript proposal has reviewed the list of existing ARIC Study manuscript proposals and has found no overlap between this proposal and previously approved manuscript proposals either published or still in active status. ARIC Investigators have access to the publications lists under the Study Members Area of the web site at: Yes No References: 1.Desmond DW; Tatemichi TK; Paik M; Stern Y. Risk Factors for cerebrovascular disease as correlates of cognitive function in a stroke-free cohort. Arch Neurol 1993; 50: Breteler MM; VAN Swieten JC; Bots ML; Grobbee DE; Claus JJ; van den Hout JH; van Harskamp F; Tanghe HL; de Jong PT, van Gijn J. Cerebral white matter lesions, vascular risk factors, and cognitive function in a population-based study: the Rotterdam Study. Neurology 1994; 44: Ferruci L; Guralnik JM; Salive ME; Pahor M; Corti MC; Baroni A; Havlik RJ. Cognitive inpairment and risk of stroke in the older population. J Am Geriatr Soc 1996; 44: Kuller LH; Lynn S; Manolio T; Haan M; Fried L; Bryan N; Burke GL; Tracy R; Bhadelia R. Relationship between Apo E, MRI findings, and cognitive function in the Cardiovascular Health Study. Stroke 1998; 29: Zhu L; Fratiglioni L; Guo Z; Winblad B; Viitanen M. Incidence of stroke in relation to cognitive function and dementia in the Kungsholmen Project. Neurology 2000; 54:

4 4 6.Kase CS; Wolf A; Kelly-Hayes M; Kannel WB; Beiser A; D Agostino RB. Intellectual Decline after Stroke. The Framingham Study. Stroke 1998; 29: Di Carlo A; Baldereschi M; Amaducci L; Maggi S; Grogoletto F; Scarlato G; Inzitari D. Cognitive impairment without dementia in older people: prevalence, vascular risk factors, impact on disability. The Italian Longitudinal Study on Aging. J Am Geriatr Soc 2000; 48: Knopman D; Boland L; Mosley T; Howard G; Liao D; Szklo M; Mc Govern P; Folsom AR. Cardiovascular risk factors and cognitive decline in middle-aged adults: The Atherosclerosis Risk in Communities (ARIC) Study Investigators. Neurology 2001; 56: Moraes SA; Szklo M; Knopman D; Park E. Prospective assessment of estrogen replacement therapy and cognitive functioning: Atherosclerosis Risk in Communities (ARIC) Study. Am J Epidemiol, In Press. 10.Pohjasvaara T; Mantyla R; Aronen HJ; Leskela M; Salonen O; Kaste M; Erkinjuntti T. Clinical and radiologigal determinants of prestroke cognitive decline in a stroke cohort. J Neurol Neurosurg Psychiatry 1999; 67: Kalaria RN; Ballard C. Stroke and cognition. Curr Atheroscler Rep 2001; 3: Newman MF; Kirchner JL; Phillips-Bute B; Gaver V; Grocott H; Jones RH; Mark DB; Reves JG; Blumenthal JA. Longitudinal assessment of neurocognitive function after coronaryartery bypass surgery. N Engl J Med : Symes E; Maruff P; Ajani A; Currie J. Issues associated with the identification of cognitive change following coronary artery bypass grafting. Aut NZ Psychiatry : Diegeler A; Hirsch R; Schneider LO; Falk V; Rauch T; Mohr FW. Neuromonitoring and neurocognitive outcome in off-pump versus conventional coronary bypass operation. Ann Thorac Surg 2000; 69: van Dijk D; Keiser AM; Diephuis JC; Durand C; Vos LJ; Hijman R. Neurocognitive dysfunction after coronary artery bypass surgery: a systematic review. J thorac Cardiovasc Surg 2000; 120: Borger MA; Peniston CM; Weisel RD; Vasiliou M; Green RE; Feindel CM. Neuropsychologic impairment after coronary bypass surgery: effect of gaseous microemboli during perfusionist interventions. J Thorac Cardiovasc Surg 2001; 121: Wyke S; Ford G. Competing explanations for associations between marital status and health. Soc Sci Med 1992; 34: Clements K; Turpin G. Life event exposure, physiological reactivity, and psychological strain. J Behav Med 2000; 23:

5 5 19.Krause N. Early parental loss, recent life events, and changes in health among older adults. J Aging Health 1998; 10: Cheng Y; Kawachi I; Coakley EH; Schwartz J; Colditz G. Association between psychological work characteristics and health functioning in American wemen: prospective study. BMJ 2000; 320: Horowitz MJ; Weiss DS; Kaltreider N; Krupnick J; Marmar C; Wilner N; DeWitt K. Reactions to the death of a parent. Results form patients and field subjects. J Nerv Ment Dis 1984; 172: Singer B; Ryff CD. Hierarchies of life histories and associated health risks. Ann NY Acad Sci 1999: 896: Stata Corp Stata Statistical Software: Release 7.0. College Station, TX: Stata Corporation. 24.Maldonado G; Sander Greenland. Simulation study of confounder-selection strategies. Am J Epidemiol 1993; 138: