Abstract Acute cardiovascular (CV) events occur in deployed military personnel yet little is known about the CV risk profile of deployed U.S. military service members who experience ACS. Stress as a potential confounder of CV events in service members deployed in the ongoing Global War on Terror (GWOT) has not been addressed. The primary aim of this dissertation was to use a case-control design to compare CV risk factors between a group of 93 service members deployed in support of the GWOT who experienced acute coronary syndromes (ACS) and 136 rank, area of operations, and ethnicity-matched controls who did not experience ACS while deployed in support of GWOT. The matching variables controlled for the confounding effects of SES, stress, and ethnicity. Of the 93 ACS cases, 81.7% had an acute myocardial infarction and 18.3% had unstable angina. Most major CV risk factors were significantly different between the two groups except blood sugar and history of dyslipidemia. In a univariate conditional logistic regression model, all CV risk factors except blood sugar were significant predictors of ACS. In a multivariate logistic regression model, higher age [1.24 (1.11, 1.40)], higher total cholesterol/high density lipoprotein cholesterol ratio [2.85 (1.65, 4.93)], and family history of premature coronary artery disease [4.93 (1.66, 14.64)] remained significant independent predictors of ACS in service personnel deployed overseas in the GWOT. Both groups had Framingham risk scores that categorized them as "low risk". Improved CV health surveillance programs are needed in the military population to identify those with multiple CV risk factors. Interventions to reduce CV risk in military service members, especially prior to an overseas deployment, are essential. Based on the findings of this study, additional biomarkers that enhance the predictive ability of the Framingham risk score must be sought to improve a clinician's ability to stratify cardiac risk in young military men.

Heart failure (HF) is a chronic progressive condition, with debilitating symptoms. Despite the pivotal role family caregivers play in the care of HF patients, family caregiving has received little attention in HF research.

The primary aims of this dissertation were to describe the nature of family caregiving in the context of heart failure (HF) and to identify factors associated with the impact of caregiving. A particular focus was on the positive aspect of caregiving and the role of social support on the impact of caregiving. This dissertation includes a review of the literature and findings from three research studies.

The first study is a secondary analysis of data from 338 partners of HF patients and 1202 partners of healthy individuals. Care tasks performed by partners were compared between the two groups. Partners of HF patients were more likely to provide personal care and emotional care than partners of healthy individuals, even when only non-HF-specific care tasks were investigated.

In the second study, data were obtained from 76 HF patient-family caregiver dyads. Caregiving had both positive and negative impact on family caregivers. The level of caregiver perceived control and social support were important factors in the impact of caregiving measured with the Caregiver Reaction Assessment. The severity of HF and patients' clinical events were also associated with the impact of caregiving.

In the third study, family caregiving was examined in the context of a specific etiology of HF, pulmonary arterial hypertension (PAH). Among the 35 family caregivers of PAH patients in the study, 14% were identified as having moderate to severe depressive symptoms. Most caregivers were involved in managing care for the patient and helped the patient with self-management activities. Lower level of social support was significantly associated with more severe depressive symptoms in caregivers.

The role of family caregivers becomes increasingly important with the rising prevalence of HF and increased emphasis on self-management. The needs of family caregivers should not be overlooked in clinical practice. Social support and information to meet the demands of caregiving need to be provided to family caregivers in order to optimize the caregiving experience.

Heart failure with preserved systolic function (HFPSF) accounts for approximately half of all heart failure (HF) patients, a majority of whom are older women. Little is known about this HF subgroup since they have not been included in most HF clinical trials and other research studies. Moreover, the characteristics of those who have advanced disease have not been well described.

The primary aims of this dissertation were 1) to use a cross-sectional design to describe the characteristics of older women with advanced HFPSF and 2) to examine potential factors influencing their quality of life (QOL).The variables included were demographic, clinical, symptom, comfort, and functional capacity.

Sixty women (76 ± 7.7 years; 86.7% Caucasian) with New York Heart Association Class III HFPSF were recruited from two outpatient HF clinics. The women had high symptom prevalence (13.2 ± 6.4) and burden (2.1 ± 0.43 on a 0-4 scale), impaired functional capacity (mean 6-minute walk distance: 201.4 ± 117.1 meters) and multiple co-morbidities (4.65 ± 1.55). Co-morbid medical conditions associated with increased mortality and morbidity risk in HFPSF included pulmonary hypertension (76%), compromised renal function (73%), atrial fibrillation (66.7%), coronary artery disease (45%), and diabetes (40%).

Using a multiple linear regression model to control for disease severity, clinical status, and functional capacity, age (p = .023), comfort (p = .002) and symptom burden (p = .001) were significantly associated with QOL. The final overall model explained 66% of the variance in QOL (p < .001). Age explained 4% of the variance (p = 0.023), total symptom burden explained 14% of the variance (p = < .001), and comfort explained 7% of the variance (p = 0.002) in QOL.

Interventions reducing symptom burden and enhancing comfort for older women with advanced HFPSF may result in improved QOL. Addressing factors germane to QOL is congruent with palliative care in advanced chronic illness, since QOL enhancement is a palliative care goal.

The unrecognized palliative need of advanced HFPSF patients, a group comprised largely of older women, must be addressed. This segment of our aging society deserves better quality in the last phase of their life journey.

Background: Adherence to medications is critical to prevent morbidity and mortality in patients with coronary heart disease (CHD). Mobile technology may provide an innovative, practical, and inexpensive means to promote medication adherence.

Objectives: The primary aim of this randomized controlled trial was to compare adherence to antiplatelet and statin medications among patients after myocardial infarction and/or coronary stent procedure who: 1) received text messages (TM) for medication reminders and health education (TM Reminders + TM Education), 2) received TM for health education (TM Education Alone), and 3) did not receive TM (No TM). Secondary aims were to: 1) explore feasibility and patient satisfaction, 2) compare self-efficacy, and 3) identify predictors of medication adherence.

Methods: Customized TM were delivered over 30 days. Adherence was assessed with electronic devices [Medication Event Monitoring System (MEMS)], two-way TM response rates, and the Morisky Medication Adherence Scale. Questionnaires on patient satisfaction with TM and self-efficacy were administered.

Results: Among 90 patients (76% male, mean age 59.2 years), MEMS revealed a significant difference in adherence among groups for antiplatelets only (p<.05). The TM Reminders + TM Education group had a higher percentage of correct doses taken (88.0 ± 14.0 vs. 72.4 ± 27.6; p=.016) and a higher percentage of prescribed doses taken on schedule compared to the No TM group (86.2 ± 15.4 vs. 69.0 ± 29.2; p=.01). The TM Education Alone group had a higher percentage number of doses taken compared to the No TM group (95.8 ± 9.5 vs. 79.1 ± 27.7; p=.01). Two-way TM response rates were higher for antiplatelets than statins (90.2 ± 9 vs. 83.4 ±15.8; p=.01). Self-reported adherence improved for all groups over time, but did not differ among groups, similar to findings with self-efficacy. Feasibility was established and high patient satisfaction reported. Less depression and higher social support predicted higher medication adherence at 30 days.

Conclusions: TM increased adherence to antiplatelet therapy demonstrated by MEMS and TM responses. Addressing depression and social support in clinical practice should be a priority to improve medication adherence. Further research is needed to explore the full potential of mobile health.

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Asian Americans constitute one of the fastest growing groups in the United States. This dissertation study explores healthcare disparities in Asian Americans (Asians) through the window of examining those who had coronary artery bypass graft (CABG) surgery in California. The mandatory clinical data registry for CABG surgery, the California CABG Outcomes Reporting Program (CCORP), when linked to California's Patient Discharge Data (PDD), offers a unique opportunity to study Asians. Though the data did not show a significant difference in the overall observed or risk-adjusted operative mortality between Asians and Caucasians, a marginal significant difference was found between Asian females and Asian males (OR, 1.4, p=.057).

More significant differences in preoperative clinical characteristics existed between Asians and Caucasians and within genders in Asians. Twice as many Asians had a very low body mass index (BMI) <18.5 and developed heart disease at a lower mean BMI than Caucasians. Asians suffered more diabetes, hypertension, cerebrovascular disease, renal disease, heart failure, multivessel disease, and mitral insufficiency than Caucasians. Upon further analysis, Asian females were found to contribute to the aforementioned differences more so than Asian males. The finding that significantly fewer Asians had previous CABG surgery or other procedures than Caucasians may indicate problems in disease detection, denial, and referral, as well as access to care.

A significantly higher percentage of Asians compared to Caucasians had CABG surgery performed in the low-volume hospitals, while the converse was true for Caucasians. Significant differences were found for operative mortality between the low-volume and high-volume hospital groups when both racial groups were examined jointly, But these differences became not significant when Asians were examined alone.

Major limitations in this study include lack of information on postoperative complications, ambiguity in the identification of the Asian race, and the absence of other process and outcome data in relation to language and cultural traits. Longitudinal mortality follow-up and quality of life data to assess the cost/benefit ratio of surgery are also lacking. Despite these limitations, this is an important study that employed a large clinical dataset to study CABG surgery with a dedicated focus on Asians. The results provide critical health information that clinicians can use to improve access and clinical outcomes for Asian patients needing CABG surgery.

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