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Keywords: Editorials; diffusion of innovation; implementation science; information dissemination EN Editorials diffusion of innovation implementation science information dissemination 1515 1517 3 05/15/23 20230516 NES 230516 The field of cardiology is fortunate to have a robust legacy of evidence-driven approaches to improve care and outcomes of patients with cardiovascular disease. A key question going forward is whether waiving copays for particular patient subgroups or particular medications where the cost of the copay relative to the patients' financial resources is high may improve hard outcomes. In ARTEMIS,[9] >1 in 4 patients did not use the provided copayment waiver vouchers when they filled their medications, suggesting the usefulness of waiving a copayment in that patient subgroup was negligible. [Extracted from the article]

Corresponding Author [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to assess the impact of extreme (class III) obesity (body mass index [BMI] ≥40 kg/m2) on care and outcomes in patients with ST-segment elevation myocardial infarction (STEMI). Background: Although its prevalence is increasing rapidly, little is known about the impact of extreme obesity on STEMI presentation, treatments, complication rates, and outcomes. Methods: The relationship between BMI and baseline characteristics, treatment patterns, and risk-adjusted in-hospital outcomes was quantified for 50,149 patients with STEMI from the National Cardiovascular Data Registry (NCDR) ACTION Registry–GWTG. Results: The proportions of patients with STEMI by BMI category were as follows: underweight (BMI <18.5 kg/m2) 1.6%, normal weight (18.5 kg/m2 ≤BMI <25 kg/m2) 23.5%, overweight (25 kg/m2 ≤BMI <30 kg/m2) 38.7%, class I obese (30 kg/m2 ≤BMI <35 kg/m2) 22.4%, class II obese (35 kg/m2 ≤BMI <40 kg/m2) 8.7%, and class III obese 5.1%. Extreme obesity was associated with younger age at STEMI presentation (median age 55 years for class III obese vs. 66 years for normal weight); a higher prevalence of diabetes, hypertension, and dyslipidemia; a lower prevalence of smoking; and less extensive coronary artery disease and higher left ventricular ejection fraction. Process-of-care measures were similar across BMI categories, including the extremely obese. Using class I obesity as the referent, risk-adjusted in-hospital mortality rates were significantly higher only for class III obese patients (adjusted odds ratio: 1.64; 95% confidence interval: 1.32 to 2.03). Conclusions: Patients with extreme obesity present with STEMI at younger ages and have less extensive coronary artery disease, better left ventricular systolic function, and similar processes and quality of care. Despite these advantages, extreme obesity remains independently associated with higher in-hospital mortality. [Copyright &y& Elsevier]

The relations between renal function and circulating B-type natriuretic peptide (BNP) and the amino-terminal fragment of its prohormone (NT-pro-BNP) in the general population have not been fully elucidated. A total of 2,784 subjects from the Dallas Heart Study, a multiethnic population-based sample of Dallas County, Texas, residents, was studied. Detailed cardiac phenotyping, including magnetic resonance imaging and electron beam computed tomography, as well as measurements of NT-pro-BNP and BNP, were performed. Associations between estimated glomerular filtration rate (eGFR) and both NT-pro-BNP and BNP were evaluated using multivariable statistical analysis techniques. Median eGFR in this young, predominantly healthy population was 97 ml/min/1.73 m 2 (interquartile range 84 to 112). Natriuretic peptide levels were not associated with renal function over the normal range of eGFR. Below a threshold eGFR of 90 ml/min/1.73 m 2 , both NT-pro-BNP and BNP increased in an exponential fashion with decreasing eGFR. These associations remained significant after adjustment for multiple potential confounders (p <0.001 for all). For eGFR <90 ml/min/1.73 m 2 , the relative increase in NT-pro-BNP was twice as great as that for BNP for a given decrease in eGFR. In conclusion, a threshold effect regarding the association between renal function and natriuretic peptides was shown. With eGFR <90 ml/min/1.73 m 2 , both NT-pro-BNP and BNP were inversely and independently associated with renal function, with a greater magnitude of association with renal impairment noted for NT-pro-BNP. [Copyright &y& Elsevier]

The article focuses on predicting and preventing myocardial infarction (MI) in the young. Topics inlcude the Partners YOUNG-MI registry who has suffered a first MI, the diabetes prevalence and longterm cardiovascular outcomes has stratified by diabetes status, and the diabetes has well-established risk factor for major adverse cardiovascular events (MACE).

The relation between hematocrit and progression from asymptomatic left ventricular (LV) systolic dysfunction to symptomatic heart failure (HF) was examined in 2,821 patients from the Studies of Left Ventricular Dysfunction Prevention trial. Patients in the lowest hematocrit quartile (hematocrit ≤40%) were at increased risk for the development of HF symptoms (hazard ratio [HR] 1.79, 95% confidence interval [CI] 1.37 to 2.34), first HF hospitalization (HR 2.35, 95% CI 1.52 to 3.62), and death or the development of HF symptoms (HR 1.60, 95% CI 1.28 to 1.99) compared with patients in the highest hematocrit quartile (hematocrit >46%). [Copyright &y& Elsevier]

Background: Obesity is a significant public health problem in the United States. Comprehensive obesity prevalence data among veterans have not been previously reported. Methods: This is a cross-sectional analysis of 1,803,323 veterans receiving outpatient care at 136 Veterans Affairs (VA) medical facilities in 2000. Measured weight, height, and demographic data were used to obtain age-adjusted prevalences of body mass index (BMI) categories, which were stratified by gender and examined by age and race/ethnicity. Results: Of 93,290 women American veterans receiving care at VA medical facilities during 2000, 68.4% were at least overweight (body mass index [BMI]≥25 kg/m2), with 37.4% classified as obese (BMI≥30 kg/m2), and 6.0% as class-III obese (BMI≥40 kg/m2). Of 1,710,032 men, 73.0% were at least overweight, 32.9% were obese, and 3.3% were class-III obese. Among women, obesity prevalence increased into the sixth and seventh decade of life before prevalence began to decline. Among men, prevalence was lowest for those aged <30 and >70. By race/ethnicity, Native American women (40.7%) and men (35.1%) had the highest prevalence of obesity, while Asian-American women (12.8%) and men (20.6%) had the lowest. Conclusions: There is a substantial burden of obesity among veterans using VA medical facilities. A comprehensive approach for weight management by the Veterans Health Administration is needed. [Copyright &y& Elsevier]

This JAMA Performance Improvement article uses the case of a patient with acute myocardial infarction and heart failure who developed cardiogenic shock after being given carvedilol as part of a standard STEMI admission order set to discuss the limits of orders sets and of guideline-based care and the need to optimize each for individual patient circumstances. [ABSTRACT FROM AUTHOR]

The author discusses the study of Kutty and colleagues on the decline of mortality as a result of the advances in cardiac medicine including an improved cardiac resuscitation. It mentions the result of improving medical resuscitation and the decline in mortality. It discusses the related medical advances and their benefits in addressing mortality.

Background: Medication nonadherence is associated with worse outcomes in patients with atherosclerotic cardiovascular disease (ASCVD), a group who requires long-term therapy for secondary prevention. It is important to understand to what extent drug costs, which are potentially actionable factors, contribute to medication nonadherence.Methods: In a nationally representative survey of US adults in the National Health Interview Survey (2013-2017), we identified individuals ≥18 years with a reported history of ASCVD. Participants were considered to have experienced cost-related nonadherence (CRN) if in the preceding 12 months they reported skipping doses to save money, taking less medication to save money, or delaying filling a prescription to save money. We used survey analysis to obtain national estimates.Results: Of the 14 279 surveyed individuals with ASCVD, a weighted 12.6% (or 2.2 million [95% CI, 2.1-2.4]) experienced CRN, including 8.6% or 1.5 million missing doses, 8.8% or 1.6 million taking lower than prescribed doses, and 10.5% or 1.9 million intentionally delaying a medication fill to save costs. Age <65 years, female sex, low family income, lack of health insurance, and high comorbidity burden were independently associated with CRN, with >1 in 5 reporting CRN in these subgroups. Survey respondents with CRN compared with those without CRN had 10.8-fold higher odds of requesting low-cost medications and 8.9-fold higher odds of using alternative, nonprescription, therapies.Conclusions: One in 8 patients with ASCVD reports nonadherence to medications because of cost. The removal of financial barriers to accessing medications, particularly among vulnerable patient groups, may help improve adherence to essential therapy to reduce ASCVD morbidity and mortality. [ABSTRACT FROM AUTHOR]

The article presents the discussion on significant evidence exists that supports a range of interventions to improve diabetes outcomes. Topics include diabetes is a complex, chronic condition requiring continuous medical care with multifactorial risk-reduction strategies beyond glycemic management; and provide comprehensive management plans for conditions that require specialized care, such as mental illness.

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC. [ABSTRACT FROM AUTHOR]

Objective: The aims of this research were to evaluate concordance of practice patterns for preoperative electrocardiogram (EKG) and chest X-ray for benign hysterectomy with institutional and international guidelines, and to assess implications for perioperative management. Materials and Methods: For this retrospective cohort study (Canadian Task Force II-2), medical records of 587 women who underwent hysterectomy for benign indications at a single institution, from January 1 through December 31, 2016, were reviewed. Each EKG and chest X-ray (CXR) was evaluated for indications, concordance with institutional and with the United Kingdom's National Institute for Health and Care Excellence (NICE) guidelines, results, effects on management, and association with perioperative complications. Descriptive statistics were used for analysis. Results: Subjects were, on average, 45 (range: 27–76) years old, with primarily Hispanic (58.4%) and black (30.0%) race. For 587 hysterectomies, 182 EKGs (31.0%) and 70 CXRs (11.9%) were ordered. EKG was indicated for s90 (49.5%) patients per institutional criteria and for 177 (97.3%) patients per NICE criteria. Findings were abnormal in 81 (44.5%) of 182 EKGs. Further work-up was pursued for 16 (19.8%) patients. There were 2 case delays, but no cancellations. Notable perioperative events included nonspecific EKG changes and airway edema in 2 patients with abnormal preoperative EKGs. Of 70 CXRs ordered, 17 (24.3%) were in concordance with institutional criteria. No CXRs were indicated per NICE criteria. There were abnormal findings on 10 (14.3%) chest X-rays. The anesthesia department was consulted for 1 patient. There were no case delays/cancellations or perioperative cardiopulmonary complications. Conclusions: Preoperative EKGs and CXRs offer little clinical utility for patients undergoing benign hysterectomy. [ABSTRACT FROM AUTHOR]

Background: Housing instability is a key social determinant of health and has been linked to adverse short- and long-term health. Eviction reflects a severe form of housing instability and disproportionately affects minority and women residents in the USA; however, its relationship with mortality has not previously been described. Objective: To evaluate the independent association of county-level eviction rates with all-cause mortality in the USA after adjustment for county demographic, socioeconomic, and health-related characteristics. Design: Cross-sectional. Participants: Six hundred eighty-six US counties with available 2016 county-level eviction and mortality data. Exposure: 2016 US county-level eviction rate. Outcome: 2016 US county-level age-adjusted all-cause mortality. Key Results: Among 686 counties (66.1 million residents, 50.5% [49.7–51.2] women, 2% [0.5–11.1] Black race) with available eviction and mortality data in 2016, we observed a significant and graded relationship between county-level eviction rate and all-cause mortality. Counties in the highest eviction tertile demonstrated a greater proportion of residents of Black race and women and a higher prevalence of poverty and comorbid health conditions. After adjustment for county-level sociodemographic traits and prevalent comorbid health conditions, age-adjusted all-cause mortality was highest among counties in the highest eviction tertile (Tertile 3 vs 1 (per 100,000 people) 33.57: 95% CI: 10.5–56.6 p=.004). Consistent results were observed in continuous analysis of eviction, with all-cause mortality increasing by 9.32 deaths per 100,000 people (4.77, 13.89, p<.0001) for every 1% increase in eviction rates. Significant interaction in the relationship between eviction and all-cause mortality was observed by the proportion of Black and women residents. Conclusions: In this cross-sectional analysis, county-level eviction rates were significantly associated with all-cause mortality with the strongest effects observed among counties with the highest proportion of Black and women residents. State and federal protections from evictions may help to reduce the health consequences of housing instability and address disparities in health outcomes. [ABSTRACT FROM AUTHOR]

The article presents a summary of revisions to the American Diabetes Association's (ADA) 2023 Standards of Care in Diabetes. Topcis of the changes include improvement of care and health promotion, classification and diagnosis of diabetes, prevention or delay of type 2 diabetes and associated comorbidities, medical evaluation and assessment of comorbidities, health behaviors and well-being to improve health outcomes, glycemic targets, diabetes technology, diabetes and weight management.

The article introduces the American Diabetes Association (ADA) Standards of Care in Diabetes for 2023. It presents the scope of the guidelines and identifies target audience of the standards including primary care physicians, endocrinologists and nurse practitioners. It outlines the methodology and procedure of Standards of Care in Diabetes that include disclosure and duality of interest management, evidence review, grading of evidence and recommendation development and revision process.

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC. [ABSTRACT FROM AUTHOR]

Background: Multiple epidemiological studies from Europe and Asia have demonstrated increased cardiovascular risks associated with isolated elevation of home blood pressure (BP) or masked hypertension (MH). Previous studies have not addressed cardiovascular outcomes associated with MH and white-coat hypertension (WCH) in the general population in the United States.Objectives: The goal of this study was to determine hypertensive target organ damage and adverse cardiovascular outcomes associated with WCH (high clinic BP, ≥140/90 mm Hg; normal home BP, <135/85 mm Hg), MH (high home BP, ≥135/85 mm Hg; normal clinic BP, <140/90 mm Hg), and sustained hypertension (high home and clinic BP) in the DHS (Dallas Heart Study), a large, multiethnic, probability-based population cohort.Methods: Associations among WCH, MH, sustained hypertension, and aortic pulsed wave velocity by magnetic resonance imaging; urinary albumin-to-creatinine ratio; and cystatin C were evaluated at study baseline. Then, associations between WCH and MH with incident cardiovascular outcomes (coronary heart disease, stroke, atrial fibrillation, heart failure, and cardiovascular death) over a median follow-up period of 9 years were assessed.Results: The study cohort comprised 3,027 subjects (50% African Americans). The sample-weighted prevalence rates of WCH and MH were 3.3% and 17.8%, respectively. Both WCH and MH were independently associated with increased aortic pulsed wave velocity, cystatin C, and urinary albumin-to-creatinine ratio. Both WCH (adjusted hazard ratio: 2.09; 95% confidence interval: 1.05 to 4.15) and MH (adjusted hazard ratio: 2.03; 95% confidence interval: 1.36 to 3.03) were independently associated with higher cardiovascular events compared with the normotensive group, even after adjustment for traditional cardiovascular risk factors.Conclusions: In a multiethnic U.S. population, both WCH and MH were independently associated with increased aortic stiffness, renal injury, and incident cardiovascular events. Because MH is common and associated with an adverse cardiovascular profile, home BP monitoring should be routinely performed among U.S. adults. [ABSTRACT FROM AUTHOR]

Therapies targeting high-density lipoprotein cholesterol content (HDL-C) have not improved coronary heart disease (CHD) outcomes. High-density lipoprotein particle concentration (HDL-P) may better predict CHD. However, the impact of race/ethnicity on the relations between HDL-P and subclinical atherosclerosis and incident CHD events has not been described. Participants from the Dallas Heart Study (DHS), a multiethnic, probabilitybased, population cohort of Dallas County adults, underwent the following baseline measurements: HDL-C, HDL-P by nuclear magnetic resonance imaging, and coronary artery calcium by electron-beam computed tomography. Participants were followed for a median of 9.3 years for incident CHD events (composite of first myocardial infarction, stroke, coronary revascularization, or cardiovascular death). The study comprised 1,977 participants free of CHD (51% women, 46% black). In adjusted models, HDL-C was not associated with prevalent coronary artery calcium (p = 0.13) or incident CHD overall (hazard ratio [HR] per 1 SD 0.89, 95% confidence interval [CI] 0.76 to 1.05). However, HDL-C was inversely associated with incident CHD among nonblack (adjusted HR per 1 SD 0.67, 95% CI 0.46 to 0.97) but not black participants (HR 0.94,95% CI 0.78 to 1.13, Pinteraction = 0.05). Conversely, HDL-P, adjusted for risk factors and HDL-C, was inversely associated with prevalent coronary artery calcium (p = 0.009) and with incident CHD overall (adjusted HR per 1 SD 0.73, 95% CI 0.62 to 0.86), with no interaction by black race/ethnicity (Pinteraction = 0.57). In conclusion, in contrast to HDL-C, the inverse relation between HDL-P and incident CHD events is consistent across ethnicities. These findings suggest that HDL-P is superior to HDL-C in predicting prevalent atherosclerosis as well as incident CHD events across a diverse population and should be considered as a therapeutic target. [ABSTRACT FROM AUTHOR]

Background: Out-of-pocket costs are a serious barrier to care and drive suboptimal medical therapy. Understanding of these costs can lead to care oriented around the limits they generate. Despite this, there is minimal attention paid to these costs in post-graduate education. Objective: To define a potential knowledge gap regarding costs experienced by patients by surveying Internal Medicine residents at our large academic institution. Methods: We surveyed Internal Medicine residents in spring 2019 about knowledge and practices surrounding patient out-of-pocket costs. Participants answered questions considering their most recent inpatient panel and their clinic patient panel. Familiarity was ranked on a 5-point Likert scale, and for the purposes of presentation, was divided into "Poor" and "Moderate or Better." Non-parametric analysis was used to test differences between outpatients and inpatients and by year of training. Results: Of 159 residents, 109 (67%) responded. Familiarity with patient insurance status was moderate or better in 85%. Reported understanding of costs associated with medications, testing, and clinic visits was less common. Respondents had higher familiarity with out-of-pocket costs for clinic patients compared with inpatients. Knowledge of cost of care was not an often-considered factor in decision making. There was no significant difference in response by year of training. Conclusion: Patient out-of-pocket costs are an important dimension of patient care which Internal Medicine Trainees at our institution do not confidently understand or utilize. Improvements in education around this topic may enable more patient-centered care. [ABSTRACT FROM AUTHOR]

Background: Out-of-pocket costs are a serious barrier to care and drive suboptimal medical therapy. Understanding of these costs can lead to care oriented around the limits they generate. Despite this, there is minimal attention paid to these costs in post-graduate education. Objective: To define a potential knowledge gap regarding costs experienced by patients by surveying Internal Medicine residents at our large academic institution. Methods: We surveyed Internal Medicine residents in spring 2019 about knowledge and practices surrounding patient out-of-pocket costs. Participants answered questions considering their most recent inpatient panel and their clinic patient panel. Familiarity was ranked on a 5-point Likert scale, and for the purposes of presentation, was divided into "Poor" and "Moderate or Better." Non-parametric analysis was used to test differences between outpatients and inpatients and by year of training. Results: Of 159 residents, 109 (67%) responded. Familiarity with patient insurance status was moderate or better in 85%. Reported understanding of costs associated with medications, testing, and clinic visits was less common. Respondents had higher familiarity with out-of-pocket costs for clinic patients compared with inpatients. Knowledge of cost of care was not an often-considered factor in decision making. There was no significant difference in response by year of training. Conclusion: Patient out-of-pocket costs are an important dimension of patient care which Internal Medicine Trainees at our institution do not confidently understand or utilize. Improvements in education around this topic may enable more patient-centered care. [ABSTRACT FROM AUTHOR]

Elevated plasma levels of B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT–pro-BNP) are seen in the setting of cardiac ischemia and are associated with adverse outcomes in patients with coronary artery disease. The mechanisms leading to natriuretic peptide elevation in patients with coronary artery disease, including the contribution of coronary atherosclerosis itself, have not been fully elucidated. Measurement of NT–pro-BNP, electron beam computed tomography, and cardiac magnetic resonance imaging were performed in 2,445 subjects from the Dallas Heart Study who were free of heart failure and renal insufficiency. Electron beam computed tomography–determined coronary artery calcium scores were categorized as none (<10), mild (≥10 to <100), moderate (≥100 to <400), and severe (≥400). NT–pro-BNP levels increased significantly across increasing coronary artery calcium score categories (p <0.0001 for trend). In multivariate models adjusted for age, gender, race, body mass index, hypertension, history of myocardial infarction, angina, angiotensin-converting enzyme inhibitor use, β-blocker use, left ventricular (LV) ejection fraction, and LV mass, higher coronary artery calcium scores remained independently associated with higher log NT–pro-BNP levels (p = 0.03). This association persisted in similar models excluding patients with low LV ejection fractions, LV hypertrophy, angina pectoris, and a history of myocardial infarction. In conclusion, these findings support the hypothesis that coronary atherosclerosis may directly influence the activation of the cardiac neurohormonal system. [Copyright &y& Elsevier]

Background: The coronavirus disease 2019 (COVID-19) pandemic has exposed longstanding racial and ethnic inequities in health risks and outcomes in the United States. We aimed to identify racial and ethnic differences in presentation and outcomes for patients hospitalized with COVID-19.Methods: The American Heart Association COVID-19 Cardiovascular Disease Registry is a retrospective observational registry capturing consecutive patients hospitalized with COVID-19. We present data on the first 7868 patients by race/ethnicity treated at 88 hospitals across the United States between January 17, 2020, and July 22, 2020. The primary outcome was in-hospital mortality. Secondary outcomes included major adverse cardiovascular events (death, myocardial infarction, stroke, heart failure) and COVID-19 cardiorespiratory ordinal severity score (worst to best: death, cardiac arrest, mechanical ventilation with mechanical circulatory support, mechanical ventilation with vasopressors/inotrope support, mechanical ventilation without hemodynamic support, and hospitalization alone. Multivariable logistic regression analyses were performed to assess the relationship between race/ethnicity and each outcome adjusting for differences in sociodemographic, clinical, and presentation features, and accounting for clustering by hospital.Results: Among 7868 patients hospitalized with COVID-19, 33.0% were Hispanic, 25.5% were non-Hispanic Black, 6.3% were Asian, and 35.2% were non-Hispanic White. Hispanic and Black patients were younger than non-Hispanic White and Asian patients and were more likely to be uninsured. Black patients had the highest prevalence of obesity, hypertension, and diabetes. Black patients also had the highest rates of mechanical ventilation (23.2%) and renal replacement therapy (6.6%) but the lowest rates of remdesivir use (6.1%). Overall mortality was 18.4% with 53% of all deaths occurring in Black and Hispanic patients. The adjusted odds ratios for mortality were 0.93 (95% CI, 0.76-1.14) for Black patients, 0.90 (95% CI, 0.73-1.11) for Hispanic patients, and 1.31 (95% CI, 0.96-1.80) for Asian patients compared with non-Hispanic White patients. The median odds ratio across hospitals was 1.99 (95% CI, 1.74-2.48). Results were similar for major adverse cardiovascular events. Asian patients had the highest COVID-19 cardiorespiratory severity at presentation (adjusted odds ratio, 1.48 [95% CI, 1.16-1.90]).Conclusions: Although in-hospital mortality and major adverse cardiovascular events did not differ by race/ethnicity after adjustment, Black and Hispanic patients bore a greater burden of mortality and morbidity because of their disproportionate representation among COVID-19 hospitalizations. [ABSTRACT FROM AUTHOR]

BACKGROUND: Obesity may contribute to adverse outcomes in coronavirus disease 2019 (COVID-19). However, studies of large, broadly generalizable patient populations are lacking, and the effect of body mass index (BMI) on COVID-19 outcomes-particularly in younger adults-remains uncertain. METHODS: We analyzed data from patients hospitalized with COVID-19 at 88 US hospitals enrolled in the American Heart Association's COVID-19 Cardiovascular Disease Registry with data collection through July 22, 2020. BMI was stratified by World Health Organization obesity class, with normal weight prespecified as the reference group. RESULTS: Obesity, and, in particular, class III obesity, was overrepresented in the registry in comparison with the US population, with the largest differences among adults ≤50 years. Among 7606 patients, in-hospital death or mechanical ventilation occurred in 2109 (27.7%), in-hospital death in 1302 (17.1%), and mechanical ventilation in 1602 (21.1%). After multivariable adjustment, classes I to III obesity were associated with higher risks of in-hospital death or mechanical ventilation (odds ratio, 1.28 [95% CI, 1.09-1.51], 1.57 [1.29-1.91], 1.80 [1.47-2.20], respectively), and class III obesity was associated with a higher risk of in-hospital death (hazard ratio, 1.26 [95% CI, 1.00-1.58]). Overweight and class I to III obese individuals were at higher risk for mechanical ventilation (odds ratio, 1.28 [95% CI, 1.09-1.51], 1.54 [1.29-1.84], 1.88 [1.52-2.32], and 2.08 [1.68-2.58], respectively). Significant BMI by age interactions were seen for all primary end points (P-interaction<0.05 for each), such that the association of BMI with death or mechanical ventilation was strongest in adults ≤50 years, intermediate in adults 51 to 70 years, and weakest in adults >70 years. Severe obesity (BMI ≥40 kg/m2) was associated with an increased risk of in-hospital death only in those ≤50 years (hazard ratio, 1.36 [1.01-1.84]). In adjusted analyses, higher BMI was associated with dialysis initiation and with venous thromboembolism but not with major adverse cardiac events. CONCLUSIONS: Obese patients are more likely to be hospitalized with COVID-19, and are at higher risk of in-hospital death or mechanical ventilation, in particular, if young (age ≤50 years). Obese patients are also at higher risk for venous thromboembolism and dialysis. These observations support clear public health messaging and rigorous adherence to COVID-19 prevention strategies in all obese individuals regardless of age. [ABSTRACT FROM AUTHOR]

Ticagrelor is a cornerstone of modern antithrombotic therapy alongside aspirin in patients with acute coronary syndrome and after percutaneous coronary intervention. Adverse effects such as bleeding and dyspnea have been associated with premature ticagrelor discontinuation, which may limit any potential advantage of ticagrelor over clopidogrel. The randomized trials of ticagrelor captured adverse events, offering the opportunity to more precisely quantify these effects across studies. Therefore, a meta-analysis of 4 randomized clinical trials of ticagrelor conducted between January 2007 and June 2017 was performed to quantify the incidence and causes of premature ticagrelor discontinuation. Among 66,870 patients followed for a median 18 months, premature ticagrelor discontinuation was seen in 25%; bleeding was the most common cause of discontinuation followed by dyspnea. Versus the comparators, the relative risk of dyspnea-related discontinuation during follow-up was 6.4-fold higher, the relative risk of bleeding was 3.2-fold higher, and the relative risk of discontinuation due to any adverse event was 59% higher for patients receiving ticagrelor. Understanding these potential barriers to adherence to ticagrelor is crucial for informed patient-physician decision making and can inform future efforts to improve ticagrelor adherence. This review discusses the incidence, causes, and biological mechanisms of ticagrelor-related adverse effects and offers strategies to improve adherence to ticagrelor. [ABSTRACT FROM AUTHOR]

Objectives To investigate biotin interference on three cardiac troponin (cTn) assays and demonstrate a method to overcome biotin interference. Methods cTn levels were measured in (1) plasma from healthy volunteers on 10-mg daily biotin supplementation mixed with a plasma with known elevated troponin, (2) plasmas with known elevated cTn after mixing in reagent biotin to simulate supplementation, and (3) biotin-spiked plasma specimens pretreated with streptavidin-agarose beads. Results Daily biotin ingestion (10 mg) and studies simulating daily biotin use resulted in significant interference in the Gen5 cardiac troponin T (cTnT) assay; the contemporary Gen 4 cTnT and high-sensitivity cardiac troponin I (hs-cTnI) assays were unaffected. The biotin interference threshold was 31, 315, and more than 2,000 ng/mL for Gen5 cTnT, cTnT, and hs-cTnI assays, respectively. Streptavidin pretreatment blocked biotin interference in cTn assays. Conclusions Biotin interference is possible at plasma concentrations achievable by ingestion of over-the-counter supplements that may lead to delayed or missed diagnosis of myocardial injury with the Gen5 cTnT assay. [ABSTRACT FROM AUTHOR]

The article highlights a report from the American Heart Association (AHA), in conjunction with the National Institutes of Health and other government agencies, on statistics related to heart disease, stroke, and the cardiovascular risk factors which include health behaviors and health factors that contribute to cardiovascular health. Topics include statistical update representing a critical resource for policy makers, clinicians, healthcare administrators, researchers, and health advocates.

Each year, the American Heart Association (AHA), in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together in a single document the most up-to-date statistics related to heart disease, stroke, and the factors in the AHA's Life's Simple 7 (Figure1), which include core health behaviors (smoking, physical activity [PA], diet, and weight) and health factors (cholesterol, blood pressure [BP], and glucose control) that contribute to cardiovascular health. The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions. Cardiovascular disease (CVD) and stroke produce immense health and economic burdens in the United States and globally. The Update also presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure (HF), valvular disease, venous disease, and peripheral arterial disease) and the associated outcomes (including quality of care, procedures, and economic costs). Since 2006, the annual versions of the Statistical Update have been cited >20 000 times in the literature. In 2015 alone, the various Statistical Updates were cited ≈4000 times. Each annual version of the Statistical Update undergoes revisions to include the newest nationally representative data, add additional relevant published scientific findings, remove older information, add new sections or chapters, and increase the number of ways to access and use the assembled information. This year-long process, which begins as soon as the previous Statistical Update is published, is performed by the AHA Statistics Committee faculty volunteers and staff and government agency partners. This year's edition includes new data on the monitoring and benefits of cardiovascular health in the population, new metrics to assess and monitor healthy diets, a new chapter on venous disease and pulmonary hypertension (PH), new information on stroke in young adults, an enhanced focus on underserved and minority populations, a substantively expanded focus and chapter on the global burden of CVD, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the AHA's 2020 Impact Goals. Below are a few highlights from this year's Update. [ABSTRACT FROM AUTHOR]

A correction is presented to the article "Cardiovascular disease and risk management: Standards of Care in Diabetes—2023."

We describe the validation and implementation of the new 5th generation high sensitivity Troponin T assay (Roche Diagnostics®). In addition to the assay improved sensitivity, the numerical values, reporting units, reference intervals, and critical limits are markedly different. We describe the use of clinical correlation as the basis for implementation and validation of the fifth-generation hs-TnT assay at a large teaching county hospital. [ABSTRACT FROM AUTHOR]

Objective: To review the literature systematically to determine whether noninvasive or invasive risk stratification, such as with an electrophysiological study of patients with asymptomatic pre-excitation, reduces the risk of arrhythmic events and improves patient outcomes.Methods: PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials (all January 1, 1970, through August 31, 2014) were searched for randomized controlled trials and cohort studies examining noninvasive or invasive risk stratification in patients with asymptomatic pre-excitation. Studies were rejected for low-quality design or the lack of an outcome, population, intervention, or comparator of interest or if they were written in a language other than English.Results: Of 778 citations found, 9 studies met all the eligibility criteria and were included in this paper. Of the 9 studies, 1 had a dual design-a randomized controlled trial of ablation versus no ablation in 76 patients and an uncontrolled prospective cohort of 148 additional patients-and 8 were uncontrolled prospective cohort studies (n=1594). In studies reporting a mean age, the range was 32 to 50 years, and in studies reporting a median age, the range was 19 to 36 years. The majority of patients were male (range, 50% to 74%), and <10% had structural heart disease. In the randomized controlled trial component of the dual-design study, the 5-year Kaplan-Meier estimates of the incidence of arrhythmic events were 7% among patients who underwent ablation and 77% among patients who did not undergo ablation (relative risk reduction: 0.08; 95% confidence interval: 0.02 to 0.33; P<0.001). In the observational cohorts of asymptomatic patients who did not undergo catheter ablation (n=883, with follow-up ranging from 8 to 96 months), regular supraventricular tachycardia or benign atrial fibrillation (shortest RR interval >250 ms) developed in 0% to 16%, malignant atrial fibrillation (shortest RR interval ≤250 ms) in 0% to 9%, and ventricular fibrillation in 0% to 2%, most of whom were children in the last case.Conclusions: The existing evidence suggests risk stratification with an electrophysiological study of patients with asymptomatic pre-excitation may be beneficial, along with consideration of accessory-pathway ablation in those deemed to be at high risk of future arrhythmias. Given the limitations of the existing data, well-designed and well-conducted studies are needed. [ABSTRACT FROM AUTHOR]

Objective: To review the literature systematically to determine whether noninvasive or invasive risk stratification, such as with an electrophysiological study of patients with asymptomatic pre-excitation, reduces the risk of arrhythmic events and improves patient outcomes.Methods: PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials (all January 1, 1970, through August 31, 2014) were searched for randomized controlled trials and cohort studies examining noninvasive or invasive risk stratification in patients with asymptomatic pre-excitation. Studies were rejected for low-quality design or the lack of an outcome, population, intervention, or comparator of interest or if they were written in a language other than English.Results: Of 778 citations found, 9 studies met all the eligibility criteria and were included in this paper. Of the 9 studies, 1 had a dual design-a randomized controlled trial of ablation versus no ablation in 76 patients and an uncontrolled prospective cohort of 148 additional patients-and 8 were uncontrolled prospective cohort studies (n=1,594). In studies reporting a mean age, the range was 32 to 50 years, and in studies reporting a median age, the range was 19 to 36 years. The majority of patients were male (range, 50% to 74%), and <10% had structural heart disease. In the randomized controlled trial component of the dual-design study, the 5-year Kaplan-Meier estimates of the incidence of arrhythmic events were 7% among patients who underwent ablation and 77% among patients who did not undergo ablation (relative risk reduction: 0.08; 95% confidence interval: 0.02 to 0.33; p<0.001). In the observational cohorts of asymptomatic patients who did not undergo catheter ablation (n=883, with follow-up ranging from 8 to 96 months), regular supraventricular tachycardia or benign atrial fibrillation (shortest RR interval >250 ms) developed in 0% to 16%, malignant atrial fibrillation (shortest RR interval ≤250 ms) in 0% to 9%, and ventricular fibrillation in 0% to 2%, most of whom were children in the last case.Conclusions: The existing evidence suggests risk stratification with an electrophysiological study of patients with asymptomatic pre-excitation may be beneficial, along with consideration of accessory-pathway ablation in those deemed to be at high risk of future arrhythmias. Given the limitations of the existing data, well-designed and well-conducted studies are needed. [ABSTRACT FROM AUTHOR]

Premature clopidogrel discontinuation is an important cause of stent thrombosis, myocardial infarction, and death after drug-eluting stent (DES) placement. Previous studies of clopidogrel nonadherence after DES placement have had short follow-up and have relied on self-reported adherence. All patients who underwent DES placement from January 2008 to December 2011 at a single safety-net hospital and received medications through the county-subsidized health plan were considered for inclusion; those with <1-year follow-up were excluded. We retrospectively collected 1-year refill data from a large, closed pharmacy system. Our primary outcome was time to failure to obtain a clopidogrel refill, allowing a 5-day grace period. Our study cohort (n = 369) was 34% female, 39% Hispanic, 26% white, and 26% African-American; 26% identified Spanish as their primary language. The time to failure to obtain a clopidogrel refill was 153 days. Cumulative failure to obtain at least 1 refill was 23% for the first refill, increasing to 52% at 6 months and 68% at 1 year. Examining the proportion of days covered (PDC), 21% of patients had 100% coverage, whereas 34% had PDC <80%. There were no independent predictors of nonadherence (PDC <80%). In conclusion, we identified a high rate of clopidogrel nonadherence in a multiethnic urban poor patient population where clopidogrel was provided at discharge and at nominal cost thereafter. In this cohort, prediction models of nonadherence performed poorly. Novel strategies are needed to address this important problem. [ABSTRACT FROM AUTHOR]

The article presents a summary of the updates made to the Heart Disease and Stroke Statistical Update in 2016 which is developed by the nonprofit organization American Heart Association (AHA). Updates include the status of the U.S. Cardiovascular Health, the development of effective approaches that promotes cardiovascular health improvement and the health behaviors of Americans.

The article presents a summary of the updates made to the Heart Disease and Stroke Statistical Update in 2016 outlined by the nonprofit organization American Heart Association (AHA). Updates include the cardiovascular health behaviors of the U.S. children and adults, the development of effective approaches towards the improvement of cardiovascular health and health behaviors including tobacco use, physical inactivity and obesity.

The article discusses the evaluation of a novel rule-out myocardial infarction (MI) protocol incorporating high-sensitivity troponin T at Parkland Health and Hospital System in the U.S. It describes the protocol for rapid rule-out of MI using the hs-cTnT assay, applied to a contemporary emergency department population, ruled out more patients than the current protocol using the traditional assay.

Primary aldosteronism ( PA) is present in up to 20% of patients with treatment-resistant hypertension ( TRH). Investigation for PA in patients with TRH is recommended by current guidelines after medication nonadherence is excluded. Studies using therapeutic drug monitoring ( TDM) have shown that >50% of patients with TRH are nonadherent to their prescribed antihypertensive medications. However, the relationship between the prevalence of PA and medication adherence as confirmed by TDM has not been previously assessed. A retrospective analysis from a hypertension referral clinic showed that prevalence of PA in adherent patients with TRH by TDM was significantly higher than in nonadherent patients (28% vs 8%, P<.05). Furthermore, cost analysis showed that TDM-guided PA screening was $590.69 less expensive per patient, with minimal impact on the diagnostic accuracy. These data support a TDM-guided PA screening approach as a cost-saving strategy compared with routine PA screening for TRH. [ABSTRACT FROM AUTHOR]

Sedentary behavior is an adverse health risk factor that is independent of physical activity. The relationship between sedentary behavior, exercise activity and the ankle-brachial index (ABI) is not well understood. We analyzed data from the National Health and Nutrition Examination Survey (NHANES) 2003–2004. Accelerometer data were used to quantify exercise and sedentary time for each participant. A low ABI was defined as a value <1.0 (including borderline values). Multi-variable adjusted logistic regression analyses were performed with sedentary and exercise times as independent variables, adjusting for important confounders. There were 1443 asymptomatic participants (mean age 61 years, 49% female, 55% current/prior smokers) with mean daily sedentary and exercise times of 454±144 and 18±20 minutes, respectively. Of the participants, 23% had an ABI <1.0 (8.7% with ABI <0.9). Sedentary time was positively associated with a low ABI (odds ratio [OR] 1.22 per 1 standard deviation [SD], [95% confidence interval (CI), 1.03–1.43]; p=0.02) while exercise time was inversely associated with a low ABI (OR 0.71 per 1 SD, [95% CI, 0.57–0.89]; p=0.003). Sedentary time is associated with low ABI values in the asymptomatic population. This association appears to be independent of exercise time and warrants further investigation. [ABSTRACT FROM AUTHOR]

Introduction Despite a proposed connection between neighborhood environment and obesity, few longitudinal studies have examined the relationship between change in neighborhood socioeconomic deprivation, as defined by moving between neighborhoods, and change in body weight. The purpose of this study is to examine the longitudinal relationship between moving to more socioeconomically deprived neighborhoods and weight gain as a cardiovascular risk factor. Methods Weight (kilograms) was measured in the Dallas Heart Study (DHS), a multiethnic cohort aged 18–65 years, at baseline (2000–2002) and 7-year follow-up (2007–2009, N=1,835). Data were analyzed in 2013–2014. Geocoded addresses were linked to Dallas County, TX, census block groups. A block group-level neighborhood deprivation index (NDI) was created. Multilevel difference-in-difference models with random effects and a Heckman correction factor (HCF) determined weight change relative to NDI change. Results Forty-nine percent of the DHS population moved (263 to higher NDI, 586 to lower NDI, 47 within same NDI), with blacks more likely to move than whites or Hispanics ( p <0.01), but similar baseline BMI and waist circumference were observed in movers versus non-movers ( p >0.05). Adjusting for HCF, sex, race, and time-varying covariates, those who moved to areas of higher NDI gained more weight compared to those remaining in the same or moving to a lower NDI (0.64 kg per 1-unit NDI increase, 95% CI=0.09, 1.19). Impact of NDI change on weight gain increased with time ( p =0.03). Conclusions Moving to more–socioeconomically deprived neighborhoods was associated with weight gain among DHS participants. [ABSTRACT FROM AUTHOR]

Background Obesity has been linked to the development of hypertension, but whether total adiposity or site-specific fat accumulation underpins this relationship is unclear. Objectives This study sought to determine the relationship between adipose tissue distribution and incident hypertension. Methods Normotensive participants enrolled in the Dallas Heart Study were followed for a median of 7 years for the development of hypertension (systolic blood pressure [SBP] ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or initiation of blood pressure medications). Visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) was quantified by magnetic resonance imaging and proton-spectroscopic imaging, and lower body fat (LBF) was imaged by dual-energy x-ray absorptiometry. Multivariable relative risk regression was performed to test the association between individual fat depots and incident hypertension, adjusting for age, sex, race/ethnicity, diabetes, smoking, SBP, and body mass index (BMI). Results Among 903 participants (median age, 40 years; 57% women; 60% nonwhite; median BMI 27.5 kg/m 2 ), 230 (25%) developed incident hypertension. In multivariable analyses, higher BMI was significantly associated with incident hypertension (relative risk: 1.24; 95% confidence interval: 1.12 to 1.36, per 1-SD increase). However, when VAT, SAT, and LBF were added to the model, only VAT remained independently associated with incident hypertension (relative risk: 1.22; 95% confidence interval: 1.06 to 1.39, per 1-SD increase). Conclusions Increased visceral adiposity, but not total or subcutaneous adiposity, was robustly associated with incident hypertension. Additional studies will be needed to elucidate the mechanisms behind this association. [ABSTRACT FROM AUTHOR]

Objective The aim of this study is to examine a relationship between neighborhood-level socioeconomic deprivation and weight change in a multi-ethnic cohort from Dallas County, Texas and whether behavioral/psychosocial factors attenuate the relationship. Methods Non-movers (those in the same neighborhood throughout the study period) aged 18-65 (N=939) in Dallas Heart Study (DHS) underwent weight measurements between 2000 and 2009 (median 7-year follow-up). Geocoded home addresses defined block groups; a neighborhood deprivation index (NDI) was created (higher NDI=greater deprivation). Multi-level modeling determined weight change relative to NDI. Model fit improvement was examined with adding physical activity and neighborhood environment perceptions (higher score=more unfavorable perceptions) as covariates. A significant interaction between residence length and NDI was found (p-interaction=0.04); results were stratified by median residence length (11years). Results Adjusting for age, sex, race/ethnicity, smoking, and education/income, those who lived in neighborhood > 11years gained 1.0kg per one-unit increment of NDI (p=0.03), or 6kg for those in highest NDI tertile compared with those in the lowest tertile. Physical activity improved model fit; NDI remained associated with weight gain after adjustment for physical activity and neighborhood environment perceptions. There was no significant relationship between NDI and weight change for those in their neighborhood ↜ 11years. Conclusions Living in more socioeconomically deprived neighborhoods over a longer time period was associated with weight gain in DHS. [ABSTRACT FROM AUTHOR]

Objectives: The goal of this study was to investigate the association between natriuretic peptides and body fat distribution in a multiethnic cohort. Background: Natriuretic peptides stimulate lipolysis, reduce weight gain, and promote adipocyte browning in animal models, but data are lacking in humans. Methods: A total of 2,619 participants without heart failure in the Dallas Heart Study underwent measurements of 1) B-type natriuretic peptide (BNP) and N-terminal pro–B-type natriuretic peptide (NT-proBNP); and 2) body fat distribution by dual energy x-ray absorptiometry and magnetic resonance imaging. Cross-sectional associations of natriuretic peptides with adiposity phenotypes were examined after adjustment for age, sex, race, comorbidities, and body mass index. Results: Median BNP and NT-proBNP levels in the study cohort (mean age 44 years; 56% women, 48% African Americans, 32% obese) were 3.0 and 28.1 pg/ml, respectively. Natriuretic peptide levels above the median were associated with a more favorable body fat profile and less insulin resistance, including lower visceral fat, liver fat, and homeostasis model assessment of insulin resistance index, and increased lower body fat and higher adiponectin (p < 0.05 for each). In multivariable analyses, NT-proBNP remained inversely associated with visceral fat (beta coefficient = −0.08; p < 0.0001) and liver fat (beta coefficient = −0.14; p < 0.0001) and positively associated with lower body fat (beta coefficient = 0.07; p < 0.0001) independent of age, sex, race, and obesity status; findings were similar with BNP. Adjustment for body composition, homeostasis model assessment of insulin resistance index, circulating androgens, and adipocytokines did not attenuate the associations. Conclusions: Higher natriuretic peptide levels were independently associated with a favorable adiposity profile, characterized by decreased visceral and liver fat and increased lower body fat, suggesting a link between the heart and adipose tissue distribution mediated through natriuretic peptides. [Copyright &y& Elsevier]