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ObjectivesTo investigate the associations between county-level proportions of adults not engaging in leisure-time physical activity (no LTPA) and age-adjusted cardiovascular mortality (AACVM) rates in the overall US population and across demographics.MethodsAnalysing 2900 US counties from 2011 to 2019, we used the Centers for Disease Control and Prevention (CDC) databases to obtain annual AACVM rates. No LTPA data were sourced from the CDC’s Behavioural Risk Factor Surveillance System survey and county-specific rates were calculated using a validated multilevel regression and poststratification modelling approach. Multiple regression models assessed associations with county characteristics such as socioeconomic, environmental, clinical and healthcare access factors. Poisson generalised linear mixed models were employed to calculate incidence rate ratios (IRR) and additional yearly deaths (AYD) per 100 000 persons.ResultsOf 309.9 million residents in 2900 counties in 2011, 7.38 million (2.4%) cardiovascular deaths occurred by 2019. County attributes such as socioeconomic, environmental and clinical factors accounted for up to 65% (adjusted R2=0.65) of variance in no LTPA rates. No LTPA rates associated with higher AACVM across demographics, notably among middle-aged adults (standardised IRR: 1.06; 95% CI (1.04 to 1.07)), particularly women (1.09; 95% CI (1.07 to 1.12)). The highest AYDs were among elderly non-Hispanic black individuals (AYD=68/100 000).ConclusionsOur study reveals a robust association between the high prevalence of no LTPA and elevated AACVM rates beyond other social determinants. The most at-risk groups were middle-aged women and elderly non-Hispanic black individuals. Further, county-level characteristics accounted for substantial variance in community LTPA rates. These results emphasise the need for targeted public health measures to boost physical activity, especially in high-risk communities, to reduce AACVM.

The benefit of intensive (<120 mmHg) blood pressure (BP) treatment, reduction in all-cause mortality (ACM), was attenuated when mediated through non-fatal major adverse cardiovascular events. This was driven by cardiovascular mortality (CVM).The harm of intensive BP treatment, increase in ACM, was amplified when mediated through serious adverse events. This was driven by non-CVM.Current reporting of treatment effects in cardiovascular trials does not allow for expansion of the lens to focus on important occurrences after the index event.Graphical Abstract

Many studies support the notion that polygenic risk scores (PRS) improve risk prediction for coronary heart disease (CHD) beyond conventional risk factors. However, PRS are not yet considered risk-enhancing factor in guidelines. Our objective was to determine the predictive performance of a commercially available PRS (CARDIO inCode-Score®) compared with the Pooled Cohorts Equations (PCE) in a contemporary, multi-ethnic cohort.

ObjectivesTo determine the association between moderate-to-vigorous intensity physical activity (MVPA) trajectories (course over age and time) through the adult life course and onset of metabolic disease (diabetes and dyslipidaemia).MethodsWe analysed prospective community-based cohort data of 5115 participants in the Coronary Artery Risk Development in Young Adults study, who were black and white men and women aged 18–30 years at baseline (1985–1986) at four urban sites, collected through 30 years of follow-up. Individualised MVPA trajectories were developed for each participant using linear mixed models.ResultsLower estimated MVPA score at age 18 was associated with a 12% (95% CI 6% to 18%) higher odds of incident diabetes, a 4% (95% CI 1% to 7%) higher odds of incident low high-density lipoprotein (HDL) and a 6% (95% CI 2% to 11%) higher odds of incident high triglycerides. Each additional annual 1-unit reduction in the MVPA score was associated with a 6% (95% CI 4% to 9%) higher annual odds of diabetes incidence and a 4% (95% CI 2% to 6%) higher annual odds of high triglyceride incidence. Analysing various MVPA trajectory groups, participants who were in the most active group at age 18 (over 300 min/week), but with sharp declines in midlife, had higher odds of high low-density lipoprotein and low HDL incidence, compared with those in the most active group at age 18 with subsequent gains.ConclusionGiven recent trends in declining MVPA across the life course and associated metabolic disease risk, young adulthood is an important time period for interventions to increase and begin the maintenance of MVPA.

The American Heart Association Life's Simple 7 schema can be used to categorize patients’ cardiovascular health status as poor, intermediate, or ideal on the basis of smoking, BMI, physical activity, dietary patterns, blood pressure, cholesterol, and fasting blood sugar. This study examined the association between cardiovascular health status and subsequent healthcare utilization.

•Hypertension prevalence in Filipino adults is high, in the range of Black adults•Hypertension prevalence is higher in Filipino than White and Hispanic adults•Hypertension prevalence is higher in Filipino than South Asian and Chinese adults•These differences in prevalence are observed across age decades from ages 30 to 79

We use variables from a recently derived acute heart failure risk-stratification rule (STRATIFY) as a basis to develop and optimize risk prediction using additional patient clinical data from electronic health records and machine-learning models.

Cannabis, or marijuana, has potential therapeutic and medicinal properties related to multiple compounds, particularly Δ-9-tetrahydrocannabinol and cannabidiol. Over the past 25 years, attitudes toward cannabis have evolved rapidly, with expanding legalization of medical and recreational use at the state level in the United States and recreational use nationally in Canada and Uruguay. As a result, the consumption of cannabis products is increasing considerably, particularly among youth. Our understanding of the safety and efficacy of cannabis has been limited by decades of worldwide illegality and continues to be limited in the United States by the ongoing classification of cannabis as a Schedule 1 controlled substance. These shifts in cannabis use require clinicians to understand conflicting laws, health implications, and therapeutic possibilities. Cannabis may have therapeutic benefits, but few are cardiovascular in nature. Conversely, many of the concerning health implications of cannabis include cardiovascular diseases, although they may be mediated by mechanisms of delivery. This statement critically reviews the use of medicinal and recreational cannabis from a clinical but also a policy and public health perspective by evaluating its safety and efficacy profile, particularly in relationship to cardiovascular health.

IMPORTANCE: Long-term blood pressure (BP) variability has emerged as a reproducible measure that is associated with heart failure independent of systemic BP. Visit-to-visit BP variability may be associated with the risk of heart failure early in the life course and thus may be reflected in subclinical alterations in cardiac structure and function. OBJECTIVE: To evaluate the association between visit-to-visit BP variability in early adulthood and myocardial structure and function in middle age. DESIGN, SETTING, AND PARTICIPANTS: This cohort study used data from the Coronary Artery Risk Development in Young Adults (CARDIA) study, a community-based cohort study of 5115 participants aged 18 to 30 years at baseline (year 0; March 25, 1985, to June 7, 1986) and followed up over a 30-year interval. A total of 2400 CARDIA study participants underwent evaluation at 4 field sites (Birmingham, Alabama; Oakland, California; Chicago, Illinois; and Minneapolis, Minnesota). Blood pressure was measured at 8 visits over a 25-year interval and participants received echocardiograms at year 25 (June 1, 2010, to August 31, 2011). Data analysis was conducted from June 7, 1986, to August 31, 2011. EXPOSURES: Visit-to-visit systolic and diastolic BP variability measures included SD, average real variability, and variability independent of the mean. MAIN OUTCOMES AND MEASURES: Echocardiographic indices of myocardial structure, systolic function, and diastolic function at the year 25 examination. RESULTS: Of the 2400 participants, 1024 were men (42.7%) and 976 were African American (40.7%); mean (SD) age at the year 25 examination was 50.4 (3.6) years. Per 1-SD increment, greater visit-to-visit systolic BP variability independent of the mean was associated with higher left-ventricular (LV) mass index (β [SE], 2.66 [0.4] g/m2, P &lt; .001), worse diastolic function (early peak diastolic mitral annular velocity [é]) (β [SE], −0.40 [0.1] cm/s, P &lt; .001), higher LV filling pressures (mitral inflow velocity to early diastolic mitral annular velocity [E/é]) β [SE], 0.37 [0.1] cm/s, P &lt; .001), and worse global longitudinal strain (β [SE], 0.17 [0.1], P = .002). Similarly, greater visit-to-visit diastolic BP variability was associated with higher LV mass index (β [SE], 3.21 [0.5] g/m2, P &lt; .001), worse diastolic function (é: β [SE], −0.24 [0.1] cm/s [P &lt; .001]; E/é: β [SE], 0.23 [0.1] cm/s [P &lt; .001]), and worse global longitudinal strain (β [SE], 0.13 [0.1], P = .02). The findings remained consistent when other BP variability measures were used (SD and average real variability). CONCLUSIONS AND RELEVANCE: In this cohort study using data from the CARDIA study, greater visit-to-visit systolic and diastolic BP variability have been associated with adverse alterations in cardiac structure as well as systolic and diastolic function independent of mean BP levels.

IMPORTANCE: A deceleration in the rate of decrease of heart disease (HD) mortality between 2011 and 2014 has been reported. In the context of the rapid increase in the population of adults aged 65 years and older, extending the examination of HD mortality through 2017 has potentially important implications for public health and medical care. OBJECTIVE: To examine changes in the age-adjusted mortality rate and the number of deaths within subcategories of HD from 2011 to 2017 in conjunction with the change in the size of the US population during the same period. DESIGN, SETTING, AND PARTICIPANTS: In this quality improvement study, the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) data set was used to identify national changes in the US population aged 65 years and older and in the age-adjusted mortality rates and number of deaths that were listed with an underlying cause of HD, coronary heart disease (CHD), heart failure, and other HDs from January 1, 2011, to December 31, 2017. MAIN OUTCOMES AND MEASURES: Changes from 2011 to 2017 in the US population and in age-adjusted mortality rates and number of deaths that were listed with an underlying cause of HD, CHD, heart failure (both as an underlying and a contributing cause), and other HDs overall, by sex and race/ethnicity. RESULTS: The total size of this population of US adults aged 65 years and older increased 22.9% from 41.4 million to 50.9 million between January 1, 2011, and December 31, 2017, while the population of adults younger than 65 years increased by only 1.7%. During this period, the age-adjusted mortality rate decreased 5.0% for HD and 14.9% for CHD while increasing 20.7% for heart failure and 8.4% for other HDs. The number of deaths increased 8.5% for HD, 38.0% for heart failure, and 23.4% for other HDs while decreasing 2.5% for CHD. A total of 80% of HD deaths occurred in the group of adults aged 65 years and older. CONCLUSIONS AND RELEVANCE: The substantial increase in the growth rate of the group of adults aged 65 years and older who have the highest risk of HD was associated with an increase in the number of HD deaths in this group despite a slowly declining HD mortality rate in the general population. With the number of adults aged 65 years and older projected to increase an additional 44% from 2017 to 2030, innovative and effective approaches to prevent and treat HD, particularly the substantially increasing rates of heart failure, are needed.

To evaluate 25-year physical activity (PA) trajectories from young to middle age and assess associations with the prevalence of coronary artery calcification (CAC).

This study sought to evaluate the association between early-life cardiorespiratory fitness (CRF) and measures of left ventricular (LV) structure and function in midlife.

Patients with diabetes have a high residual risk for cardiovascular disease (CVD) and adverse outcomes despite statin therapy and lifestyle modifications. Particular to individuals with diabetes is the pattern of elevated triglycerides, small dense low density lipoprotein cholesterol, and reduced levels of high density lipoprotein cholesterol, described as dyslipidemia of diabetes. The role of combination therapy with an additional agent such as niacin, ezetimibe, fenofibrate, and n-3 fatty acids has been studied; however, at the same time, these agents have come under criticism for their limitations. We performed a review of key trials assessing the benefit of combination therapy to reduce CVD risk from dyslipidemia. Of the currently available agents that can be used in combination with statins, ezetimibe has the most favorable risk profile, with a recent trial demonstrating modest incremental benefit when given in addition to statins. PCSK9 inhibitors are a promising category, although clinical outcome data in individuals with diabetes are pending.

IMPORTANCE: Statins remain a mainstay in the prevention and treatment of atherosclerotic cardiovascular disease (ASCVD). OBJECTIVE: To detail the trends in use and total and out-of-pocket (OOP) expenditures associated with statins in a representative US adult population from 2002 to 2013. DESIGN, SETTING, AND PARTICIPANTS: This retrospective longitudinal cohort study was conducted from January 2002 to December 2013. Demographic, medical condition, and prescribed medicine information of adults 40 years and older between 2002 and 2013 were obtained from the Medical Expenditure Panel Survey database. MAIN OUTCOMES AND MEASURES: Estimated trends in statin use, total expenditure, and OOP share among the general adult population, those with established ASCVD, and those at risk for ASCVD. Costs were adjusted to 2013 US dollars using the Gross Domestic Product Index. RESULTS: From 2002 to 2013, more than 157 000 Medical Expenditure Panel Survey participants were eligible for the study (mean [SD] age, 57.7 [39.9] years; 52.1% female). Overall, statin use among US adults 40 years of age and older in the general population increased 79.8% from 21.8 million individuals (17.9%) in 2002-2003 (134 million prescriptions) to 39.2 million individuals (27.8%) in 2012-2013 (221 million prescriptions). Among those with established ASCVD, statin use was 49.8% and 58.1% in 2002-2003 and 2012-2013, respectively, and less than one-third were prescribed as a high-intensity dose. Across all subgroups, statin use was significantly lower in women (odds ratio, 0.81; 95% CI, 0.79-0.85), racial/ethnic minorities (odds ratio, 0.65; 95% CI, 0.61-0.70), and the uninsured (odds ratio, 0.33; 95% CI, 0.30-0.37). The proportion of generic statin use increased substantially, from 8.4% in 2002-2003 to 81.8% in 2012-2013. Gross domestic product–adjusted total cost for statins decreased from $17.2 billion (OOP cost, $7.6 billion) in 2002-2003 to $16.9 billion (OOP cost, $3.9 billion) in 2012-2013, and the mean annual OOP costs for patients decreased from $348 to $94. Brand-name statins were used by 18.2% of statin users, accounting for 55% of total costs in 2012-2013. CONCLUSION AND RELEVANCE: Statin use increased substantially in the last decade among US adults, although the uptake was suboptimal in high-risk groups. While total and OOP expenditures associated with statins decreased, further substitution of brand-name to generic statins may yield more savings.

Introduction:Coronary artery calcification (CAC) score, physical activity (PA), and cardiorespiratory fitness (CRF) are all associated with cardiovascular disease (CVD) risk. While a U-shaped relationship between PA and CRF with CAC has been reported, CAC presence among highly fit individuals was suggested to be benign.Objective:To determine interactive associations of PA/CRF and CAC with outcomes in a cohort of middle-aged adults and to evaluate the relationship of PA/CRF with CAC incidence.Methods:CARDIA participants with CT-assessed CAC at year 20 (2005-06) were included (n=3141, mean age 45y, 57% female, 45% Black). Moderate to vigorous intensity PA (MVPA) was assessed by self-report and accelerometer. CRF was estimated with a treadmill test. Incident CVD events were adjudicated, and mortality data were obtained through 2019. CAC was reassessed at year 25 (2010-11). Cox models assessed hazard ratios (HRs) for CVD and mortality in groups defined by CAC and MVPA/CRF. Logistic models assessed associations with CAC incidence.Results:At baseline, more favorable CVD risk was found among participants with higher MVPA, higher CRF (> median sex-specific duration), and absence of CAC. During a mean follow-up of 13 years, 166 CVD events and 171 deaths occurred. After multivariable adjustment, compared with no CAC and higher CRF (ref), the HRs (95% CIs) for CVD were 5.04 (2.49-10.20) for CAC and higher CRF, 2.26 (1.24-4.12) for no CAC and lower CRF, and 4.27 (2.24-8.14) for CAC and lower CRF (Figure, left panel). The respective HRs for mortality were 1.12 (0.45-2.77), 1.54 (0.91-2.60), and 3.23 (1.82-5.72) (Figure, right panel). Similar findings were observed with self-reported or accelerometer MVPA replacing CRF. Higher CRF and accelerometer MVPA were dose-responsively associated with a lower probability of developing CAC in a 5-year follow-up (P < .01).Conclusions:PA and CRF were inversely associated with CAC incidence in middle-aged adults. CAC presence eliminated the cardiovascular risk advantage of high PA or high CRF.

Background:The association between variability in body mass index (BMI) in early adulthood and cardiac structure and function in midlife has not been previously examined.Methods:We examined 2371 Coronary Artery Risk Development in Young Adults (CARDIA) participants who had BMI assessments across 25-years (CARDIA exam year 0 [1985-1986], 2 [1987-1989], 5 [1990-1991], 7 [1992-1993], 10 [1995-1996], 15 [2000-2001], 20 [2005-2006], and 25 [2010-2011]) as well as echocardiography data at the year-25 exam (2010-2011). BMI variability was assessed by standard deviation (SD) across 25 years. Adjusted multivariable linear regression models were used to assess the association between echocardiography variables (dependent variable) and SD of BMI (independent variable). Model 1 was adjusted for standard cardiac risk factors (age, sex, race, education, blood pressure, anti-hypertension medication use, smoking, fasting plasma glucose, alcohol consumption, physical activity, HDL and total cholesterol. Model 2 was additionally adjusted for mean BMI.Results:Among participants included in the analysis, mean [SD] age at the year 25 exam [2010-2011] was 50.4 [3.6] years; 44.5% were men; and 41.3% were black). In model 1, greater SD of BMI was associated with greater left ventricular mass (β 5.18g, p<0.001), left ventricular global longitudinal strain 0.08, p=0.01, and left atrial volume (β 1.60ml, p<0.001). Additional adjustment for mean BMI, attenuated associations (p>.05 for all). Greater SD of BMI was associated with worse diastolic function (E/é) (β 0.11, p<0.001). Observed association between BMI variability and E/é persisted even after accounting for mean BMI (β 0.08, p=0.01).Conclusions:Greater body weight variability in young adulthood was associated with modest unfavorable midlife alterations in diastolic function.

Breast arterial calcification (BAC) detected in mammograms is an emerging risk-enhancing factor for atherosclerotic cardiovascular disease (ASCVD). The predictive value of coronary artery calcification (CAC) for risk of ASCVD above and beyond traditional risk factors is well-established in women. However, there are few studies that have simultaneously evaluated BAC and CAC. The Multiethnic study of breast arterial calcium gradation and cardiovascular disease (MINERVA) cohort, a large, racially and ethnically diverse cohort of postmenopausal women aged 60-69 (n=5,059) was recruited in 2012-15 at Kaiser Permanente of Northern California (KPNC). BAC was assessed using a densitometry method, and presence of BAC was defined as a calcium mass score>0 mg. Searching the electronic health record up to 5 years after baseline, we identified 33 women (39% non-white) who underwent cardiac computed tomography (CT) because of medical indication. BAC was present in 33% (11/33) whereas CAC (Agastston score >0) was present in 61% (20/33). Nine (27%) were BAC and CAC -; 7 (21%) were BAC and CAC+; 4 (12%) were BAC+ and CAC -; and 13 (39%) were BAC - and CAC+. The correlation between log (BAC+1) and log (CAC+1) was 0.45 (p=0.02) in the entire sample (n=33) and was 0.68 (p=0.09) in the 7 women who were BAC and CAC+. The concordance, sensitivity, specificity, PPV, NPV for BAC considering CAC as the gold standard were 0.48, 0.35, 0.69, 0.63 and 0.41, respectively. The unadjusted odds ratio for log (CAC+1)>0 as a function of Log (BAC+1) was 1.21 (95% CI, 0.27-5.38; p=0.80). Although our sample was small, the findings reflect real-world evidence and suggest that BAC and CAC are not entirely overlapping and thus may convey independent predictive information for ASCVD.

Introduction:Measures of atherogenic particle number (apoB and LDL particle number [LDL-P]) are stronger predictors of atherosclerotic cardiovascular disease (ASCVD) risk than measures of cholesterol concentration (LDL-C, non-HDL-C, total cholesterol [TC]) in middle-aged adults. It is unclear if this is true for younger adults.Methods:Among CARDIA participants (ppts), NMR was used to measure apoB and LDL-P. Non-HDL-C and TC were measured using standard assays; LDL-C was calculated using the Friedewald equation. We stratified the ppts into two age windows: age 20-30y (n=1645) and age 30-40y (n=2922). We used adjusted Cox proportional hazards models to assess the associations of 1SD higher apoB, LDL-P, non-HDL-C, LDL-C, or TC with incident ASCVD events. We substituted each measure of atherogenic lipid burden for TC in a modified Pooled Cohort Equation (PCE) model (with and without HDL-C); and model performance (discrimination and reclassification) was evaluated.Results:There were 81 and 163 ASCVD events over (median [IQR]) 31.8y (31.1-32.0y) for the age 20-30 age window and over 26.8y (19.1-27.1y) for the 30-40y age window, respectively. In ppts age 20-30y, a 1SD higher apoB, LDL-P, non-HDL-C, and LDL-C were significantly associated with incident ASCVD in demographic adjusted models. The strengths of associations with ASCVD were not significantly different across these measures. For the 30-40y age window, all measures of atherogenic lipoproteins were significantly associated with ASCVD; the strengths of association were not significantly different across atherogenic lipid measures in all models. There were no significant differences in the C-statistic and no improvement in reclassification when each measure was used to replace TC in the PCE model.Conclusions:ApoB, LDL-P, LDL-C or non-HDL-C may be slightly better markers of long-term ASCVD risk than TC in adults < 30y. However, in adults between 30-40y all measures of atherogenic lipid burden appeared to be equivalent predictors of long-term risk.

Introduction:Hypertension risk increases with higher age and body mass index (BMI). We previously found that the prevalence of diagnosed hypertension among Filipino adults is similar to Black adults and higher than White, Chinese, and South Asian adults aged 45-84y. Among young women, the difference between Filipina and Chinese adults was >2-fold. We now examine disparities in hypertension prevalence across the adult lifespan, accounting for differences in weight status.Methods:This cross-sectional study used electronic health record data for 1,018,159 non-Hispanic White (White), 146,517 Black, 348,715 Hispanic, 128,124 Filipino, 126,321 Chinese, and 80,723 South Asian adults aged 30-79 who were members of a Northern California health plan in 2016. Hypertension prevalence (ICD 9/10 diagnosis in 2016) was examined by race/ethnicity and sex for ages 30-39, 40-49, 50-59, 60-69, 70-79y. Poisson regression was used to estimate prevalence ratios (aPRs) for hypertension compared to White adults in each age decade, adjusting for age, English language, current smoking, and BMI category (underweight, healthy weight, overweight, obesity class 1, 2, 3). Lower BMI thresholds were used for Asian adults.Results:Across all age decades, Filipino adults had a prevalence of hypertension similar to Black adults and higher than White, Chinese, and South Asian adults. In each age decade, the Filipino:White aPRs approached or exceeded the Black:White aPRs and were much higher than South Asian:White and Chinese:White aPRs (Figure). Differences in hypertension risk were greatest for those aged 30-59y.Conclusions:Filipino adults, similar to Black adults, had earlier onset and higher prevalence of hypertension than White, Chinese, and South Asian adults across 5 age decades, a disparity that persisted after adjusting for weight status, smoking, and language. These results support the need for earlier and more aggressive blood pressure screening in high-risk populations.

Introduction:We previously reported that Chinese, Filipino, and South Asian adults have higher prevalence of prediabetes (PreDM) than non-Hispanic White (White) adults, with nearly twice the burden in healthy BMI ranges. This study further examines the differential burden of diabetes (DM) in these Asian subgroups using Asian specific BMI categories.Methods:283,110 White, 33,263 Chinese, 38,766 Filipino, and 17,959 South Asian adults aged 45-64y in a 2016 Northern California health plan with height and weight were examined. PreDM and DM were classified based on lab data, diagnoses, or DM treatment. Modified log Poisson regression was used to determine Asian group vs. White prevalence ratios (PRs) for DM and preDM, adjusted for age and BMI within healthy weight, overweight, and obesity ranges (BMI 18.5 to <25, 23 to <30, ≥30 kg/m2 for Whites; BMI 18.5 to <23, 23 to <27.5, ≥27.5 kg/m2 for Asians).Results:Across all BMI categories, DM prevalence was higher for the Asian groups than White adults. DM prevalence was also higher for Filipino and South Asian vs White than Chinese vs White, especially at healthy BMI levels. PRs for South Asian men/women at healthy BMI were 1.8/2.8 for preDM and 5.9/8.0 for DM (Figure). PRs for Filipino men/women at healthy BMI were 1.8/2.6 for preDM and 5.0/7.5 for DM, respectively. For Chinese men/women at healthy BMI, the PRs for preDM were similar (2.1/2.9) to the other Asian groups, but the PRs for DM were lower (2.1/3.4).Conclusion:The largest difference in DM prevalence relative to White adults was observed in the healthy BMI range for South Asian and Filipino adults. While PreDM risk in these 2 groups was similar to the preDM risk in Chinese compared with White adults at healthy BMI, their DM risk was 5-8 times greater than White adults at healthy BMI. Our data emphasize the disproportionate metabolic risk among middle-aged adults of different Asian groups and underscore the need for DM screening among high-risk Asian subgroups at healthy BMI levels.

IMPORTANCE: Heart disease (HD) and cancer are the 2 leading causes of death in the United States. During the first decade of the 21st century, HD mortality declined at a much greater rate than cancer mortality and it appeared that cancer would overtake HD as the leading cause of death. OBJECTIVES: To determine whether changes in national trends had occurred in recent years in mortality rates due to all cardiovascular disease (CVD), HD, stroke, and cancer and to evaluate the gap between mortality rates from HD and cancer. DESIGN, SETTING, AND PARTICIPANTS: The Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research data system was used to determine national trends in age-adjusted mortality rates due to all CVD, HD, stroke, and cancer from January 1, 2000, to December 31, 2011, and January 1, 2011, to December 31, 2014, overall, by sex, and by race/ethnicity. The present study was conducted from December 30, 2105, to January 18, 2016. MAIN OUTCOMES AND MEASURES: Comparison of annual rates of change and trend in gap between HD and cancer mortality rates. RESULTS: The rate of the decline in all CVD, HD, and stroke mortality decelerated substantially after 2011, and the rate of decline for cancer mortality remained relatively stable. Reported as percentage (95% CI), the annual rates of decline for 2000-2011 were 3.79% (3.61% to 3.97%), 3.69% (3.51% to 3.87%), 4.53% (4.34% to 4.72%), and 1.49% (1.37% to 1.60%) for all CVD, HD, stroke, and cancer mortality, respectively; the rates for 2011-2014 were 0.65% (−0.18% to 1.47%), 0.76% (−0.06% to 1.58%), 0.37% (−0.53% to 1.27%), and 1.55% (1.07% to 2.04%), respectively. Deceleration of the decline in all CVD mortality rates occurred in males, females, and all race/ethnicity groups. For example, the annual rates of decline for total CVD mortality for 2000-2011 were 3.69% (3.48% to 3.89%) for males and 3.98% (3.81% to 4.14%) for females; for 2011-2014, the rates were 0.23% (−0.71% to 1.16%) and 1.17% (0.41% to 1.93%), respectively. The gap between HD and cancer mortality persisted. CONCLUSIONS AND RELEVANCE: Deceleration in the decline of all CVD, HD, and stroke mortality rates has occurred since 2011. If this trend continues, strategic goals for lowering the burden of CVD set by the American Heart Association and the Million Hearts Initiative may not be reached.

Supplemental Digital Content is available in the text.

IMPORTANCE: Although cardiorespiratory fitness (CRF) is prognostic in older adults, the effect of CRF during early adulthood on long-term cardiovascular structure, function, and prognosis is less clear. OBJECTIVE: To examine whether CRF in young adults is associated with long-term clinical outcome and subclinical cardiovascular disease (CVD). DESIGN, SETTING, AND PARTICIPANTS: Prospective study of 4872 US adults aged 18 to 30 years who underwent treadmill exercise testing at a baseline study visit from March 25, 1985, to June 7, 1986, and 2472 individuals who underwent a second treadmill test 7 years later. Median follow-up was 26.9 years, with assessment of obesity, left ventricular mass and strain, coronary artery calcification (CAC), and vital status and incident CVD. Follow-up was complete on August 31, 2011, and data were analyzed from recruitment through the end of follow-up. MAIN OUTCOMES AND MEASURES: The presence of CAC was assessed by computed tomography at years 15 (2000-2001), 20 (2005-2006), and 25 (2010-2011), and left ventricular mass was assessed at years 5 (1990-1991) and 25 (with global longitudinal strain). Incident CVD and all-cause mortality were adjudicated. RESULTS: Of the 4872 individuals, 273 (5.6%) died and 193 (4.0%) experienced CVD events during follow-up. After comprehensive adjustment, each additional minute of baseline exercise test duration was associated with a 15% lower hazard of death (hazard ratio [HR], 0.85; 95% CI, 0.80-0.91; P &lt; .001) and a 12% lower hazard of CVD (HR, 0.88; 95% CI, 0.81-0.96; P = .002). Higher levels of baseline CRF were associated with significantly lower left ventricular mass index (β = −0.24; 95% CI, −0.45 to −0.03; P = .02) and significantly better lobal longitudinal strain (β = −0.09; 95% CI, −0.14 to −0.05; P &lt; .001) at year 25. Fitness was not associated with CAC. A 1-minute reduction in fitness by year 7 was associated with 21% and 20% increased hazards of death (HR, 1.21; 95% CI, 1.07-1.37; P = .002) and CVD (HR, 1.20; 95% CI, 1.06-1.37; P = .006), respectively, along with a more impaired strain (β = 0.15; 95% CI, 0.08-0.23; P &lt; .001). No association between change in fitness and CAC was found. CONCLUSIONS AND RELEVANCE: Higher levels of fitness at baseline and improvement in fitness early in adulthood are favorably associated with lower risks for CVD and mortality. Fitness and changes in fitness are associated with myocardial hypertrophy and dysfunction but not CAC. Regular efforts to ascertain and improve CRF in young adulthood may play a critical role in promoting cardiovascular health and interrupting early CVD pathogenesis.

Despite aggressive low-density lipoprotein cholesterol lowering, patients continue to be at significant risk of cardiovascular events. Assessment of non-high-density lipoprotein cholesterol (non-HDL-C) provides a measure of cholesterol contained in all atherogenic particles. In the third Adult Treatment Panel guidelines, non-HDL-C was introduced as a secondary target of therapy.

Introduction:Obesity represents a major health and economic burden worldwide and is a key target for cardiovascular disease prevention. With emerging therapeutic options to manage obesity, we aimed to quantify the overall expenditures and resource utilization in adults with and without atherosclerotic cardiovascular disease (ASCVD) across obesity categories.Methods:We used the 2018 Medical Expenditure Panel Survey (MEPS), a nationally representative US survey. BMI (calculated from self-reported height and weight) was divided into 4 groups: overweight (BMI 25 to 30), mild (BMI 30 to 35), moderate (BMI 35 to 40), and morbid obesity (BMI ≥40). Cardiovascular risk factors (hypertension, diabetes, hypercholesterolemia, insufficient physical activity) and ASCVD were ascertained by ICD10 codes and/or self-report. Two-part econometric models were used to study cost data; a generalized linear model with gamma distribution and link log was used to assess expenditures.Results:Among the 19,569 sampled MEPS adults (mean age 48 years [SD 14]), 6.2% had morbid obesity (~ 14 million). Among those without ASCVD, morbid obesity was associated with higher odds for prescription medication utilization, ED and outpatient visits when compared to those with overweight (Figure). Even though individuals with ASCVD reported higher prevalence of all metrics of resource utilization, we found no statistically significant differences between BMI categories in this group. The marginal overall per capita expenditure when comparing those with morbid obesity vs overweight was $2,165 (p=0.11) in those with ASCVD, and $1,605 (p=0.03) in those without ASCVD.Conclusions:Morbid obesity was associated with increased healthcare expenditures and resource utilization, especially in those without ASCVD. Our study findings could aid in policy discussions to discern appropriate candidates for emerging novel anti-obesity therapeutics, as well as apt resource allocation.

Introduction:Black adults experience higher rates of cardiovascular disease (CVD) compared with White adults, particularly across young adulthood. To identify intervention targets to reduce disparities, we quantified the contribution of individual- and neighborhood-level determinants across young adulthood to Black-White differences in incidence of premature CVD.Methods:In Black and White adults (baseline age 18-30 years) in the Coronary Artery Risk Development in Young Adults (CARDIA) Study, the associations of clinical, lifestyle, psychosocial, socioeconomic, and neighborhood determinants with racial disparities in incident CVD were evaluated with sex-stratified Cox proportional hazards models adjusted for time-updated risk factors. Percent reduction in the ß estimate (log-hazard ratio [HR]) for race quantified the contribution of each risk factor group, individually and combined, to incident CVD racial disparities.Results:In 1707 Black and 2001 White young adults followed for median 33.9 (IQR 33.7-34.0) years, Black adults had higher risk of incident CVD than White adults (Figure). The fully adjusted model yielded significant attenuation of the disparity: HR 1.22 (0.68-2.21) for Black vs. White women, HR 1.42 (0.91-2.23) for Black vs. White men. In women, clinical risk factors were associated with the largest percent reduction in the ß estimate (83%) for race. In men, socioeconomic, lifestyle and clinical risk factors were each associated with significant percent reductions in ß estimates (45%, 37%, and 28%, respectively).Conclusions:In CARDIA, risk for premature CVD was no longer significantly higher in Black vs. White adults after adjustment for upstream determinants across multiple domains. The largest contribution to racial disparities was from clinical factors in women and socioeconomic factors in men. These findings may inform earlier-life interventions to reduce disparities in premature CVD.