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Although the use of oral anticoagulants (vitamin K antagonists) has been abandoned in primary cardiovascular prevention due to lack of a favorable benefit-to-risk ratio, the indications for aspirin use in this setting continue to be a source of major debate, with major international guidelines providing conflicting recommendations. Here, we review the evidence in favor and against aspirin therapy in primary prevention based on the evidence accumulated so far, including recent data linking aspirin with cancer protection. While awaiting the results of several ongoing studies, we argue for a pragmatic approach to using low-dose aspirin in primary cardiovascular prevention and suggest its use in patients at high cardiovascular risk, defined as ≥2 major cardiovascular events (death, myocardial infarction, or stroke) projected per 100 person-years, who are not at increased risk of bleeding., (Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Funding Support and Author Disclosures Dr S.C. You has served as the CEO of PHI Digital Healthcare; and received grants from Daiichi-Sankyo. Dr Bikdeli has been supported by a Career Development Award from the American Heart Association and VIVA Physicians (no. 938814), the Scott Schoen and Nancy Adams IGNITE Award, and the Mary Ann Tynan Research Scientist award from the Mary Horrigan Connors Center for Women’s Health and Gender Biology at Brigham and Women’s Hospital and the Heart and Vascular Center Junior Faculty Award from Brigham and Women’s Hospital; has served as a consulting expert, on behalf of the plaintiff, for litigation related to 2 specific brand models of IVC filters (but has not been involved in the litigation in 2022 or 2023 nor received any compensation in 2022 or 2023); and has served as a member of the Medical Advisory Board for the North American Thrombosis Forum and on the Data and Safety Monitory Board of the NAIL-IT trial funded by the National Heart, Lung, and Blood Institute and Translational Sciences. Dr Spatz has received grant funding from the Centers for Disease Control and Prevention (20042801-Sub01), the U.S. Food and Drug Administration to support projects within the Yale-Mayo Clinic Center of Excellence in Regulatory Science and Innovation (U01FD005938), the National Heart, Lung, and Blood Institute (R01HL151240), and the Patient-Centered Outcomes Research Institute (HM-2022C2-28354) (all reported activities are outside of the submitted work). Dr X. Yao has reported that she has no relationships relevant to the contents of this paper to disclose.

This consensus statement emerges from collaborative efforts among leading figures in critical care cardiology throughout the United States, who met to share their collective expertise on issues faced by those active in or pursuing contemporary critical care cardiology education. The panel applied fundamentals of adult education and curriculum design, reviewed requisite training necessary to provide high-quality care to critically ill patients with cardiac pathology, and devoted attention to a purposeful approach emphasizing diversity, equity, and inclusion in developing this nascent field. The resulting paper offers a comprehensive guide for current trainees, with insights about the present landscape of critical care cardiology while highlighting issues that need to be addressed for continued advancement. By delineating future directions with careful consideration and intentionality, this Expert Panel aims to facilitate the continued growth and maturation of critical care cardiology education and practice., Competing Interests: Funding Support and Author Disclosures Dr Elliott is the director of the Critical Care Cardiology Education Summit; has received grant funding from the American College of Cardiology; and has received educational honoraria from Zoll. Dr Bartos has received grant funding from the National Institutes of Health and the Leona M. and Harry B. Helmsley Charitable Trust. Dr Barnett has received research funding from Merck; and has received educational honorarium from Zoll. Drs Barnett, Alviar, Gage, Horowitz, and Katz are co-course directors of the NYU Langone Critical Care Cardiology Symposium, and the course has received industry support. Dr Roswell is the chair of the American College of Cardiology Critical Care Cardiology member section; and chair-elect of the American Board of Internal Medicine Board of Directors. Dr Alviar has received research funds from Baxter; and has served on the Speakers Bureau for Zoll and Abiomed. Drs Bennett and Jentzer are co-course directors of Heart to Heart: Advances in Cardiovascular Critical Care and Resuscitation. Dr Berg has received institutional grants to Brigham & Women’s Hospital from AstraZeneca and Pfizer; has received honoraria from the Medical Education Speakers Network and USV Private Limited; has received consulting fees from AstraZeneca, MobilityBio, Pfizer, and Youngene Therapeutics; and has served on clinical endpoint committees for studies sponsored by Beckman Coulter, Kowa Pharmaceuticals, and Tosoh Biosciences. Dr Bohula has received personal consulting fees from Novo Nordisk, Servier, and Esperion; has served on an events adjudication committee for Kowa; and has received research support from Regeneron. Drs Dahiya and Senman are the founders of www.ccc1stop.com and CCCEnthusiasts, LLC, which has received unrestricted funding support from Zoll and CardioNerds. Dr Gage has served on the Speakers Bureau (historic) and received honoraria from Abiomed; and has received educational honoraria from Zoll. Dr Higgins has received educational honoraria from Abbott. Dr Horowitz has received research funds from Inari and Penumbra. Dr Katz has served on the data safety monitoring board member for the Abiomed RECOVER IV trial; has received research support from Abbott Corporation; and has received speaker honoraria from Zoll. Dr Lee has received educational honoraria from Getinge. Dr Metkus has received consulting fees/honoraria from TelaDoc, BestDoctors, and Oakstone-EBIX; and receives textbook royalties from McGraw-Hill. Dr Solomon has received intramural research funds from the National Institutes of Health Clinical Center; and is the chair-elect of the American College of Cardiology Critical Care Cardiology member section. Dr Dudzinski is course director of 5C: Concepts in Contemporary Critical Care Cardiology, and this course has received educational grants from Abbott, Abiomed, and Zoll. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Funding Support and Author Disclosures Dr Yeh has received research support from the National Heart, Lung, and Blood Institute (R01HL164561 and K23HL148525) and the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology; has received personal fees from Biosense Webster; and has received grants and personal fees from Abbott Vascular, AstraZeneca, Boston Scientific, and Medtronic, outside of the submitted work. Dr Wadhera has received research support from the National Heart, Lung, and Blood Institute; and has served as a consultant for Abbott, CVS Health, and Chambercardio, outside of the submitted work. The other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Competing Interests: Funding Support and Author Disclosures Dr Chen was supported by National Heart, Lung, and Blood Institute grant RO1 3UG1CA189955-08S3. Dr Tamirisa has served as a speaker for Abbott and Sanofi. Dr Ogunniyi has received institutional research support grants from AstraZeneca, Boehringer Ingelheim, Cardurion Pharmaceuticals, and Pfizer, outside the submitted work. Dr Contreras has served as a speaker for Merck and Boehringer Ingelheim; served as a consulting advisor for Alnylam, AstraZeneca, and Lexicon; and has received grant support from Novo Nordisk. Dr Tong has served as a speaker for Bristol Myers Squibb. Dr Kadiyala has served as a consultant for HeartFlow Inc. Dr Tremmel has served as a consultant for Abbott Vascular, Boston Scientific, Shockwave, and Avinger; has served on the advisory board for Abbott Vascular; and has received research support from Boston Scientific. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Background: Women in cardiology experience considerable gender disparities in publications, which hinders their career advancements to higher faculty and senior leadership positions. However, the extent of these disparities across different types of cardiovascular literature is not well understood., Objectives: We investigated gender differences in authorship across various cardiovascular publications over a decade and examined geographic variations in the representation of women authors., Methods: All papers published from January 1, 2010, to December 31, 2019, in 4 major cardiovascular journals (Journal of the American College of Cardiology, European Heart Journal, Journal of the American Medical Association Cardiology, and Nature Reviews Cardiology) were reviewed., Results: Of the 18,535 papers with 111,562 authors, 20.6% of the authors were women, and 47.7% of the papers had no women authors. Over 10 years, the proportion of women authors remained low (20.7% in 2010 to 21.4% in 2019), with the lowest proportion in editorial papers (14.8%) and the highest in research papers (21.8%). More women as first (34.6%) and last (47.6%) authors were affiliated with institutions in the United States compared with other countries. The proportion of women middle-order authors was higher on papers with women as first authors (29.4% vs 20.5%) or last authors (30.6% vs 21.3%), compared with papers with men as first or last authors, respectively., Conclusions: Over the past decade, the proportion of women authors across all article types in major cardiovascular journals remained low. A call to action is needed to promote women in cardiology and provide them with equitable opportunities., Competing Interests: Funding Support and Author Disclosures Dr D.D. Wang is a consultant for Abbott, Boston Scientific, Edwards Lifesciences, Materialise, and NeoChord; and has received research grant support from Boston Scientific assigned to her employer, Henry Ford Hospital. Dr T.Y. Wang has received research grants to the Duke Clinical Research Institute from Abbott, AstraZeneca, Bristol Myers Squibb, Boston Scientific, Artivion (formerly Cryolife), Chiesi, Merck, Portola, and Regeneron; and has received consulting honoraria from AstraZeneca, Bristol Myers Squibb, Artivion (formerly Cryolife), CSL Behring, and Novartis. Dr R. Mehran has received grants from Abbott Laboratories, AstraZeneca, Bayer, Beth Israel Deaconess, Bristol Myers Squibb, CSL Behring, DSI, Medtronic, Novartis Pharmaceuticals, and OrbusNeich; has received personal fees from Abbott Laboratories, Boston Scientific, Medscape/WebMD, Siemens Medical Solutions, PLx Opco (dba PLx Pharma), Roivant Sciences, Sanofi, Medtelligence, and Janssen Scientific Affairs; has received other compensation from Abbott Laboratories, Abiomed, Bristol Myers Squibb, Claret Medical, Elixir Medical, The Medicines Company, Spectranetics/Philips/Volcano Corp, and Watermark Research Partners; and has received nonfinancial support from Regeneron Pharmaceuticals and Idorsia Pharmaceuticals. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Funding Support and Author Disclosures Dr Devries is the salaried executive director of the Gaples Institute, an educational nonprofit that offers accredited continuing medical education courses for sale to health professionals (courses are developed entirely through philanthropy to the Gaples Institute, a nonprofit that does not seek or receive corporate support; Dr Devries does not receive royalties or personal consideration of any kind from the sale of these courses). The other author has reported that he has no relationships relevant to the contents of this paper to disclose.

Background: The American College of Cardiology (ACC) recently published an Expert Consensus Decision Pathway for chest pain., Objectives: The purpose of this study was to validate the ACC Pathway in a multisite U.S., Methods: An observational cohort study of adults with possible acute coronary syndrome was conducted. Patients were accrued from 5 U.S. Emergency Departments (November 1, 2020, to July 31, 2022). ECGs and 0- and 2-hour high-sensitivity troponin (Beckman Coulter) measures were used to stratify patients according to the ACC Pathway. The primary safety outcome was 30-day all-cause death or myocardial infarction (MI). Efficacy was defined as the proportion stratified to the rule-out zone. Negative predictive value for 30-day death or MI was assessed among the whole cohort and in a subgroup of patients with coronary artery disease (CAD) (prior MI, revascularization, or ≥70% coronary stenosis)., Results: ACC Pathway assessments were complete in 14,395 patients, of whom 51.7% (7,437 of 14,395) were women with a median age of 56 years (Q1-Q3: 44-68 years). Known CAD was present in 23.5% (3,386 of 14,395) and 30-day death or MI occurred in 8.1% (1,168 of 14,395). The ACC Pathway had an efficacy of 48.1% (95% CI: 47.3%-49.0%). Among patients in the rule-out zone, 0.3% (22 of 6,930) had death or MI at 30 days, yielding a negative predictive value of 99.7% (95% CI: 99.5%-99.8%). In patients with known CAD, 20.0% (676 of 3,386) were classified to the rule-out zone, of whom 1.5% (10 of 676) had death or MI., Conclusions: The ACC expert consensus decision pathway was safe and efficacious. However, it may not be safe for use among patients with known CAD., Competing Interests: Funding Support and Author Disclosures This study was funded internally by Wake Forest University Health Systems. The Wake Forest Clinical and Translational Science Institute, supported by the National Center for Advancing Translational Sciences (NCATS), National Institutes of Health, through UL1TR001420. Dr Mahler has received funding/support from Roche Diagnostics, Abbott Laboratories, QuidelOrtho Clinical Diagnostics, Siemens, Grifols, Pathfast, Genetesis, Cytovale, Beckman Coulter, Brainbox, AHRQ (R01HS029017 and R21HS029234), The Duke Endowment, National Foundation of Emergency Medicine, and HRSA (1H2ARH399760100); is a consultant for Roche, Abbott, Siemens, QuidelOrtho, Genetesis, Inflammatix, and Radiometer; and is the Chief Medical Officer for Impathiq Inc. Dr Ashburn has received funding from AHRQ (R01HS029017). Dr Supples has received funding from the National Institutes of Health (UL1TR001420), HRSA (1H2ARH399760100), and the National Foundation of Emergency Medicine. Dr Snavely has received funding from Abbott Laboratories, AHRQ (R01HS029017), and HRSA (1H2ARH399760100). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Each week, I record audio summaries for every paper in JACC, as well as an issue summary. This process has become a true labor of love due to the time they require, but I am motivated by the sheer number of listeners (16M+), and it has allowed me to familiarize myself with every paper that we publish. Thus, I have selected the top 100 papers (Original Investigations, Review Articles, Society Documents, and the Global Burden of Diseases) from distinct specialties each year. In addition to my personal choices, I have included papers that have been the most accessed or downloaded on our websites, as well as those selected by the JACC Editorial Board members. In order to present the full breadth of this important research in a consumable fashion, we will present these abstracts in this issue of JACC, as well as their Central Illustrations∗ and podcasts. The highlights comprise the following sections: Aorta; Basic and Translational Science; Cardiac Failure, Myocarditis, and Pericarditis; Cardiomyopathies and Genetics; Congenital Heart Disease; Coronary, Peripheral, and Structural Interventions; Coronavirus; Health Promotion and Preventive Cardiology; Imaging; Metabolic and Lipid Disorders; Neurovascular Disease and Dementia; Rhythm Disorders and Thromboembolism; and Valvular Heart Disease. 1-104 ∗ To view the full manuscript, including the full-sized Central Illustration, please refer to the original publication in JACC., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Sports participation in patients with congenital heart disease is an evolving subject. The American Heart Association/American College of Cardiology released a set of guidelines that advise the type and level of sports participation based primarily on anatomical defects with secondary consideration given to hemodynamic effects. Recently, the European Association of Preventive Cardiology/European Society of Cardiology/Association for European Paediatric and Congenital Cardiology offered a contrasting approach to sports participation that is based on hemodynamic and electrophysiological profiles of each patient, regardless of anatomical consideration. These guidelines are drastically different in their approaches but do have some similarities. In this review, we compare both documents, focusing on the aim, population, classification of sports, and the methodology of making recommendations. This review aims to assist practicing cardiologists in integrating the available published data and recommendations when counseling patients for sports participation., Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Over the last several decades, the cardiac intensive care unit (CICU) has seen a substantial evolution in the patient population, comorbidities, and diagnoses. However, the generation of high-quality evidence to manage these complex and critically ill patients has been slow. Given the scarcity of clinical trials focused on critical care cardiology (CCC), CICU clinicians are often left to extrapolate from studies that either exclude or poorly represent the patient population admitted to CICUs. The lack of high-quality evidence and limited guidance from society guidelines has led to significant variation in practice patterns for many of the most common CICU diagnoses. Several barriers, both common to critical care research and unique to CCC, have impeded progress. In this multinational perspective, we describe key areas of priority for CCC research, current challenges for investigation in the CICU, and essential elements of a path forward for the field., Competing Interests: Funding Support and Author Disclosures Drs Bohula and Morrow are members of the TIMI Study Group, which has received institutional research grant support through Brigham and Women’s Hospital from Abbott Laboratories, Abiomed, Amgen, Anthos Therapeutics, Arca Biopharma, AstraZeneca, Daiichi-Sankyo, Intarcia, Janssen, Merck, Novartis, Pfizer, Poxel, Quark Pharmaceuticals, Regeneron, Roche, Siemens, and Zora Biosciences. Dr Pöss receives institutional research fees from the German Cardiac Society, German Heart Research Foundation, Dr Rolf M. Schwiete Foundation and Getinge. Dr Solomon receives research support from the National Institutes of Health Clinical Center intramural research funds. Dr Kristensen is National Coordinator of the SOS-AMI study (Idorsia departmental grant). Dr Morrow has received consulting fees from Abbott Laboratories, Arca Biopharma, InCarda, Inflammatix, Merck, Novartis, and Roche Diagnostics. Dr Krychtiuk has received speaker fees from Zoll Medical, Sanofi, and Daiichi-Sankyo. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. All rights reserved.)

Valvular heart disease (VHD) is common and poses important challenges from the standpoints of diagnosis and therapeutic management. Clinical practice guidelines have been developed to help health care professionals to overcome these challenges and provide optimal management to patients with VHD. The American College of Cardiology, in collaboration with the American Heart Association, and the European Society of Cardiology, in collaboration with the European Association for Cardio-Thoracic Surgery, recently updated their guidelines on the management of VHD. Although these 2 sets of guidelines are generally concordant, there are some substantial differences between these guidelines, which may have significant implications for clinical practice. This review prepared on behalf of the EuroValve Consortium describes the consistencies and discrepancies between the guidelines and highlights the gaps in these guidelines and the future research perspectives to fill these gaps., Competing Interests: Funding Support and Author Disclosures Dr Garbi was The NICE Topic Adviser for the NICE Guidelines on heart valve disease presenting in adults: investigation and management. Dr Dahl has received speaker fees from Edwards. Dr Barbanti has served as a consultant for Edwards Lifesciences, Medtronic, and Boston Scientific. Dr Vannan has received research grants and a speaker honorarium (to Piedmont Heart Institute, not to self) from Abbott, Medtronic, and Edwards Lifesciences. Dr Vassiliou served as an advisor for the NICE Guidelines on valvular heart disease (NG208) referred to in this paper; and has received grants for investigator-initiated research by Medtronic and B Braun Ltd. Dr de Paulis has received royalties from Edwards for a mitral ring; and has received speaker fees from Edwards and Medtronic. Dr Pibarot has received institutional research grants from Edwards Lifesciences, Medtronic, Pi-Cardia, Cardiac Success, and Roche Diagnostics. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: The 2022 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Failure Society of America (HFSA) clinical practice guideline proposed an updated definition for heart failure (HF) stages., Objectives: This study aimed to compare prevalence and prognosis of HF stages according to classification/definition originally described in 2013 and 2022 ACC/AHA/HFSA definitions., Methods: Study participants from 3 longitudinal cohorts (the MESA [Multi-Ethnic Study of Atherosclerosis], CHS [Cardiovascular Health Study], and the FHS [Framingham Heart Study]), were categorized into 4 HF stages according to the 2013 and 2022 criteria. Cox proportional hazards regression was used to assess predictors of progression to symptomatic HF and adverse clinical outcomes associated with each HF stage., Results: Among 11,618 study participants, according to the 2022 staging, 1,943 (16.7%) were healthy, 4,348 (37.4%) were in stage A (at risk), 5,019 (43.2%) were in stage B (pre-HF), and 308 (2.7%) were in stage C/D (symptomatic HF). Compared to the classification/definition originally described in 2013, the 2022 ACC/AHA/HFSA approach resulted in a higher proportion of individuals with stage B HF (increase from 15.9% to 43.2%); this shift disproportionately involved women as well as Hispanic and Black individuals. Despite the 2022 criteria designating a greater proportion of individuals as stage B, the relative risk of progression to symptomatic HF remained similar (HR: 10.61; 95% CI: 9.00-12.51; P < 0.001)., Conclusions: New standards for HF staging resulted in a substantial shift of community-based individuals from stage A to stage B. Those with stage B HF in the new system were at high risk for progression to symptomatic HF., Competing Interests: Funding Support and Author Disclosures This work was partially supported by the National Heart, Lung, and Blood Institute (NHLBI) (Framingham Heart Study: contract N01-HC25195 and HHSN268201500001I; Cardiovascular Health Study: contracts HHSN268201200036C, HHSN268200800007C, N01HC55222, N01HC85079, N01HC85080, N01HC85081, N01HC85082, N01HC85083, N01HC85086, 75N92021D00006, and U01HL130114 and grant U01HL080295, Multi-Ethnic Study of Atherosclerosis: contracts HHSN268201500003I, N01-HC-95159, N01-HC-95160, N01-HC-95161, N01-HC-95162, N01-HC-95163, N01-HC-95164, N01-HC-95165, N01-HC-95166, N01-HC-95167, N01-HC-95168, N01-HC-95169, UL1-TR-000040, UL1-TR-001079, UL1-TR-001420, UL1-TR-001881, and DK063491). Funding support for the Multi-Ethnic Study of Atherosclerosis Renal Function data set was provided by grant DK083538-01. The Cardiovascular Health Study received additional contributions from the National Institute of Neurological Disorders and Stroke and grant R01AG023629 from the National Institute on Aging. A full list of principal Cardiovascular Health Study investigators and institutions can be found at https://chs-nhlbi.org/. A full list of participating Multi-Ethnic Study of Atherosclerosis investigators and institutions can be found at https://www.mesa-nhlbi.org. Dr Mohebi has received grants from the Barry Fellowship. Dr Lau has received grants from the NIH (K23-HL159243) and the American Heart Association 18SFRN34110082. Dr Psaty has served on the Steering Committee of the Yale Open Data Access Project funded by Johnson & Johnson. Dr Benjamin has received grants from R01HL092577, 2U54HL120163, and the Sheila Balson Endowed Cardiac Scholarship. Dr Januzzi has received grants from the Hutter Family Professorship, Abbott Diagnostics, Applied Therapeutics, HeartFlow, Innolife, and Roche Diagnostics; has been a Trustee of the American College of Cardiology; has been a board member of Imbria Pharmaceuticals; has been a Director at Jana Care; has received consulting income from Abbott Diagnostics, Boehringer Ingelheim, Janssen, Novartis, Prevencio, Roche Diagnostics; and has participated in clinical endpoint committees/data safety monitoring boards for AbbVie, Siemens, Takeda, and Vifor. Dr Ho has received grants from the NIH (R01 HL134893, R01 HL140224, R01 HL160003, and K24 HL153669) and Bayer, AG. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. All rights reserved.)

Background: Migraine with aura (MA) is associated with cardiovascular disease (CVD) independently from traditional vascular risk factors. However, the importance of MA on CVD occurrence relative to existing cardiovascular prediction tools remains unclear., Objectives: In this study, we sought to determine if adding MA status to 2 CVD risk prediction models improves risk prediction., Methods: Participants enrolled in the Women's Health Study self-reported MA status and were followed for incident CVD events. We included MA status as a covariable in the Reynolds Risk Score and the American Heart Association (AHA)/American College of Cardiology (ACC) pooled cohort equation and assessed discrimination (Harrell c-index), continuous and categorical net reclassification improvement (NRI), and integrated discrimination improvement (IDI)., Results: MA status was significantly associated with CVD after including covariables in the Reynolds Risk Score (HR: 2.09; 95% CI: 1.54-2.84) and the AHA/ACC score (HR: 2.10; 95% CI: 1.55-2.85). Adding information on MA status improved discrimination of the Reynolds Risk Score model (from 0.792 to 0.797; P = 0.02) and the AHA/ACC score model (from 0.793 to 0.798; P = 0.01). We observed a small but statistically significant improvement in the IDI and continuous NRI after adding MA status to both models. We did not, however, observe significant improvements in the categorical NRI., Conclusions: Adding information on MA status to commonly used CVD risk prediction algorithms enhanced model fit but did not substantially improve risk stratification among women. Despite the strong association of migraine with CVD risk, the relatively low prevalence of MA compared with other CV risk factors limits its usefulness in improving risk classification at the population level., Competing Interests: Funding Support and Author Disclosures The Women’s Health Study is funded by grants from the National Cancer Institute (CA047988 and UM1 CA182913) and the National Heart, Lung, and Blood Institute (HL043851, HL080467, and HL099355). Dr Rist was supported by a Career Development Award from the National Heart, Lung, and Blood Institute (K01 HL128791). This project was supported by a grant from the American Headache Society. Dr Rist received support from the American Headache Society for this work. Dr Kurth has received research grants from the Gemeinsamer Bundesausschuss (Federal Joint Committee, Germany) and the Bundesministerium für Gesundheit (Federal Ministry of Health, Germany); and has received personal compensation from Eli Lilly & Company, Teva Pharmaceuticals, TotalEnergies, BMJ, and Frontiers. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Studies have shown that diverse care teams optimize patient outcomes. Describing the current representation of women and minorities has been a critical step in improving diversity across several fields., Objectives: To address the lack of data specific to pediatric cardiology, the authors conducted a national survey., Methods: U.S. academic pediatric cardiology programs with fellowship training programs were surveyed. Division directors were invited (July 2021 to September 2021) to complete an e-survey of program composition. Underrepresented minorities in medicine (URMM) were characterized using standard definitions. Descriptive analyses at the hospital, faculty, and fellow level were performed., Results: Altogether, 52 of 61 programs (85%) completed the survey, representing 1,570 total faculty and 438 fellows, with a wide range in program size (7-109 faculty, 1-32 fellows). Although women comprise approximately 60% of faculty in pediatrics overall, they made up 55% of fellows and 45% of faculty in pediatric cardiology. Representation of women in leadership roles was notably less, including 39% of clinical subspecialty directors, 25% of endowed chairs, and 16% of division directors. URMM comprise approximately 35% of the U.S. population; however, they made up only 14% of pediatric cardiology fellows and 10% of faculty, with very few in leadership roles., Conclusions: These national data suggest a "leaky pipeline" for women in pediatric cardiology and very limited presence of URRM overall. Our findings can inform efforts to elucidate underlying mechanisms for persistent disparity and reduce barriers to improving diversity in the field., Competing Interests: Funding Support and Author Disclosures This work was supported by University of Michigan ADVANCE program. The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Mental illness among physicians is an increasingly recognized concern. Global data on mental health conditions (MHCs) among cardiologists are limited., Objectives: The purpose of this study was to investigate the global prevalence of MHCs among cardiologists and its relationships to professional life., Methods: The American College of Cardiology conducted an online survey with 5,931 cardiologists globally in 2019. Data on demographics, practice, MHC, and association with professional activities were analyzed. The P values were calculated using the chi-square, Fischer exact, and Mann-Whitney U tests. Univariate and multivariate logistic regression analysis determined the association of characteristics with MHC., Results: Globally, 1 in 4 cardiologists experience any self-reported MHC, including psychological distress, or major or other psychiatric disorder. There is significant geographic variation in MHCs, with highest and lowest prevalences in South America (39.3%) and Asia (20.1%) (P < 0.001). Predictors of MHCs included experiencing emotional harassment (OR: 2.81; 95% CI: 2.46-3.20), discrimination (OR: 1.85; 95% CI: 1.61-2.12), being divorced (OR: 1.85; 95% CI: 1.27-2.36), and age <55 years (OR: 1.43; 95% CI: 1.24-1.66). Women were more likely to consider suicide within the past 12 months (3.8% vs 2.3%), but were also more likely to seek help (42.3% vs 31.1%) as compared with men (all P < 0.001). Nearly one-half of cardiologists reporting MHCs (44%) felt dissatisfied on at least one professional metric including feeling valued, treated fairly, and adequate compensation., Conclusions: More than 1 in 4 cardiologists experience self-reported MHCs globally, and the association with adverse experiences in professional life is substantial. Dedicated efforts toward prevention and treatment are needed to maximize the contributions of affected cardiologists., Competing Interests: Funding Support and Author Disclosures Dr Sharma is supported by the Blumenthal Scholarship in Preventive Cardiology at the Ciccarone Center for the Prevention of Cardiovascular Disease and AHA HRSN. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Together, heart failure and arrhythmia represent the most important cardiovascular sources of morbidity and mortality among adults with congenital heart disease (ACHDs). Although traditionally conceptualized as operating within 2 distinct clinical silos, these scenarios frequently coexist within the same individual; consequently the mechanistic, therapeutic, and prognostic overlap between them demands increased recognition. In fact, given the near ubiquity of heart failure and arrhythmia among ACHDs, there is perhaps no other arena within cardiology where this critical intersection is more frequently observed. Optimal care for ACHDs therefore requires a heightened awareness of the relevant interactions as well as the pharmacologic and interventional resources that are increasingly available to the treating cardiologist. This review explores and highlights the overlap between these 2 fields to recommend a parallel, yet interactive, multidisciplinary approach to clinical management. Congenital heart disease categories are broken down into their archetypal subtypes to highlight subtleties of the pathophysiology, evaluation, and therapeutic approach., Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Published by Elsevier Inc.)

Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

The burden of vascular diseases and complexity of their management have been growing. Vascular medicine specialists may help to bridge gaps in care, especially as part of multidisciplinary teams. However, there is a limited number of vascular medicine specialists because of constraints in training. Despite established pathways for training in vascular medicine, there are obstacles that restrict completion of training in dedicated programs. A key factor is lack of funding as a result of inadequate recognition by key national accrediting and credentialing organizations. A concerted effort is required to overcome the obstacles to expand vascular medicine training programs and ultimately the pool of vascular medicine specialists. Well-trained vascular medicine specialists will be well positioned to ease the burden of vascular disease and optimize patient outcomes., Competing Interests: Funding Support and Author Disclosures Dr Garcia has received research support from Abbott, Boston Scientific, and Medtronic; has served as a consultant for Phillips, Abbott, Boston Scientific, and Medtronic; has equity in Primacea, Syntervention, Tissue Gen, Orchestra, and Cagent R3 Medical; and is founder of Innovation Vascular Partners Consulting, LLC. Dr Mena-Hurtado has served as a consultant for Abbott, Cardinal Health, Cook, Medtronic, and Optum labs. Dr Rogers has received research grant support from Phillips; and is on adjudication committees for trials sponsored by Bayer and ARCA Biopharma. Dr Sethi has received research grant support from the American Heart Association; and has received honoraria or consulting fees from Boston Scientific, Chiesi, Inari, and Janssen. Dr Piazza has received research grant support from Boston Scientific Corporation, Bayer, the Bristol Myers Squibb/Pfizer Alliance, Alexion, Amgen, and Janssen; and has received consulting fees from Amgen, Pfizer, Boston Scientific Corporation, Agile, Syntactx, and Prairie Education and Research Cooperative. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. All rights reserved.)

The National Cardiovascular Data Registry is a group of registries maintained by the American College of Cardiology Foundation. These registries are used by a diverse constituency to improve the quality and outcomes of cardiovascular care, to assess the safety and effectiveness of new therapies, and for research. To achieve these goals, registry data must be complete and reliable. In this article, we review the process of National Cardiovascular Data Registry data collection, assess data completeness and integrity, and report on the current state of the data. Registry data are complete. Accuracy is very good but variable, and there is room for improvement. Knowledge of the quality of data is essential to ensuring its appropriate use., Competing Interests: Funding Support and Author Disclosures Dr Malenka has served as chair of the National Cardiovascular Data Registry (NCDR) Data Quality Subcommittee of the NCDR Science and Quality Oversight Committee; and has served as a consultant for Anthem. Dr Bhatt has served on the Advisory Board of Cardax, CellProthera, Cereno Scientific, Elsevier Practice Update Cardiology, Level Ex, Medscape Cardiology, MyoKardia, PhaseBio, PLx Pharma, and Regado Biosciences; has served on the Board of Directors of Boston Veterans Affairs Research Institute, Society of Cardiovascular Patient Care, and TobeSoft; has served as chair of the American Heart Association Quality Oversight Committee; has served on the Data Monitoring Committee of Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for the PORTICO trial, funded by St. Jude Medical, now Abbott), Cleveland Clinic (including for the ExCEED trial, funded by Edwards), Contego Medical (chair, PERFORMANCE 2), Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine (for the ENVISAGE trial, funded by Daiichi-Sankyo), and Population Health Research Institute; has received honoraria from the American College of Cardiology (senior associate editor, Clinical Trials and News,” vice chair, ACC Accreditation Committee), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE-DUAL PCI clinical trial steering committee, funded by Boehringer Ingelheim; AEGIS-II executive committee, funded by CSL Behring), Belvoir Publications (Editor-in-Chief, Harvard Heart Letter), Canadian Medical and Surgical Knowledge Translation Research Group (clinical trial steering committees), Duke Clinical Research Institute (clinical trial steering committees, including for the PRONOUNCE trial, funded by Ferring Pharmaceuticals), HMP Global (editor-in-chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (guest editor, associate editor), K2P (cochair, interdisciplinary curriculum), Level Ex, Medtelligence/ReachMD (continuing medical education steering committees), MJH Life Sciences, Population Health Research Institute (for the COMPASS operations committee, publications committee, steering committee, and USA national coleader, funded by Bayer), Slack Publications (chief medical editor, Cardiology Today’s Intervention), Society of Cardiovascular Patient Care (secretary/treasurer), WebMD (continuing medical education steering committees); has served as deputy editor for Clinical Cardiology, chair of the NCDR-ACTION Registry Steering Committee, and chair of the VA CART Research and Publications Committee; has received research funding from Abbott, Afimmune, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Cardax, Chiesi, CSL Behring, Eisai, Ethicon, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, Idorsia, Ironwood, Ischemix, Lexicon, Lilly, Medtronic, MyoKardia, Pfizer, PhaseBio, PLx Pharma, Regeneron, Roche, Sanofi, Synaptic, and The Medicines Company; has received royalties from Elsevier (editor, Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease); has served as site coinvestigator for Biotronik, Boston Scientific, CSI, St. Jude Medical (now Abbott), and Svelte; has served as trustee for the American College of Cardiology; and has conducted unfunded research for FlowCo, Merck, Novo Nordisk, and Takeda. Dr Abbott has received grant/research/clinical trial support from AstraZeneca (coronary artery disease), Bristol Myers Squibb (atrial fibrillation), Abbott (percutaneous coronary intervention), Biosensors Research USA (percutaneous coronary intervention), CSL Behring, LLC (hyperlipidemia), Sinomed (percutaneous coronary intervention); and has served as a consultant/on the Advisory Board for Recor (renal denervation), Philips (artificial intelligence, fellowship education), and Boston Scientific (coronary physiology). Dr Curtis receives salary support under contract with the National Cardiovascular Data Registry to provide analytic services; receives salary support from the Centers for Medicare and Medicaid Services to develop and maintain performance measures that are used for public reporting; has a contract with the American College of Cardiology for his role as senior medical officer, National Cardiovascular Data Registry; and holds equity interest in Medtronic. Dr Roe has received stock options from Verana Health (since February, 2020); has received research grant funding from Sanofi, AstraZeneca, Patient Centered Outcomes Research Institute, Ferring Pharmaceuticals, MyoKardia, Familial Hypercholesterolemia Foundation, and Bayer; has received personal fees and honoraria from AstraZeneca (consulting), Amgen (consulting), Cytokinetics (consulting), Eli Lilly (consulting, service on a clinical endpoint adjudication committee), Roche-Genentech (service on a data safety monitoring committee), Janssen Pharmaceuticals (consulting), Regeneron (consulting, service on a data safety monitoring committee), Novo Nordisk (service on a clinical endpoint adjudication committee), Pfizer (consulting), Sanofi (service on a clinical endpoint adjudication committee), Signal Path (consulting), and Elsevier Publishers (service as an associate editor for the American Heart Journal). Dr Masoudi has a contract with the American College of Cardiology for his role as chief scientific advisor, National Cardiovascular Data Registry. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

This review compares the primary prevention recommendations of the recent 2021 European Society of Cardiology (ESC) and 2019 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines on cardiovascular disease (CVD) prevention. Although the 2019 ACC/AHA guideline represents its inaugural version, the ESC guideline is an update to its 2016 statement. Both guidelines address prevention using a holistic approach and agree on the importance of lifestyle optimization and intensified risk factor management. Cardiovascular (CV) risk assessment tools differ, reflecting the unique populations being screened as well as philosophical differences to their approach. Conventional risk factors are used to estimate CV risk, but each guideline acknowledges the role of risk modifiers to refine risk calculation. The ESC guideline recognizes the importance of nonclassical risk factors, including environmental issues, that impact CV health at the population level and calls for legislative action at the local, regional, and national levels., Competing Interests: Funding Support and Author Disclosures Dr Yang has received grant support from Amgen; has ownership in Clocktree; and has been a consultant to Genentech. Dr Gianos has received grant support from AstraZeneca; and has been a consultant to Med-IQ. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Funding Support and Author Disclosures Dr Barnett is the co-chair of the ABIM critical care medicine exam committee. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Obesity is a significant risk factor for arrhythmic cardiovascular death. Interactions between epicardial adipose tissue (EAT) and myocytes are thought to play a key role in the development of arrhythmias. In this review, the authors investigate the influence of EAT on arrhythmogenesis. First, they summarize electrocardiographic evidence showing the association between increased EAT volume and atrial and ventricular conduction delay. Second, they detail the structural cross talk between EAT and the heart and its arrhythmogenicity. Adipose tissue infiltration within the myocardium constitutes an anatomical obstacle to cardiac excitation. It causes activation delay and increases the risk of arrhythmias. Intercellular electrical coupling between cardiomyocytes and EAT can further slow conduction and increase the risk of block, favoring re-entry and arrhythmias. Finally, EAT secretes multiple substances that influence cardiomyocyte electrophysiology either by modulating ion currents and electrical coupling or by stimulating fibrosis. Thus, structural and paracrine cross talk between EAT and cardiomyocytes facilitates arrhythmias., Competing Interests: Funding Support and Author Disclosures Dr Ernault was supported by Fondation pour la Recherche Médicale (FRM; PBR201810007613). Dr Meijborg was supported by Leducq Foundation grant (RHYTHM): 16CVD02. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Funding Support and Author Disclosures This work was self-funded by the American College of Cardiology. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Objectives: The third annual Cardiovascular Diseases (CV) Fellowship Program Directors (PDs) Survey sought to understand burnout and well-being among CV fellowship PDs., Background: Physician burnout is a common phenomenon. Data on burnout among cardiologists, specifically CV PDs, remain limited., Methods: The survey contained 8 questions examining satisfaction, stress, and burnout among CV fellowship PDs. Burnout was defined based on the self-reported presence of ≥1 symptom of burnout, constant feelings of burnout, or complete burnout., Results: Survey response rate was 57%. Most respondents were men (78%) and 54% represented university-based programs. Eighty percent reported satisfaction with their current job as PD, and 96% identified interactions with fellows as a driver of their satisfaction. Forty-five percent reported feeling a great deal of stress from their job. Stress was higher among women PDs, early-career PDs, and PDs of larger and university-based programs. Twenty-one percent reported some symptoms of burnout, and only 36% reported enjoyment without stress or burnout. Rates of enjoyment without stress or burnout were higher among men and late-career PDs, PDs of smaller programs, and PDs of community-based programs. Seventeen percent of PDs reported a high likelihood of resigning in the next year, of which the most common reason was the tasks of PDs were becoming overwhelming., Conclusions: Most CV fellowship PDs are satisfied with their position, but stress and burnout remain common. Women PDs, early-career PDs, and PDs of larger, university-based programs demonstrate more adverse markers of well-being. Opportunities exist to support CV fellowship PDs in their critical role., Competing Interests: Funding Support and Author Disclosures Mr. Theriot is a paid employee of the American College of Cardiology. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Background: Despite the increase in the number of female physicians across most specialties within cardiology, <10% of clinical cardiac electrophysiology (EP) fellows are women., Objectives: This study sought to determine the factors that influence fellows-in-training (FITs) to pursue EP as a career choice and whether this differs by gender., Methods: The authors conducted an online multiple-choice survey through the American College of Cardiology to assess the decision factors that influence FITs in the United States and Canada to pursue cardiovascular subspecialties., Results: A total of 933 (30.5%) FITs completed the survey; 129 anticipated specializing in EP, 259 in interventional cardiology (IC), and 545 in a different field or were unsure. A total of 1 in 7 (14%) FITs indicated an interest in EP. Of this group, more men chose EP than women (84% vs 16%; P < 0.001). The most important factor that influenced FITs to pursue EP was a strong interest in the field. Women were more likely to be influenced by having a female role model (P = 0.001) compared with men. After excluding FITs interested in IC, women who deselected EP were more likely than men to be influenced by greater interest in another field (P = 0.004), radiation concerns (P = 0.001), lack of female role models (P = 0.001), a perceived "old boys' club" culture (P = 0.001) and discrimination/harassment concerns (P = 0.001)., Conclusions: Women are more likely than men to be negatively influenced by many factors when it comes to pursuing EP as a career choice. Addressing those factors will help decrease the gender disparity in the field., Competing Interests: Funding Support and Author Disclosures Dr Abdulsalam was a second- and third-year fellow-in-training (FIT) in the Cardiovascular Fellowship Program at the University of Nebraska Medical Center in Omaha, Nebraska, during this study; she is currently a first-year FIT in the Cardiac Clinical Electrophysiology Fellowship Program at the University of Washington in Seattle, Washington. Dr Killic was an FIT in the Interventional Cardiology Program at Brown University during this study; she is currently on the faculty at the University of Oregon Health and Science Center in Portland, Oregon. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)