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BACKGROUND: Noninvasive cardiac testing (NICT) has been associated with decreased long-term risks of major adverse cardiac events (MACEs) among emergency department patients at high coronary risk. It is unclear whether this association extends to patients without evidence of myocardial injury on initial ECG and cardiac troponin testing. METHODS: A retrospective cohort study was conducted of patients presenting with chest pain between 2013 and 2019 to 21 emergency departments within an integrated health care system in Northern California, excluding patients with ST-segment-- elevation myocardial infarction or myocardial injury by serum troponin testing. To account for confounding by indication, we grouped patient encounters by the NICT referral rate of the initially assigned emergency physician relative to local peers within discrete time periods. The primary outcome was MACE within 2 years. Secondary outcomes were coronary revascularization and MACE, inclusive of all-cause mortality. Associations between the NICT referral group (low, intermediate, or high) and outcomes were assessed using risk-adjusted proportional hazards methods with censoring for competing events. RESULTS: Among 144 577 eligible patient encounters, the median age was 58 years (interquartile range, 48--68) and 57% were female. Thirty-day NICT referral was 13.0%, 19.9%, and 27.8% in low, intermediate, and high NICT referral groups, respectively, with a good balance of baseline covariates between groups. Compared with the low NICT referral group, there was no significant decrease in the adjusted hazard ratio of MACE within the intermediate (adjusted hazard ratio, 1.08 [95% CI, 1.02--1.14]) or high (adjusted hazard ratio, 1.05 [95% CI, 0.99--1.11]) NICT referral groups. Results were similar for MACE, inclusive of all-cause mortality, and coronary revascularization, as well as subgroup analyses stratified by estimated risk (history, electrocardiogram, age, risk factors, troponin [HEART] score: percent classified as low risk, 48.2%; moderate risk, 49.2%; and high risk, 2.7%). CONCLUSIONS: Increases in NICT referrals were not associated with changes in the hazard of MACE within 2 years following emergency department visits for chest pain without evidence of acute myocardial injury. These findings further highlight the need for evidence-based guidance regarding the appropriate use of NICT in this population. [ABSTRACT FROM AUTHOR]

[Figure: see text]. [ABSTRACT FROM AUTHOR]

Recent evidence links long-term (visit-to-visit) blood pressure (BP) variability to the risk of cardiovascular disease, independent of mean BP levels. Potential associations between long-term BP variability and cardiovascular disease risk may be reflected in early life course alterations in coronary artery calcium (CAC) and carotid intima-media thickness. We evaluated 2482 CARDIA study (Coronary Artery Risk Development in Young Adults) participants (mean [SD] age at the year 20 exam [2005-2006] was 45.4 [3.6] years, 43.2% men, and 41.3% black). We included participants with BP assessments across 20-years (year 0, 2, 5, 7, 10, 15, 20 exams) and carotid intima-media thickness and CAC data at the year 20 exam. BP variability was assessed using variability independent of the mean and SD. Adjusted multivariable linear or logistic regression models (as appropriate) were used to assess associations between long-term BP variability measures and carotid intima-media thickness. and CAC (ln [CAC+1] and prevalent CAC). Long-term systolic BP variability independent of the mean (per 1 SD) was positively associated with carotid intima-media thickness (β=10 μm, SE=3, P=0.002). Similarly, long-term diastolic BP variability independent of the mean was associated with carotid intima-media thickness (β=10 μm, SE (3), P=0.001). Long-term BP variability was not associated with either ln [CAC+1] or prevalent CAC. Long-term systolic and diastolic BP variability across early adulthood was positively associated with modest adverse midlife alterations in carotid intima-media thickness but not to CAC. Our findings provide further insights into pathophysiologic mechanisms that link long-term BP variability to cardiovascular disease. [ABSTRACT FROM AUTHOR]

Background: The American Heart Association's 2020 Strategic Goals emphasize the value of optimizing risk factor status to reduce the burden of morbidity and mortality. In this study, we aimed to quantify the overall and marginal impact of favorable cardiovascular risk factor (CRF) profile on healthcare expenditure and resource utilization in the United States among those with and without cardiovascular disease (CVD).Methods and Results: The study population was derived from the 2012 Medical Expenditure Panel Survey (MEPS). Direct and indirect costs were calculated for all-cause healthcare resource utilization. Variables of interest included CVD diagnoses (coronary artery disease, stroke, peripheral artery disease, dysrhythmias, or heart failure), ascertained by International Classification of Diseases, Ninth Edition, Clinical Modification codes, and CRF profile (hypertension, diabetes mellitus, hypercholesterolemia, smoking, physical activity, and obesity). Two-part econometric models were used to study expenditure data. The final study sample consisted of 15 651 MEPS participants (58.5±12 years, 54% female). Overall, 5921 (37.8%) had optimal, 7002 (44.7%) had average, and 2728 (17.4%) had poor CRF profile, translating to 54.2, 64.1, and 24.9 million adults in United States, respectively. Significantly lower health expenditures were noted with favorable CRF profile across CVD status. Among study participants with established CVD, overall healthcare expenditures with optimal and average CRF profile were $5946 and $3731 less compared with those with poor CRF profile. The respective differences were $4031 and $2560 in those without CVD.Conclusions: Favorable CRF profile is associated with significantly lower medical expenditure and healthcare utilization among individuals with and without established CVD. [ABSTRACT FROM AUTHOR]

Background: We explored whether, the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) coronary and abdominal risk scores measured at 18 to 30 years of age and changes in these scores would more strongly predict coronary artery calcium (CAC) and abdominal aortic calcium (AAC) assessed 25 years later, than scores measured 25 years later.Methods and Results: In the Coronary Artery Risk Development in Young Adults (CARDIA) study, 3008 participants had measurements of risk score components at 5-year intervals beginning at 18 to 30 years of age. CAC and AAC were assessed at 43 to 55 years of age. Odds ratios (ORs) for the presence and extent of CAC/AAC per/point higher score and c-statistics for predicting CAC/AAC were calculated. The prevalence of CAC was 28% and AAC was 53%. For each 1 point higher PDAY score, the odds of CAC were higher using baseline scores than year 25 scores (OR, 1.29; 95% confidence interval [CI], 1.25-1.33 versus OR, 1.12; 95% CI, 1.11-1.14). For AAC, ORs at years 0 and 25 were similar (OR, 1.29; 95% CI, 1.24-1.34 versus OR, 1.22; 95% CI, 1.19-1.26). C-statistic for CAC prediction was higher at year 0 than year 25 (0.731 versus 0.705) but similar at years 0 and 25 for AAC (0.665 versus 0.670). ORs for CAC were highest at baseline, and, for AAC, ORs were highest at year 10. Including change in PDAY scores with baseline scores improved prediction.Conclusions: Atherosclerosis risk and change in risk assessed in young adulthood years before subclinical atherosclerosis imaging provide strong prediction of future subclinical atherosclerosis. CAC and AAC reflect chronic risk exposure in addition to risk measured at the time of study. [ABSTRACT FROM AUTHOR]

Given the higher prevalence of HFpEF noted in women, it would have been interesting to examine whether sex differences exist in the association between LV stiffness and concomitant LV hypertrophy and biomarker elevations. In addition, because the selection criteria inherently preselected for concentric LV hypertrophy, we wonder whether the findings extend to eccentric hypertrophy (since LV dilation is also related to myocardial fibrosis). However, some may argue that before assessing the role of interventions, additional data are needed to convincingly demonstrate the prognostic significance of quantified myocardial stiffness for HFpEF risk, independent of LV hypertrophy and biomarker elevations. [Extracted from the article]

Introduction: The American Heart Association (AHA) overall cardiovascular health (CVH) metric categorizes 7 targeted cardiovascular disease risk factors and health behaviors as "ideal," "intermediate," or "poor" for adults. We examined the association between these CVH categories and subsequent healthcare utilization in a large, diverse population. Methods: Kaiser Permanente Northern California (KPNC) is an integrated health care delivery system caring for >4.4 million members. We assessed 6 AHA metrics (smoking, physical activity, body mass index, blood pressure, total cholesterol, and blood glucose), each graded on a scale of 0 to 2, with 2 indicating "ideal" status, 1 "intermediate" status, and 0 "poor" status. Points were summed across health metrics to define three overall CVH categories: Poor (0-6), Intermediate (7-9) and Ideal (10-12). Individual-level health care utilization and costs (in 2015) were extracted from administrative databases for hospital, outpatient, pharmacy, emergency department (ED) and other services. We calculated average cost per patient from the total population, and then we determined costs for each service relative to the 'average cost per patient', across CVH categories and stratified by age categories. Results: Among 991,698 adult members (57.0% female) with all 6 metrics, 194,003 (19.6%) were age 18-39, 554,129 (55.9%) age 40-64, and 243,566 (24.6%) age ≥65 years. Poor CVH was present in 21.2%, intermediate CVH in 52.6% and ideal CVH in 26.2%. Overall costs increased monotonically across age categories, but better overall CVH was associated with lower relative cost in each age group (p<0.001 for trend; Figure). Conclusions: In a large real-world population, adults with ideal CVH had significantly lower total health care costs. Future research should consider pragmatic trials to test the clinical and cost-effectiveness of upstream wellness and prevention interventions to improve CVH. [ABSTRACT FROM AUTHOR]