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Background Atherosclerotic cardiovascular disease (ASCVD) is a major cause of financial toxicity, defined as excess financial strain from healthcare, in the US. Identifying factors that put patients at greatest risk can help inform more targeted and cost-effective interventions. Specific social determinants of health (SDOH) such as income are associated with a higher risk of experiencing financial toxicity from healthcare, however, the associations between more comprehensive measures of cumulative social disadvantage and financial toxicity from healthcare are poorly understood. Methods Using the National Health Interview Survey (2013–17), we assessed patients with self-reported ASCVD. We identified 34 discrete SDOH items, across 6 domains: economic stability, education, food poverty, neighborhood conditions, social context, and health systems. To capture the cumulative effect of SDOH, an aggregate score was computed as their sum, and divided into quartiles, the highest (quartile 4) containing the most unfavorable scores. Financial toxicity included presence of: difficulty paying medical bills, and/or delayed/foregone care due to cost, and/or cost-related medication non-adherence. Results Approximately 37% of study participants reported experiencing financial toxicity from healthcare, with a prevalence of 15% among those in SDOH Q1 vs 68% in SDOH Q4. In fully-adjusted regression analyses, individuals in the 2nd, 3rd and 4th quartiles of the aggregate SDOH score had 1.90 (95% CI 1.60, 2.26), 3.66 (95% CI 3.11, 4.35), and 8.18 (95% CI 6.83, 9.79) higher odds of reporting any financial toxicity from healthcare, when compared with participants in the 1st quartile. The associations were consistent in age-stratified analyses, and were also present in analyses restricted to non-economic SDOH domains and to 7 upstream SDOH features. Conclusions An unfavorable SDOH profile was strongly and independently associated with subjective financial toxicity from healthcare. This analysis provides further evidence to support policies and interventions aimed at screening for prevalent financial toxicity and for high financial toxicity risk among socially vulnerable groups.

Review the role of coronary artery calcium (CAC) testing in designing future clinical trials in primary prevention. While there are numerous new agents that have been found to lower cardiovascular event rates in clinical trials, these studies have required a large sample size, in part due to low event rates as well as improved baseline treatments. More precise risk assessment could allow for better identification of individuals who stand to derive the most benefit from various therapies. Coronary CAC testing offers a simple method for identifying high-risk primary prevention cohorts, and thus may allow for improved efficiency of clinical trials, enhanced efficacy of various therapies, and ultimately more favorable cost-effectiveness estimates. The use of CAC testing as part of the inclusion criteria used in clinical trials may result in identifying high-risk individuals who were previously not included in such studies while achieving favorable absolute risk reductions. The advantages afforded by using CAC to enrich clinical trials offer a potential road map for future clinical trials in primary prevention.

We sought to examine the role of social and environmental conditions that determine an individual’s behaviors and risk of disease—collectively known as social determinants of health (SDOH)—in shaping cardiovascular (CV) health of the population and giving rise to disparities in risk factors, outcomes, and clinical care for cardiovascular disease (CVD), the leading cause of death in the United States (US). Traditional CV risk factors have been extensively targeted in existing CVD prevention and management paradigms, often with little attention to SDOH. Limited evidence suggests an association between individual SDOH (e.g., income, education) and CVD. However, inequities in CVD care, risk factors, and outcomes have not been studied using a broad SDOH framework. We examined existing evidence of the association between SDOH—organized into 6 domains, including economic stability, education, food, neighborhood and physical environment, healthcare system, and community and social context—and CVD. Greater social adversity, defined by adverse SDOH, was linked to higher burden of CVD risk factors and poor outcomes, such as stroke, myocardial infarction (MI), coronary heart disease, heart failure, and mortality. Conversely, favorable social conditions had protective effects on CVD. Upstream SDOH interact across domains to produce cumulative downstream effects on CV health, via multiple physiologic and behavioral pathways. SDOH are major drivers of sociodemographic disparities in CVD, with a disproportionate impact on socially disadvantaged populations. Efforts to achieve health equity should take into account the structural, institutional, and environmental barriers to optimum CV health in marginalized populations. In this review, we highlight major knowledge gaps for each SDOH domain and propose a set of actionable recommendations to inform CVD care, ensure equitable distribution of healthcare resources, and reduce observed disparities.

Introduction Given prior safety experience with other 5-HT4 agonists for chronic constipation, an observational, population-based cohort study in five data sources from Germany, Sweden, and the UK was conducted to evaluate the cardiovascular safety of prucalopride. Objectives Our objective is to describe the methods and resulting comparability of cohorts in a multi-database, multinational study of prucalopride initiators and polyethylene glycol 3350 (PEG) initiators following a harmonized protocol. Methods Prucalopride initiators were matched on age, sex, and index date to PEG initiators (1:5 ratio). Study exposures, cardiovascular risk factors, and other covariates were identified from healthcare utilization codes harmonized across databases. Cardiovascular outcomes were identified using database-specific algorithms based on diagnosis codes. The propensity score (PS) in each database was estimated using logistic regression, with prucalopride versus PEG as the outcome and including clinically relevant variables associated with major adverse cardiovascular events. Results In total, 12,030 prucalopride initiators and 59,985 PEG initiators were identified. After matching and trimming, cohorts from the UK and Sweden were well-balanced for cardiovascular risk factors and cancer. However, in Germany, PEG initiators remained older and sicker than prucalopride initiators. The prevalence of these characteristics also differed from those in the UK and Sweden. The pooled analyses included only data from the UK and Sweden. Conclusions Matching, trimming, and PS stratification yielded comparable cohorts in four of five data sources. Use of these methods could not achieve balance for key covariates within the German cohort, likely due to reimbursement differences in Germany. Electronic supplementary material The online version of this article (10.1007/s40264-019-00836-z) contains supplementary material, which is available to authorized users.

PURPOSE OF REVIEW: The main purpose of this review is to summarize the epidemiology of cardiovascular disease and its risk factors among two of the largest and most diverse immigrant groups in the United States (Hispanics/Latinos and South Asians). RECENT FINDINGS: While the migration process generates unique challenges for individuals, there is a wide heterogeneity in the characteristics of immigrant populations, both between and within regions of origin. Hispanic/Latino immigrants to the United States have lower levels of cardiovascular risk factors, prevalence and mortality, but this assessment is limited by issues related to the “salmon bias”. South Asian immigrants to the United States generally have higher levels of risk factors and higher mortality. In both cases, levels of risk factors and mortality generally increase with time of living in the US. SUMMARY: While immigration acts a social determinant of health, associations between immigration and cardiovascular disease and its risk factors are complex and vary across subpopulations.

To review the most common forms of cardiovascular toxicities from anti-cancer drugs, with a focus on their prevention via cardioprotective pharmacologic or lifestyle therapy, risk factors management, screening, monitoring, and surveillance methods. There are almost 20 million cancer survivors in the USA, and their leading cause of death besides cancer recurrence or a secondary cancer is cardiovascular disease (CVD). CVD is prevalent in this population, with the most common forms being cardiomyopathy, ischemia, atrial fibrillation, and hypertension from cancer drugs or radiation therapy. The field of cardio-oncology is continuously evolving with multi-modality risk prediction strategies, moving towards precision surveillance and interventions that allow for safe continuation of life-saving chemotherapy. Preventative measures with implementation of novel drugs (including sodium-glucose cotransporter inhibitors) and modulated chemotherapy administration can aid in cardiotoxicity risk reduction. Recently, clonal hematopoiesis of indeterminate potential has been identified as a common risk factor for atherosclerotic cardiovascular disease present in > 10% of those age 70 or older. Also, risk stratification for atrial fibrillation appears pivotal. Multidisciplinary team management might have a central role in patient management and care. There is a central role for the optimization of cardiovascular disease risk for cancer patients and survivors in multidisciplinary teams, with descriptions of four forms of cardiovascular toxicities. In addition to pharmacologic cardioprotection, lifestyle modification is becoming more prominent as a preventive tool. Moreover, studies relevant to one type of toxicity should be scrutinized routinely to determine how those result may play out in the setting of other types of toxicities. All of these areas of investigation should ultimately be pursued in the setting of personalized medicine, and will likely benefit from the integration of artificial intelligence methods. Studies in genomics and transcriptomics have identified variations in the genome and gene expression profiles that associate with induction of or protection from cardiovascular toxicity and can affect cardioprotection efforts. Larger randomized clinical trials will be needed for all patients, with a focus on incorporation of ethnic minorities likely by intentional oversampling, to overcome decades of demographic homogeneity in the trials.

In this review, we discuss a new paradigm for atherosclerotic cardiovascular disease (ASCVD) prevention that is focused on cultivating cardiovascular wellness through the promotion of “health factors.” Cardiovascular prevention efforts have contributed to falling rates of ASCVD over the past five decades. However, contemporary increases in obesity and diabetes have led to a recent slowing in the annual decline of ASCVD death rates. This slowing represents an opportunity for new thinking to change the current ASCVD prevention paradigm, i.e., the identification and treatment or control of risk factors for disease. Indeed, a new paradigm focusing on cultivating cardiovascular wellness in addition to preventing disease is gaining increased traction. With this approach, the goal of ASCVD prevention is shifting to include consideration of both treating “risk factors” and cultivating health factors. Importantly, cardiovascular wellness is more than just the absence of disease and, therefore, risk factors and health factors are not always mere opposites. We review healthy lifestyle tools such as the American Heart Association Life’s simple 7 and Fuster-BEWAT score. We summarize landmark studies of interventions aimed at improving adherence to health factors. We highlight the inherent limitations of current studies to adequately examine cardiovascular wellness. We propose new study designs that are required to identify novel health factors and measures of wellness. We conclude with recommendations regarding the utility of health factors and cardiovascular wellness in current practice.

In the recently published review "Coronary Artery Calcium: Recommendations for Risk Assessment in Cardiovascular Prevention Guidelines," the following author name was inadvertently misspelled as Alison Peng. The correct spelling of the author's name is: Allison Peng as shown above.

Our purpose was to discuss the methodological limitations of observational nutritional epidemiology research, using observational studies on coffee intake and health as a case example. A number of recent observational studies on the potential health effects of daily coffee intake have reported protective associations between higher coffee intake and a variety of health outcomes, including death. This is inconsistent with the findings from classic studies showing an increased risk of coronary heart disease events, performed in young adults with a homogeneous education level, and adjusting for tobacco use. Many nutritional epidemiological studies have important limitations, which limit their validity. These include the use of prevalent user designs, risk of reverse causality, measurement error particularly of the exposure of interest, and residual confounding by socioeconomic status. In this review, we discuss these potential issues and provide constructive recommendations intended to help minimize them.

Background Awareness represents a major modulator for the uptake of preventive measures and healthy life-style choices. Women underestimate the role of cardiovascular diseases as causes of mortality, yet little information is available about their subjective risk awareness. Methods The Berlin Female Risk Evaluation (BEFRI) study included a randomized urban female sample aged 25–74 years, in which 1,066 women completed standardized questionnaires and attended an extensive clinical examination. Subjective estimation was measured by a 3-point Likert scale question asking about subjective perception of absolute cardiovascular risk with a 10 year outlook to be matched to the cardiovascular risk estimate according to the Framingham score for women. Results An expected linear increase with age was observed for hypertension, hyperlipidemia, obesity, and vascular compliance measured by pulse pressure. Knowledge about optimal values of selected cardiovascular risk factor indicators increased with age, but not the perception of the importance of age itself. Only 41.35% of all the participants correctly classified their own cardiovascular risk, while 48.65% underestimated it, and age resulted as the most significant predictor for this subjective underestimation (OR = 3.5 for age >50 years compared to

Precise risk stratification of atherosclerotic cardiovascular disease guides best management and therefore is a public health priority. In addition to risk estimation using traditional risk factors, tools such as coronary artery calcium, high-sensitivity C-reactive protein, ankle-brachial index and carotid imaging, and clinical features such as family history of premature coronary heart disease may offer opportunities for a more personalized risk assessment. In this review, we discuss the strengths and limitations of each of these tools, focusing on the evidence provided by the latest studies relevant to the field. Among them, coronary artery calcium currently stands out as the most powerful tool for cardiovascular risk assessment, as recognized by the 2013 ACC/AHA Risk Assessment Guideline. Recent studies have expanded our knowledge regarding its value for improving the detection of both low and high absolute risk within clinically relevant subgroups, as well as for cost-effectively guiding preventive therapy allocation.