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Aim: To examine improvement in the use of optimal medical therapy (OMT) for secondary prevention in patients with atherosclerotic cardiovascular disease (ASCVD) and diabetes. Materials and Methods: Patients with ASCVD (coronary, cerebrovascular, peripheral) and low‐density lipoprotein‐cholesterol of 70 mg/dl or higher were enrolled from December 2016 to July 2018 from 107 US sites/physicians (47% cardiology, 41% primary care, 12% other) and prospectively followed for 2 years (current analysis restricted to subgroup with diabetes). OMT was defined as high‐intensity lipid‐lowering (high‐intensity statin, any statin + ezetimibe, proprotein convertase subtilisin/kexin type 9 inhibitor), antithrombotic (antiplatelet or anticoagulant), angiotensin‐converting enzyme‐inhibitor/angiotensin II receptor blocker/angiotensin receptor neprilysin inhibitor (ACE‐I/ARB/ARNI) (excluding glomerular filtration rate [GFR] < 30 ml/min/1.73m2) and sodium‐glucose co‐transporter‐2 inhibitor (SGLT2i)/glucagon‐like peptide‐1 receptor agonist (GLP‐1 RA) (excluding GFR < 30 ml/min/1.73m2 and type 1 diabetes). Results: Among 1590 patients with ASCVD and diabetes (96% type 2 diabetes), 58% were on high‐intensity lipid‐lowering therapy at the end of follow‐up, 87% antithrombotic, 71% ACE‐I/ARB/ARNI and 17% SGLT2i/GLP‐1 RA. Overall, 11% of patients received comprehensive OMT, which modestly improved over time (vs. 8% at baseline; P =.002). Patients treated by cardiologists (vs. non‐cardiologists) were more likely to be on high‐intensity lipid lowering, but less likely to be on an SGLT2i/GLP‐1 RA, and thus had lower rates of composite OMT (7.8% vs. 13.7%, P <.001). In a hierarchical multivariable model, older age was associated with lower odds of OMT (OR 0.74 per 10 years, 95% CI 0.60‐0.90), whereas private insurance (OR 1.93, 95% CI 1.32‐2.84) and coronary disease (OR 1.62, 95% CI 1.01‐2.61) were associated with higher odds. The median odds ratio was 1.82 (95% CI 1.03‐7.32), indicating a moderate variability in OMT use, independent of patient factors. Conclusions: We found suboptimal use of secondary prevention in US patients with ASCVD and diabetes, with minimal improvement over time. Further efforts are needed to improve the use of secondary prevention therapies in these patients with high residual risk. [ABSTRACT FROM AUTHOR]

Aims: To evaluate the associations between liver fat content and cardiometabolic parameters to explore potential threshold values that define metabolically healthy liver fat content, and to examine the association of liver fat content with cardiovascular events as well as its longitudinal progression. Methods: Participants in the Dallas Heart Study underwent clinical evaluation, including laboratory testing, and liver fat quantification by magnetic resonance spectroscopy (MRS) at baseline (N = 2287) and at follow‐up (N = 343) after a mean of 7.3 years. Cardiovascular events were adjudicated (>12 years). Results: The mean age at study entry was 44 years, 47% of participants were men, and 48% were African American. The following cardiometabolic biomarkers worsened across liver fat quintiles (P < 0.0001): body mass index (BMI); waist circumference; prevalence of hypertension; prevalence of diabetes; cholesterol, triglyceride, high‐sensitivity C‐reactive protein (CRP), leptin and fasting glucose levels; homeostatic model assessment of insulin resistance index (HOMA‐IR); coronary artery calcium score; visceral adipose tissue; abdominal subcutaneous adipose tissue; and lower body subcutaneous adipose tissue. Cardiovascular events were comparable across groups defined by tertile of baseline liver fat content. Change in BMI (R = 0.40), waist circumference (R = 0.35), CRP (R = 0.31), alanine aminotransferase (R = 0.27), HOMA‐IR (R = 0.26), aspartate transaminase (R = 0.15) and triglycerides (R = 0.12) significantly correlated with change in liver fat content (P < 0.01 for all). Conclusion: Clinically relevant metabolic abnormalities were higher across quintiles of liver fat, with increases noted well within normal liver fat ranges, but cardiovascular events were not associated with liver fat content. Longitudinal changes in metabolic parameters, especially adiposity‐related parameters, were correlated with change in liver fat content. [ABSTRACT FROM AUTHOR]

Background: Chronic kidney disease (CKD) is a known risk factor of atherosclerotic cardiovascular disease (ASCVD). Per the 2018 American Heart Association/American College of Cardiology cholesterol guidelines, high‐risk ASCVD patients with CKD and low‐density lipoprotein cholesterol (LDL‐C) levels ≥ $\ge $ 70 mg/dL should take a high‐intensity statin with ezetimibe and/or a proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i). Objective/Methods: We examined the changes in use of lipid lowering therapies (LLT) over two years in 3304 patients with ASCVD and CKD in the Getting to an imprOved Understanding of Low‐Density Lipoprotein Cholesterol and Dyslipidemia Management (GOULD) observational cohort study. Results: Of those with eGFR <60 ml/min/1.73 m2, 21.6% (171/791) had intensification of LLT while 10.4% (82/791) had de‐escalation of LLT. Notably, 61.6% (487/791) had no change in LLT regimen over 2 years. Statin use was 83.2% (785/944) at baseline and 80.1% (634/791) at 2 years. Statin/ezetimibe use increased from 2.9% (27/944) to 4.9% (39/791). Statin discontinuation at 2 years was greater with lower eGFR levels across all cohorts. Conclusion: Despite the recommendations of multiscociety guidelines, statin use, while high, is not ubiquitous and rates of high‐intensity statin and ezetimibe use remain low in patients with CKD. There remains a significant opportunity to optimize LLT and achieve atheroprotective cholesterol levels in the CKD population. [ABSTRACT FROM AUTHOR]

Background: Obesity is associated with subclinical myocardial injury as quantified by concentrations of cardiac troponin T, but whether lifetime excess weight history is associated with increased concentrations of cardiac troponin I (cTnI) and how indices of abdominal adiposity and glycemic dysregulation affect these associations remain unclear. Methods: We analyzed cTnI with a high‐sensitivity assay in 9739 participants in the Trøndelag Health (HUNT) Study at study visit 4 (2017–2019). BMI was assessed at study Visit 1 (1984–1986), 2 (1995–1997), 3 (2006–2008), and 4. Results: Median age at visit 4 was 68.7 years and 59% were women. Concentrations of cTnI were detectable in 84.1% of study participants, with a median of 2.5 (1.5–4.5 ng/L). We identified three clusters of BMI trajectories from visit 1 to 4, (1) stable normal weight, (2) stable overweight, and (3) stable obesity. Participants in clusters 2 and 3 were at increased risk of elevated concentrations of cTnI at visit 4 (odds ratio 1.27, 95% CI 1.09–1.47, and odds ratio 1.70, 95% CI 1.33–2.17, p for trend <0.001). Participants in cluster 3 had 22.0 (95% CI 14.1–29.9) higher concentrations of cTnI compared to participants in cluster 1 (p for trend <0.001). Dysregulated glucose metabolism and abdominal obesity did not influence our results. Conclusions: Individuals with stable overweight or obesity are at increased risk of subclinical myocardial injury, independently of glycemic dysregulation and abdominal adiposity. Our data support a direct detrimental effect of long‐standing obesity on cardiovascular health. [ABSTRACT FROM AUTHOR]

Introduction. Atherosclerosis is a low-grade inflammatory disease. Among markers of inflammation, importance has been given to the neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR). The objective of this study was to examine the association between these hematological indices of inflammation and coronary atherosclerotic calcification in clinically asymptomatic patients. Methods. This study had clinical and laboratorial data collected from consecutive asymptomatic patients that underwent computed tomography coronary artery calcium (CAC) scoring. Risk factors, NLR, and PLR were evaluated at different categories of CAC scoring. Statistical tests included chi-square, linear regression, and logistic regression. Patients (N=247; age 60.4±8.0 years and 60.7% men) were allocated into four categories according to the CAC score. Results. Respective age, sex (male), NLR, and PLR distribution within groups were as follows: CAC=0 (n=98; 52.5±13.6 years, 55%, 2.0±1.0, and 121.5±41.5), CAC 1-100 (N=64; 61.3±11.0 years, 60%, 2.2±1.2, and 125.6 ± 45.6), CAC 101-400 (N=37; 64.2±11.6 years, 67%,2.6±1.3, and 125.4±55.9), and CAC>400 (N=48; 69.3±11.1 years, 66%, 3.3±2.0, and 430.1±1787.4). The association between risk factors and CAC score was assessed. Hypertension status and smoking status were similar within groups, while the presence of diabetes (P=0.02) and older age (P≤0.001) was more prevalent in the CAC>400 group. LDL cholesterol was greater in the higher CAC score groups (P=0.002). Multivariate logistic regression of the quartile analysis showed that age and NLR were independently associated with CAC>100 (OR (CI), P value): 2.06 (1.55-2.73, P=0.00001) and 1.82 (1.33-2.49, P=0.0002), respectively. Conclusion. Within asymptomatic patients, NLR provides additional risk stratification, as an independent association between NLR extent and CAD extent was identified. Moreover, PLR was not an inflammation marker for CAD severity. [ABSTRACT FROM AUTHOR]

Background: Previous research has demonstrated a link between objective socio‐economic indicators and cognitive test performance. Although some studies include subjective indicators, such as perceived neighborhood environment, little is known about which specific factors are most strongly associated with cognitive performance and whether these measures are useful beyond traditional SES proxies. Further, in addition to being disproportionately at risk of experiencing neighborhood disadvantage and lower SES, racial/ethnic minorities are more likely to be diagnosed with dementia and receive less timely care compared with White individuals. This study aims to investigate how perceived neighborhood environment and neighborhood disadvantage are related to cognitive performance within a large diverse sample. Method: A probability‐based sample of participants (N = 3858; Female = 59%; Black = 51%; Hispanic = 14%) from the Dallas Heart Study Phase 2 (DHS‐2; Mean: Age = 50, Education = 13) were administered the Montreal Cognitive Assessment (MoCA), in addition to measures of perceptions of neighborhood physical environment and violence, and perceived SES. Multiple regression was used to determine associations of these variables with MoCA scores relative to traditional SES measures (i.e., income, education), controlling for demographic and relevant health factors. Post‐hoc analyses stratified by racial/ethnic group were conducted to determine whether indicators differentially influenced test scores. Result: After controlling for socio‐demographic and health factors, reporting lower quality neighborhood resources and difficulty paying for "very basics like food and heating" and "medical care" were associated with lower MoCA scores in the overall sample. Post‐hoc analyses revealed significant relationships between MoCA scores and quality of neighborhood resources, "food and heating," and "medical care" only in Black participants, while "violence" was significantly associated with lower MoCA scores in Hispanics. There were no significant relationships found in Whites. Overall, subjective measures of SES and neighborhood environment contributed modest variance in the overall model, specifically for Black and Hispanic participants (R2 = 3% to 5%). Conclusion: Experiencing neighborhood and economic adversity was associated with lower scores on a cognitive screening measure and accounted for more variance than income or education in Black individuals and income in Hispanic individuals, while no relationship was seen in White participants. Future research is needed to determine whether these allostatic stressors influence cognitive impairment or dementia later in life. [ABSTRACT FROM AUTHOR]

Objectives: Although psychosocial stress can result in adverse health outcomes, little is known about how perceptions of neighborhood conditions, a measure of environment-derived stress, may impact obesity. The association between perceptions of neighborhood environment and obesity (defined as body mass index [BMI] ≥ 30 kg/m2) among 5,907 participants in the Dallas Heart Study, a multi-ethnic, probability-based sample of Dallas County residents was examined. Design and Methods: Participants were asked to respond to 18 questions about perceptions of their neighborhood. Factor analysis was used to identify three factors associated with neighborhood perceptions: neighborhood violence, physical environment, and social cohesion. Logistic regression analyses were performed to determine the relationship between each factor (higher quintile = more unfavorable perceptions) and the odds of obesity. Results: Decreasing age, income, and education associated with unfavorable overall neighborhood perceptions and unfavorable perceptions about specific neighborhood factors ( P trend <0.05 for all). Increasing BMI was associated with unfavorable perceptions about physical environment ( P trend <0.05) but not violence or social cohesion. After adjustment for race, age, sex, income, education, and length of residence, physical environment perception score in the highest quintile remained associated with a 25% greater odds of obesity (OR 1.25, [95% CI 1.03-1.50]). Predictors of obesity related to environmental perceptions included heavy traffic (OR 1.39, [1.17-1.64]), trash/litter in neighborhood (OR 1.27, [1.01-1.46]), lack of recreational areas (OR 1.21, [1.01-1.46]), and lack of sidewalks (OR 1.25, [95% CI 1.04-1.51]). Conclusions: Thus, unfavorable perceptions of environmental physical conditions are related to increased obesity. Efforts to improve the physical characteristics of neighborhoods, or the perceptions of those characteristics, may assist in the prevention of obesity in this community. [ABSTRACT FROM AUTHOR]

Clinician counseling is a catalyst for lifestyle modification in obesity. Unfortunately, clinicians do not appropriately counsel all obese patients about lifestyle modification. The extent of disparities in clinician counseling is not well understood. Obese participants (BMI ≥30 kg/m2, N = 2097) in the Dallas Heart Study (DHS), a probability-based sample of Dallas County residents ages 18-65, were surveyed regarding health-care utilization and lifestyle counseling over the year prior to DHS enrollment. Health-care utilization and counseling were compared between obese participants across three categories based on the presence of 0, 1, or 2+ of the following cardiovascular (CV) risk factors: hypertension, hypercholesterolemia, or diabetes. Logistic regression modeling was used to determine likelihood of counseling in those with 0 vs. 1+ CV risk factors, stratified by race, adjusting for age, sex, insurance status, and education. Among obese subjects who sought medical care, those with 0 CV risk factors, compared to those with 1 or 2+ CV risk factors, were less likely to report counseling about losing weight (41% vs. 67% vs. 87%, P trend <0.001), dietary changes (44% vs. 71% vs. 85%, P trend <0.001), and physical activity (46% vs. 71% vs. 86%, P trend <0.001). Blacks and Hispanics without CV risk factors had a lower odds of receiving counseling than whites without risk factors on weight loss (adjusted odds ratio (OR), 95% confidence interval (CI) for nonwhites 0.19, [0.13-0.28], whites 0.48, [0.26-0.87]); dietary changes (nonwhites 0.19, [0.13-0.27], whites 0.37, [0.21-0.64]); and physical activity (nonwhites 0.22, [0.16-0.32], whites 0.32, [0.18-0.57]). Lifestyle counseling rates by clinicians are suboptimal among obese patients without CV risk factors, especially blacks and Hispanics. Systematic education about and application of lifestyle interventions could capitalize on opportunities for primary CV risk prevention. [ABSTRACT FROM AUTHOR]

Polycystic ovarian syndrome (PCOS), the most common endocrinopathy of young women, is characterized by androgen excess and is frequently associated with cardiovascular risk factors. However, it is unclear whether PCOS is a risk factor for atherosclerosis. We sought to determine in a multiethnic population-based sample whether women with PCOS have greater measures of subclinical atherosclerosis than women without PCOS. Cross-sectional study of a nested cohort from the Dallas Heart Study (2000-2002). Women between the ages of 35 and 49 ( n = 827). PCOS was defined by Rotterdam criteria. The normal control group had regular menses, total testosterone <2·78 nmol/l, no signs of hirsutism and no polycystic ovarian morphology by magnetic resonance imaging (MRI). Subclinical atherosclerosis defined as coronary artery calcium (CAC) by computed tomography and abdominal aortic plaque by MRI. The prevalence of PCOS in Dallas County was 19·6% ( n = 144), and 8·0% ( n = 56) had both oligomenorrhea and hyperandrogenism. Women with PCOS had higher body mass index, blood pressure, insulin and leptin than regularly cycling controls. Despite a greater prevalence of cardiovascular risk factors, women with PCOS did not have a greater prevalence of CAC > 10 Agatston units (PCOS 5%, controls 6·3%, P = 0·74) or abdominal aortic plaque (PCOS 25·8%, controls 34·4%, P = 0·13) than controls. In a large, multiethnic, population-based sample of premenopausal women, PCOS, defined by Rotterdam criteria, was not associated with a higher prevalence of coronary artery calcium or abdominal aortic plaque. [ABSTRACT FROM AUTHOR]

Editor's Note: The following Point/Counterpoint articles were derived from a debate presentation sponsored by the American Society for Preventive Cardiology at the March 2010 meeting of the American Heart Association Council on Epidemiology and Prevention, titled 'Should We Focus on Novel Risk Marker and Screening Tests to Better Predict and Prevent Cardiovascular Disease?' Dr. James de Lemos presented the pro side, titled 'Novel Risk Markers and Screening Tests Will Improve the Prediction and Prevention of Cardiovascular Disease,' and Dr. Donald Lloyd-Jones advocated the con side, titled 'Better Implementation of Existing Knowledge Will Save More Lives Than All of the Novel Biomarkers in the World.' The following articles include points from the debate, rebuttal, and questions raised by the audience. We thank all authors for sharing this debate with the readership. [ABSTRACT FROM AUTHOR]

Background: Patients with diabetes mellitus who undergo coronary stenting are at increased risk of restenosis. It is known that inflammation plays a crucial role in restenosis. Objective: We assessed the inflammatory response to elective coronary stent implantation (CSI) in stable diabetic and nondiabetic patients. Methods: C-reactive protein (CRP), soluble (s) P-selectin, and soluble intercellular adhesion molecule (sICAM)-1 plasma levels were determined in diabetic (n = 51) and nondiabetic (n = 56) patients before and 48 hours and 4 weeks after bare metal stenting (BMS). Results: Diabetic patients presented significantly higher inflammatory marker levels before and after CSI. Nonetheless, diabetic and nondiabetic patients had postintervention peak of markers attained within 48 hours. At baseline, diabetic and nondiabetic patients presented CRP levels of 5.0 ± 20.1 (P ≤ 0.04) and 3.8 ± 9.4 μg/ml and, at 48 hours postintervention, 22.0 ± 20.2 (P = 0.001; P = 0.002) and 12.6 ± 11.3 (P ≤ 0.0001) μg/ml. Regarding sP-selectin, diabetic and nondiabetic patients obtained levels of, at baseline, 182 ± 118 (P ≤ 0.04) and 105 ± 48 ng/ml and, at 48 hours, 455 ± 290 (P = 0.001; P ≤ 0.01) and 215 ± 120 (P ≤ 0.04) ng/ml. For diabetic and nondiabetic patients, sICAM-1 levels were, at baseline, 248 ± 98 (P ≤ 0.04) and 199 ± 94 ng/ml and, at 48 hours, 601 ± 201 (P = 0.001; P ≤ 0.01) and 283 ± 220 (P = 0.001) ng/ml. At 4 weeks, for all patients, markers returned to preprocedural levels: versus before PCI: *P = 0.001, §P ≤ 0.0001; versus nondiabetic patients: #P ≤ 0.04, ¶P = 0.002, ΥP ≤ 0.01. Conclusions: Diabetic and nondiabetic patients exhibited a temporal inflammatory response after an elective BMS. However, diabetic patients present higher preprocedural levels of CRP, sP-selectin, and sICAM-1 and reveal a further exacerbated inflammatory response after intervention. The differences in inflammatory response may have implications in restenosis within these two sets of patients. [ABSTRACT FROM AUTHOR]

Background: Cardiac troponin T and brain natriuretic peptide (BNP) are elevated in >50% of dialysis patients and are associated with poor outcomes. Few data investigated these associations in earlier chronic kidney disease (CKD)., Methods and Results: We studied whether CKD modified associations of elevated BNP, N-terminal-pro-BNP, high-sensitivity cardiac troponin T, coronary artery calcification, and left ventricular hypertrophy with all-cause death and cardiovascular death/events in 3218 multiethnic individuals followed for 12.5 years, and whether biomarkers added prognostic information to traditional cardiovascular risk factors in CKD. Of the cohort, 279 (9%) had CKD. There were 296 deaths and 218 cardiovascular deaths/events. Of non-CKD individuals, 7% died and 6% had cardiovascular death/event versus 32% and 30% of CKD participants, P <0.001 for both. The interaction between BNP and CKD on death was significant ( P =0.01): the adjusted hazard ratio in CKD was 2.05, 95% CI (1.34, 3.14), but not significant in non-CKD, 1.04 (0.76, 1.41). CKD modified the association of high-sensitivity cardiac troponin T with cardiovascular death/event, adjusted hazard ratio 3.34 (1.56, 7.18) in CKD versus 1.65 (1.16, 2.35) in non-CKD, interaction P =0.09. There was an interaction between N-terminal-pro-BNP and CKD for death in those without prior cardiovascular disease. Addition of each biomarker to traditional risk factors improved risk prediction, except coronary artery calcification was not discriminatory for cardiovascular death/event in CKD., Conclusions: Cardiac biomarkers, with the exception of coronary artery calcification, prognosticated outcomes in early-stage CKD as well as, if not better than, in non-CKD individuals, even after controlling for estimated glomerular filtration rate, and added to information obtained from traditional cardiovascular risk factors alone., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Background: Excess adipose tissue has been implicated in the pathogenesis of insulin resistance and atherosclerosis and is a key risk factor for blood pressure (BP) elevation. However, circulating levels of adiponectin, a protein produced by adipose tissue and widely implicated in the pathogenesis of insulin resistance and atherosclerosis, are inversely proportional to adiposity. The relationship between adiponectin and incident hypertension has not been determined in the general US population., Methods: Normotensive participants (n = 1233) enrolled in the Dallas Heart Study, a multiethnic, probability-based population sample of Dallas County adults were followed for median of 7 years. Retroperitoneal, intraperitoneal, visceral, and subcutaneous adipose tissue were measured at baseline by magnetic resonance imaging. Liver fat content was measured by 1 H-magnetic resonance spectroscopy. Relative risk regression was used to determine the association of adiponectin with incident hypertension after adjustment for age, race, sex, BMI, smoking, diabetes, baseline systolic BP, total cholesterol, and regional fat depot., Results: Of the 1233 study participants (median age 40 years, 40% black, and 56% women), 391 (32%) had developed hypertension over a median follow-up of 7 years. Adiponectin levels were associated with reduced risk of incident hypertension (RR 0.81, 95% CI [0.68-0.96]) in the fully adjusted model, which included liver fat. Similar results were observed after adjustment for subcutaneous or visceral fat depots when tested individually or simultaneously in the model., Conclusion: Our study suggested a protective role of adiponectin against incident hypertension independent of body fat distribution., (Copyright © 2016 John Wiley & Sons, Ltd.)

Background: Cardiorespiratory fitness (CRF) and highly sensitive cardiac troponin T (hs-cTnT) are associated with risk of all-cause and cardiovascular mortality as well as incident heart failure. A link of low CRF to subclinical cardiac injury may explain this association. We hypothesized that CRF would be inversely associated with hs-cTnT measured in healthy adults over age 50., Methods and Results: We evaluated 2498 participants (24.7% female, mean age 58.7 years) from the Cooper Center Longitudinal Study between August 2008 and January 2012. Plasma specimens obtained shortly before CRF estimates by Balke treadmill testing were used for hs-cTnT assays. CRF was grouped into low CRF (category 1), moderate CRF (categories 2-3), and high CRF (categories 4-5). Multivariable logistic regression was used to estimate the association of CRF with hs-cTnT. The prevalence of measurable hs-cTnT (≥3 ng/L) was 78.5%. In multivariable analyses, low-fit individuals were significantly more likely than high-fit individuals to have elevated hs-cTnT (≥14 ng/L) (odds ratio 2.47, 95% CI 1.10-5.36)., Conclusions: In healthy older adults, CRF is inversely associated with hs-cTnT level adjusted for other risk factors. Prospective studies are needed to evaluate whether improving CRF is effective in preventing subclinical cardiac injury., (© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)