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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.

The coronavirus disease 2019 (COVID-19) pandemic has been the defining healthcare issue since its outbreak, consuming healthcare systems and disrupting all aspects of human life throughout 2020 and continuing through 2021. When reviewing cardiovascular disease (CVD) prevention throughout the COVID-19 pandemic, the first tendency may be to focus on the negative disruption. Months of quarantine, isolation, and missed healthcare visits or delayed care may have exacerbated the epidemic of CVD in the United States. Looking back, however, perhaps it wasn't a lost year as much as a health crisis that better prepared us for the battle to improve cardiovascular health. The pandemic brought new platforms for interacting with patients eager to engage, presenting a unique opportunity to reset how we approach preventive care. In this review, we discuss what the pandemic has taught us about caring for those vulnerable patients who were most afflicted-older adults, persons of color, and people facing adverse socioeconomic circumstances-and who continue to be impacted by CVD. We also identify opportunities for enhanced CVD prevention now boosted by the overnight adoption of telemedicine and other innovative cardiac care models. Lastly, we discuss how the COVID-19 pandemic has motivated physicians and patients alike to prioritize our health above all else, if only transiently, and how we can leverage this increased health awareness and investment into long-term, meaningful disease prevention.

Background The optimal method for communicating coronary heart disease (CHD) risk to individual patients is not yet clear. Recent research supports the concept of "coronary age" for more effective risk communication. We defined an individual's coronary age as the age at which an average healthy individual would have an equivalent estimated CHD risk as that calculated for the index individual, building on our previously validated MESA (Multi‐Ethnic Study of Atherosclerosis) 10‐year CHD Risk Score equations with and without coronary artery calcium (CAC). Methods and Results We derived a coronary age by (1) calculating the MESA 10‐year CHD risk; (2) mathematically setting this equal to an equation describing risk of an average healthy MESA participant, as a function of age; and (3) solving for age. The risk discrimination of the resultant coronary age was compared with that of chronological age, the MESA CHD Risk Score, and CAC alone. Approximately 95% of coronary age values ranged from 30 years less to 30 years higher than chronological age. Although the mean chronological age of individuals experiencing CHD events compared with those free of events was 67.4 versus 61.8 years, the difference in coronary age including CAC was larger (80.6 versus 62.8 years). Coronary age with CAC had identical predictive ability to that of MESA CHD Risk Score and outperformed chronological age and CAC alone. Conclusions The newly derived coronary age is a convenient transformation of MESA CHD Risk, retaining very good risk discrimination. This easy‐to‐communicate tool will be available for patients and clinicians, potentially facilitating risk communication in routine care.

Adult working-class Americans spend on average 50% of their workday awake time at their jobs. The vast majority of these jobs involve mostly physically inactive tasks and frequent exposure to unhealthy food options. Traditionally, the workplace has been a challenging environment for cardiovascular prevention, where cardiovascular guidelines have had limited implementation. Despite the impact that unhealthy lifestyles at the workplace may have on the cardiovascular health of U.S. workers, there is currently no policy in place aimed at improving this. In this review, we discuss recent evidence on the prevalence of physical inactivity among Americans, with a special focus on the time spent at the workplace; and the invaluable opportunity that workplace-based lifestyle interventions may represent for improving the prevention of cardiovascular disease. We describe the current regulatory context, the key stakeholders involved, and present specific, guideline-inspired initiatives to be considered by both Congress and employers to improve the “cardiovascular safety” of US jobs. Additionally, we discuss how the COVID-19 pandemic has forever altered the workplace, and what lessons can be taken from this experience and applied to cardiovascular disease prevention in the new American workplace. For many Americans, long sitting hours at their job represent a risk to their cardiovascular health. We discuss how a paradigm shift in how we approach cardiovascular health, from focusing on leisure time to also focusing on work time, may help curtail the epidemic of cardiovascular disease in this country.

INTRODUCTION: The importance of receiving an annual influenza vaccine among patients with atherosclerotic cardiovascular disease (ASCVD) is well established. With the rapid community spread and the possibility of another wave of COVID-19 infections in the fall, receiving an influenza vaccine is of particular importance to mitigate the risk associated with overlapping influenza and COVID-19 infections. METHODS: We utilized cross-sectional data from the 2016 to 2019 Behavioral Risk Factor Surveillance System (BRFSS), a nationally representative U.S. telephone-based survey of adults 18 years or older. Race/ethnicity was our exposure of interest. We assessed the relative difference in influenza vaccination by race/ethnicity for each U.S. state in the overall U.S. population and among those with ASCVD as prevalence of receipt of influenza vaccination among Blacks or Hispanics minus prevalence among Whites divided by prevalence among Whites. We used multivariable-adjusted logistic regression models to evaluate the association between socioeconomic risk factors and receipt of influenza vaccination. RESULTS: The study population consisted of 1,747,397 participants of whom 21% were older than 65 years, 51% women, 63% White, 12% Black, 17% Hispanic, and 9% with history of ASCVD. The receipt of influenza vaccine was 38% in the overall population and 51% among those with self-reported ASCVD, which translates to approximately to 97 million and 12 million US adults, respectively. The receipt of influenza vaccine among individuals with ASCVD was 54% for Whites, 45% for Blacks, and 42% for Hispanics (p

Key Points Question Do high-dose zinc, high-dose ascorbic acid, and/or a combination of the 2 reduce the duration of symptoms of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)? Findings In this randomized clinical trial of 214 patients with confirmed SARS-CoV-2 infection receiving outpatient care, there was no significant difference in the duration of symptoms among the 4 groups. Meaning These findings suggest that treatment with zinc, ascorbic acid, or both does not affect SARS-CoV-2 symptoms., This randomized clinical trial examines whether high-dose zinc and/or high-dose ascorbic acid reduces the severity or duration of symptoms compared with usual care among ambulatory patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection., Importance There is limited evidence regarding early treatment of novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection to mitigate symptom progression. Objective To examine whether high-dose zinc and/or high-dose ascorbic acid reduce the severity or duration of symptoms compared with usual care among ambulatory patients with SARS-CoV-2 infection. Design, Setting, and Participants This multicenter, single health system randomized clinical factorial open-label trial enrolled 214 adult patients with a diagnosis of SARS-CoV-2 infection confirmed with a polymerase chain reaction assay who received outpatient care in sites in Ohio and Florida. The trial was conducted from April 27, 2020, to October 14, 2020. Intervention Patients were randomized in a 1:1:1:1 allocation ratio to receive either 10 days of zinc gluconate (50 mg), ascorbic acid (8000 mg), both agents, or standard of care. Outcomes The primary end point was the number of days required to reach a 50% reduction in symptoms, including severity of fever, cough, shortness of breath, and fatigue (rated on a 4-point scale for each symptom). Secondary end points included days required to reach a total symptom severity score of 0, cumulative severity score at day 5, hospitalizations, deaths, adjunctive prescribed medications, and adverse effects of the study supplements. Results A total of 214 patients were randomized, with a mean (SD) age of 45.2 (14.6) years and 132 (61.7%) women. The study was stopped for a low conditional power for benefit with no significant difference among the 4 groups for the primary end point. Patients who received usual care without supplementation achieved a 50% reduction in symptoms at a mean (SD) of 6.7 (4.4) days compared with 5.5 (3.7) days for the ascorbic acid group, 5.9 (4.9) days for the zinc gluconate group, and 5.5 (3.4) days for the group receiving both (overall P = .45). There was no significant difference in secondary outcomes among the treatment groups. Conclusions and Relevance In this randomized clinical trial of ambulatory patients diagnosed with SARS-CoV-2 infection, treatment with high-dose zinc gluconate, ascorbic acid, or a combination of the 2 supplements did not significantly decrease the duration of symptoms compared with standard of care. Trial Registration ClinicalTrials.gov Identifier: NCT04342728

This study aimed to evaluate the ability of coronary artery calcium (CAC) as an initial diagnostic tool to rule out obstructive coronary artery disease (CAD) in a very large registry of patients presenting to the emergency department (ED) with acute chest pain (CP) who were at low to intermediate risk for acute coronary syndrome (ACS).It is not yet well established whether CAC can be used to rule out obstructive CAD in the ED setting.We included patients from the Baptist Health South Florida Chest Pain Registry presenting to the ED with CP at low to intermediate risk for ACS (Thrombolysis In Myocardial Infarction risk score ≤2, normal/nondiagnostic electrocardiography, and troponin levels) who underwent CAC and coronary computed tomography angiography (CCTA) procedures for evaluation of ACS. To assess the diagnostic accuracy of CAC testing to diagnose obstructive CAD and identify the need for coronary revascularization during hospitalization, we estimated sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV).Our study included 5,192 patients (mean age: 53.5 ± 10.8 years; 46% male; 62% Hispanic). Overall, 2,902 patients (56%) had CAC = 0, of which 135 (4.6%) had CAD (114 [3.9%] nonobstructive and 21 [0.7%] obstructive). Among those with CAC0, 23% had obstructive CAD. Sensitivity, specificity, PPV, and NPV of CAC testing to diagnose obstructive CAD were 96.2%, 62.4%, 22.4%, and 99.3%, respectively. The NPV for identifying those who needed revascularization was 99.6%. Among patients with CAC = 0, 11 patients (0.4%) underwent revascularization, and the number needed to test with CCTA to detect 1 patient who required revascularization was 264.In a large population presenting to ED with CP at low to intermediate risk, CAC = 0 was common. CAC = 0 ruled out obstructive CAD and revascularization in more than 99% of the patients, and 5% with CAC = 0 had any CAD. Integrating CAC testing very early in CP evaluation may be effective in appropriate triage of patients by identifying individuals who can safely defer additional testing and more invasive procedures.

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 2018, the AHA/ACC Multisociety Guideline on the Management of Blood Cholesterol was released. Less than one year later, the 2019 ESC/EAS Dyslipidemia Guideline was published. While both provide important recommendations for managing atherosclerotic cardiovascular disease (ASCVD) risk through lipid management, differences exist. Prior to the publication of both guidelines, important randomized clinical trial data emerged on non-statin lipid lowering therapy and ASCVD risk reduction. To illustrate important differences in guideline recommendations, we use this data to help answer three key questions: 1) Are ASCVD event rates similar in high-risk primary and stable secondary prevention? 2) Does imaging evidence of subclinical atherosclerosis justify aggressive use of statin and non-statin therapy (if needed) to reduce LDL-C levels below 55 ​mg/dL as recommended in the European Guideline? 3) Do LDL-C levels below 70 ​mg/dL achieve a large absolute risk reduction in secondary ASCVD prevention? The US guideline prioritizes both the added efficacy and cost implications of non-statin therapy, which limits intensive therapy to individuals with the highest risk of ASCVD. The European approach broadens the eligibility criteria by incorporating goals of therapy in both primary and secondary prevention. The current cost and access constraints of healthcare worldwide, especially amidst a COVID-19 pandemic, makes the European recommendations more challenging to implement. By restricting non-statin therapy to a subgroup of high- and, in particular, very high-risk individuals, the US guideline provides primary and secondary ASCVD prevention recommendations that are more affordable and attainable. Ultimately, finding a common ground for both guidelines rests on our ability to design trials that assess cost-effectiveness in addition to efficacy and safety.

Introduction: Social determinants of health (SDOH) are contextual factors and shared experiences that impact an individual’s life and health. Unfavorable SDOH are recognized as a major source of excess cardiovascular disease (CVD) risk; however, prior studies have focused on restricted sets of SDOH domains. We aimed to assess the burden of multiple unfavorable SDOH at the population level, and the association between increasing cumulative burden of unfavorable SDOH features and atherosclerotic CVD (ASCVD) prevalence. Methods: Using a nationally-representative sample of 164,696 adults from the National Health Interview Survey (2013-17) we identified 39 parameters (classified as favorable or unfavorable) from the Healthy People 2020SDOH domains: Economic stability, Education, Food access, Neighborhood conditions, Social context, Health systems. An aggregate score of these features ranging 0-36 was then divided into quartiles-- the most unfavorable scores in the highest quartile. ASCVD was ascertained via self-report. Results: 15,758 individuals (8%), representing ~19.6 million Americans, had ASCVD and were more likely to experience economic instability, adverse neighborhood and social cohesion, psychologic distress, food scarcity, and significant cost and non-cost-related healthcare barriers than those without ASCVD. The age adjusted mean (SD) SDOH risk score among ASCVD vs non-ASCVD participants was 12.5 (0.13) vs 0.9 (0.03) respectively. We observed a graded increase in ASCVD prevalence with higher SDOH quartiles (Figure). In multivariate analyses, adults with highest SDOH scores had 2-fold higher odds of having ASCVD compared to those with lowest scores (Figure). Conclusions: In the US, aggregate SDOH risk significantly discriminate risk of prevalent ASCVD among US adults. Standardized SDOH risk scores have the potential to inform risk stratification models at the individual level for addressing avoidable social inequities in health status.

Introduction: Chronic inflammatory disease states are associated with higher incidence of premature atherosclerotic cardiovascular disease (ASCVD) in the young. However, data on whether younger patients with inflammatory bowel disease (IBD) are particularly at higher risk for subclinical atherosclerotic disease is scarce. Methods: Using data obtained from the CLARIFY registry (Clinicaltrials.gov NCT04075162), a prospective study of no-charge coronary artery calcium (CAC) testing at University Hospitals, we identified all patients with ulcerative colitis or Crohn’s disease and compared the presence (>0) and high (≥100) CAC with all patients in CLARIFY without IBD stratified by age group (non-elderly: ≤65 years; elderly >65 years), and adjusting for traditional ASCVD risk factors. Results: A total of 475 patients with IBD (252 UC, 196 CD, 27 both) and 43,437 controls without IBD were included. Compared with control, patients with IBD were more likely to be female (59% vs 50%, P100 compared to 28% without IBD (p=0.10). The respective prevalence was 25% vs. 21% (p=0.08) among non-elderly participants, and 45% vs. 47% (p=0.49) among elderly. In the total population, no association between IBD and CAC>0 or CAC>100 was noted. However, there was evidence of effect modification by pre-specified age strata (p-value for interaction 0.012, figure), where the odds of CAC≥100 was 1.38-fold higher (95% CI: 1.02-1.89) for IBD among participants ≤65 years vs among elderly participants [OR 0.84, 95% CI: 0.57-1.22]. Conclusions: Non-elderly IBD patients are at increased risk for significant coronary calcified atherosclerotic disease. Further studies are needed to understand underlying biological processes and implications of increased atherosclerotic disease risk among young adults with IBD.

Introduction: Sudden cardiac death (SCD) commonly presents as the initial manifestation of coronary heart disease in the general population. Coronary artery calcium (CAC), a sub-clinical marker of atherosclerosis, is a strong predictor of cardiovascular events. We assessed the ability of CAC to stratify risk of SCD. Methods: We studied 66,636 adults from the CAC Consortium, a large multi-center cohort of asymptomatic patients free of clinical CVD at baseline. We categorized participants into 4 CAC score groups—CAC=0, CAC 1-99, CAC 100-399, and CAC≥400. The primary outcome was defined by identifying accepted International Classification of Diseases codes for SCD on official death certificates obtained for all deaths from the National Death Index. Predictive value of CAC for SCD was assessed using Cox proportional hazards regression models adjusted for age, sex and traditional risk factors. We performed standard area under receiver operating curve (AUC) analyses from fully adjusted logistic regression models, with and without CAC. All analyses were also repeated among participants aged 45-75 years. Results: Mean age of the study population was 54.4 years, and 33% were females and 89% were Whites. Over a mean follow up of 12.3±3.9 years, there were 211 SCD events. Participants with CAC=0 had lower absolute SCD rates compared to those with CAC≥400 (0.05 vs 1.28 per 1000 person-years, respectively). Increasing CAC scores (reference CAC=0) were associated with increasing SCD risk [CAC 100-399: HR (95% CI) 2.8(1.6-5.0), CAC≥400: 4.3(2.4-7.7)]. Addition of CAC to the fully adjusted model (vs without CAC) improved AUC for SCD among the whole study population (0.88 vs 0.86, P P Conclusions: We demonstrate the predictive value of CAC for SCD. CAC could be a cost-effective risk-stratification tool that can be used to help identify individuals at high risk of SCD who could undergo additional screening and management.

Introduction: Cardiovascular health (CVH) and social determinants of health (SDOH) have a significant impact on maternal morbidity and mortality. We assessed the association and cumulative effects of SDOH on CVH among a nationally representative sample of pregnant women in the United States. Methods: We included cross-sectional data of pregnant women aged 18 to 49 years from the National Health Interview Survey (2013-2017). We ascertained CVH based on the following CV risk factors: hypertension, diabetes mellitus, dyslipidemia, smoking, obesity, and physical activity; classifying participants into optimal (0-1) and suboptimal (≥2) CVH. For each individual, SDOH risk score was calculated that represents the cumulative number of distinct variables (present vs absent) identified on 39 sub-components for 6 domains (economic stability, neighborhood and physical environment, community and social context, food, education, and healthcare system access). SDOH risk score was aggregated and divided into 4 quartiles. Results: Among 1,433 (3.3%, representing 2.2 million) pregnant women in US, one third (33%) of pregnant women (mean age: 33 years, 13% non-Hispanic black) had suboptimal CVH. The prevalence of hypertension, smoking, obesity and physical inactivity across the increasing SDOH quartiles were noted. Overall, 52% pregnant women with unfavorable (4 th quartile) vs 27% with favorable (1 st quartile) SDOH had suboptimal CVH. In multivariable analyses, accounting for demographics and co-morbid conditions, pregnant women with unfavorable SDOH in 4 th quartile had nearly 3-fold higher odds of suboptimal CVH. (Figure). Conclusions: Aggregate SDOH risk score provides significant discrimination of CVH in pregnant women. In pregnant women, suboptimal CVH is common and more than 1 in 2 women with highest risk of SDOH inequities have suboptimal CVH, highlighting the public health urgency for intervention in young high risk women.

Introduction: Healthcare expenses for atherosclerotic cardiovascular disease (ASCVD) are associated with substantial financial toxicity (FT). Whether certain social determinants of health (SDOH) portend an increased risk of FT in ASCVD is critical to refine care processes that may be most amenable to interventions. Methods: Using National Health Interview Survey (2013-17), we assessed patients with self-reported ASCVD. We identified 35 discrete SDOH items, rated as favorable/unfavorable, across 6 domains: economic stability, education, food access, 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 containing the most unfavorable scores. FT included presence of: difficulty paying medical bills/inability to pay them at all, and/or delayed/foregone care due to cost, and/or cost-related medication non-adherence. Results: Of 164,696 surveyed adults, of which 15,758 (weighted: 8%) reported ASCVD. Mean (SE) age-adjusted SDOH risk scores among ASCVD vs non-ASCVD patients were 11.8 (0.12) vs 9.5 (0.03), respectively. Among individuals with ASCVD, age-adjusted prevalence of any FT was directly proportional to SDOH aggregate scores, with step-wise increases noted. Prevalence of ≥ 2 FT factors among SDOH quartiles 1 st vs 4 th was 8% vs 50% among non-elderly (< 65), and 2% vs 35% among elderly adults with ASCVD, respectively (Figure). Further, in adjusted models, patients in the most unfavorable quartile for SDOH had an 8-fold higher likelihood of FT compared to those in the most favorable group. Conclusions: Among ASCVD patients, a higher number of unfavorable SDOH features is strongly associated with the presence of FT, further calling for the development of interventions to alleviate FT among those with unfavorable SDOH profiles.

Background: High out-of-pocket healthcare expenditures among US adults with atherosclerotic cardiovascular disease (ASCVD) may expose them to food insecurity, which can lead to worse health outcomes. However, few studies have examined the prevalence and determinants of food insecurity in this population. Methods: Using data from the 2013-18 National Health Interview Survey, a nationally representative annual survey of the US, we assessed prevalence and sociodemographic determinants of food insecurity among adults (≥18 years) with ASCVD. Food insecurity was defined as 3+ affirmative responses on a validated 10-item questionnaire with a 30-day look-back period. Results: Among 190,113 adults included, 18,442 (8.2%; ~19.9 million US adults annually) had ASCVD (38.3% Conclusion: Nearly 1 in 7 adults with ASCVD in the US reported food insecurity, with prevalence being as high as 50% among the most vulnerable sociodemographic subgroups. There is a critical need to address the hindrances relating to social determinants of health, including food insecurity, among adults with ASCVD in the US.

Introduction: The recent decline in use of cigarette products has been offset by an increase in non-cigarette tobacco products (NCP) among young individuals. In this study, we assess the prevalence and association of NCP use across the range of social determinants of health (SDOH) among a nationally representative population of young U.S. adults. Hypothesis: Lower SDOH is associated with higher likelihood of NCP use. Methods: We utilized cross-sectional data from the 2014-2017 National Health Interview Survey (NHIS). Current use of e-cigarettes, smokeless tobacco, and other NCP was self-reported. Relevant SDOH features were identified based on published literature and included 39 key items from 6 major domains. Each of these items was scored 1 if unfavorable and 0 if favorable and summed to derive a total SDOH risk score. Weighted multivariable logistic regression was used to assess the association between computed SDOH risk quartiles and NCP use. Results: The study population consisted of 53,023 participants (mean age 30 [SD 7] years, 50% men, 58% white), which translates to 113M US adults. Of them, 4.2%, 3.0% and 6.1% reported current use of e-cigarettes, smokeless tobacco and other NCP products, respectively with overall (any) NCP use at 11.6%. The respective prevalence in non-cigarette users was 2.3%, 2.4% and 4.4%. A graded increase in age-adjusted prevalence of specific and overall NCP was noted across increasing SDOH risk score quartiles ( Figure). Accounting for demographics and comorbidities, those in the highest SDOH risk score quartile vs lowest had 1.86-fold higher odds of use of e-cigarettes (1.49-2.34), smokeless tobacco (1.33 [1.05-1.68]) and overall NCP (1.44 [1.26-1.65]). Conclusions: In a nationally representative sample, 1 in 14 young adults with the most unfavorable SDOH profile reported NCP use. Evaluation of SDOH may provide opportunities for targeted public health approaches to prevent NCP use and its ensuing complications.

Introduction: Barriers to healthcare - financial and nonfinancial - may result in unmet health needs and adverse outcomes. Despite this, the nonfinancial barriers to care among adults with atherosclerotic cardiovascular disease (ASCVD) is poorly defined in the US. We aimed to explore the scope and determinants of nonfinancial barriers to care among individuals with ASCVD. Methods: We analyzed data from the 2013-17 National Health Interview Survey (NHIS). We included adults with self-reported ASCVD (heart attack, angina, and/or stroke). Nine key variables in the NHIS that represent nonfinancial barriers to healthcare were assessed as absent/present, and participants were classified as having 0-1, 2, or ≥3 barriers. Multinomial logistic regression (using 0-1 nonfinancial barriers as reference) was used to evaluate the relationship between various sociodemographic factors, and an increasing number of nonfinancial barriers. Results: Of all the 15,758 adults with ASCVD (8.1% annually in the US; representing 19.6 million), 23.4% reported having at least one nonfinancial barrier to care while 4.9% reported 3 nonfinancial barriers. In a multivariable multinomial logistic regression, after stratifying by age, individuals from low-income families had an almost 2-fold relative prevalence of 3 nonfinancial barriers ( Figure) . In the elderly, however, lack of insurance was the strongest predictor (relative prevalence ratio of 6.51 [95% confidence interval; 2.25, 18.87]) of having ≥3 barriers. Conclusion: Among adults with ASCVD, the relative prevalence of ≥3 nonfinancial barriers was low (4.9%) with low-income being the only modifiable predictor of reporting ≥3 nonfinancial barriers and lack of insurance being the strongest predictor in the elderly. Addressing financial barriers to healthcare may help alleviate these nonfinancial barriers.

Introduction: Inflammatory Bowel Disease (IBD), comprised of Ulcerative Colitis (UC) and Crohn’s Disease (CD) is a chronic inflammatory disease with systemic involvement. Inflammation predisposes to atherosclerosis and studies suggest that IBD is associated with premature atherosclerotic cardiovascular disease (ASCVD). There is, however, limited population-based data on cardiovascular risk factor (CRF) burden in IBD among those who have not yet developed clinical ASCVD. We sought to study the association between IBD and CRFs among a nationally representative population with IBD and without established ASCVD. Methods: The study population was derived from the 2015-2016 National Health Interview Survey database. ASCVD was defined as myocardial infarction, angina or stroke; those with ASCVD were excluded. IBD was defined as either CD or UC. We computed weighted prevalence estimates of various traditional CRFs for the US population by IBD status. Univariate and multivariate logistic regression models were used to evaluate associations between CRFs and IBD. Average and poor cardiovascular risk profiles were defined as 2-3 and ≥4 CRFs, respectively. Results: Overall 786 (1.2%) representing 2.6 million ASCVD-free adults reported IBD. Individuals with IBD had higher prevalence of multiple CRFs (Figure, top). In adjusted models those with IBD had significantly higher odds of having prevalent hypertension, diabetes mellitus and hypercholesterolemia (Figure, bottom). These associations were similar among elderly and young participants. Those with IBD were almost 2-fold more likely to have a poor cardiovascular risk profile. Conclusion: Our findings from a nationally representative US population suggest an increased burden and clustering of CRFs among IBD patients without clinical ASCVD. Future efforts are needed to understand the underlying mechanisms, and enhance the detection and treatment of these CRFs to reduce ASCVD risk in IBD patients.

Introduction: Coronary computed tomography angiography (CCTA) is a class IIA recommendation in low-intermediate risk patients with suspected acute coronary syndrome (ACS) and a normal or nondiagnostic cardiac biomarker and ECG. However, there is little consensus on whether absence of coronary artery calcium (CAC) can safely identify patients with stable and acute chest pain (CP) who can avoid more advanced downstream testing. In this study, we conducted a systematic analysis investigating utility of CAC zero in ruling out obstructive coronary artery disease (CAD) among patients with stable and acute CP undergoing coronary CT angiography (CCTA). Methods: We searched online databases (PubMed, MEDLINE) for original research articles published between 2005 and 2020 examining the relationship between CAC and significant stenosis on CCTA (defined as >50% coronary luminal narrowing) among patients with stable and acute chest pain. Results: A systematic review of published articles revealed 18 studies including 27,719 patients with stable CP and 12 studies including 7,184 patients with acute CP undergoing simultaneous CCTA and CAC scoring. Overall, 12,664 (45%, 95% CI: 39%-50%) patients with stable CP and 4,327 (56%, 95% CI: 48%-64%) patients with acute CP had CAC zero. The pooled prevalence of obstructive CAD among those with CAC=0 was 3% (95% CI: 2%-4%) among stable CP patients and 2% (95% CI: 1%-3%) among acute CP patients. The negative predictive values for any CAC ruling out obstructive disease were 97% (95% CI: 96-98%) and 98% (95% CI: 96-100%), respectively (Figure). Conclusions: Among over 34,000 patients with stable and acute CP patients undergoing CCTA, the absence of CAC was associated with a very low likelihood of obstructive CAD. These findings support role of CAC zero in a value-based healthcare delivery model as a gatekeeper for more advanced testing.

Introduction: Cardiovascular disease and cancer co-exist due to shared risk factors. The utility of coronary artery calcium (CAC) scoring in this population to predict cardiovascular events is not certain. Methods: We studied all patients enrolled in the CLARIFY registry of no-charge CAC (Clinicaltrials.gov NCT04075162) with diagnosis of any cancer. We followed patients for major adverse cardiovascular events (myocardial infarction, stroke, heart failure, coronary revascularization or mortality). Results: A total of 3,432 patients with cancer were identified. Mean age was 64±9 years, 1965 (57%) were women and 2937 (86%) were white. Overall distribution of CAC scores were as follows: CAC 0 in 35%, CAC 1-99 in 31%, CAC 100-399 in 20%, and CAC ≥ 400 in 15%. CAC distribution varied by cancer type (figure A). At a median follow-up of 663 [294-1086] days, 343 patients had MACE event. Compared with CAC 0, patients with CAC ≥ 400 had increased unadjusted risk of MACE (HR 2.57 [1.93-3.41], P Conclusions: In this large cohort of patients with cancer, coronary artery atherosclerotic calcifications are common, vary by cancer type, and are associated with major adverse cardiovascular events, independently of age and sex. Further research should focus on utility of routine CAC for cardiovascular risk stratification in patients with cancer.

Introduction: The growing prevalence of obesity has created a major burden on the health care system. To date, studies examining social determinants of obesity in adults have mostly focused on individual social determinants of health (SDOH) components. In this study, we explore the influence of cumulative SDOH on obesity among young adults (< 45) as compared with middle- aged (45-64) and elderly (≥ 65) populations in the US. Methods: We examined cross-sectional data on 164,696 adult participants from the National Health Interview Survey (2013-17). For each individual, the unfavorable SDOH risk factor was identified from 39 sub-components, stemming from 6 general domains (economic stability, neighborhood and physical environment, community and social context, food, education, and healthcare system access). Risk factors were then aggregated to develop a cumulative score, wherein individuals were divided into quartiles. Obesity was calculated from self-reported height and weight and defined as BMI ≥ 30 kg/m 2 . Adults with a BMI 2 were excluded from the analysis. Results: The age-adjusted prevalence of obesity was 32.5%, which translates to 78 million US adults annually. A linear increase in the prevalence of age-adjusted obesity was noted with increasing unfavorable SDOH prevalence across all age groups. In the overall population, those with the worst (4 th quartile) vs best (1 st quartile) SDOH profile had 1.47 higher odds of being obese in adjusted models. There was evidence, however, of effect modification by age (p-value for interaction < 0.001), with a stronger association of unfavorable SDOH risk with obesity in the young ( Conclusions: A higher burden of SDOH is more strongly associated with obesity in young adults. Estimating and understanding the impact of SDOH may have practical implications for informing effective interventions to combat early adulthood obesity and its ensuing complications.

Objectives: We sought to assess characteristics of diffuse coronary artery calcium (CAC) phenotypes and their associations with cause-specific mortality. Background: CAC is a measure of subclinical atherosclerosis and improves risk stratification. CAC characteristics including vessel involvement, number of vessels, volume, and density have been shown to differentially impact risk. Less is known about clinical predictors of a diffuse CAC phenotype and its impact on cause-specific mortality. Methods: The CAC Consortium is a retrospective, multi-site cohort of 66,636 participants without CHD who underwent CAC scoring. Risk factor data were collected at enrollment or scan. Participants with CAC>0 were included—CAC area, CAC density, and the CAC index of diffusion (the percentage of total CAC in the vessel with the highest CAC score) were calculated and the association between CAC characteristics and CVD- and CHD-specific mortality was assessed. Results: In 28,147 study participants (mean age 58.3 years, 25% female, and 89.6% white), ~66% had ≥2 calcified vessels. Diabetes, hypertension, and hyperlipidemia were predictors of multivessel involvement (p300. Among those with multivessel CAC involvement, all-cause survival was significantly worse in diffuse compared to other phenotypes. Conclusion: Diffuse CAC involvement was characterized by less dense calcification, more CAC area, multiple coronary vessel involvement, and presence of certain traditional risk factors. Multivessel CAC is associated with increased CVD- and CHD-specific mortality, particularly among CAC scores 1-299.

Introduction: Recent blood pressure (BP) guidelines recommend aggressive control of BP to prevent target organ damage, however, no population-level studies have assessed the impact of aggressive BP control on the incidence of Nonalcoholic Fatty Liver Disease (NAFLD). In this study, we investigate the implications of suboptimal BP control for incident NAFLD. Methods: We analyzed data from 6,252 consecutive participants in an employer-mandated routine health evaluation at Hospital Israelita Albert Einstein (São Paulo, Brazil) collected between 2004 to 2016 who were free of NAFLD at baseline. NAFLD was defined as liver ultrasound detected hepatic steatosis among individuals with an alcohol use disorder identification test (AUDIT) score /= 130mmHg and/or diastolic BP >/= 80 mmHg. Multivariate analysis was conducted adjusting for possible confounders as noted in the figure. Results: Over a median follow-up period of 2.9 years (range: 0.6 - 10.6 years), the incidence of NAFLD was 25.8% among individuals with hypertension (N=473) compared to 15.2% among non-hypertensive individuals (N=5,779; p Conclusions: Among persons with known hypertension, suboptimal BP is an independent risk of NAFLD. In addition, among those without known hypertension, suboptimal BP is an independent predictor of future NAFLD. Intervention studies are needed to investigate the role of BP control in the prevention of NAFLD.

Introduction: Coronary artery calcium (CAC) and extra-coronary calcification (ECC) have been associated with age-related phenotypes such as cognitive impairment. However, their relationship with poor physical function and frailty/pre-frailty in older adults is unclear. Hypothesis: CAC and ECC (aortic valve, aortic valve ring, mitral valve, ascending aorta, and descending aorta) are associated with poor physical function and frailty/pre-frailty. Methods: We defined poor physical function as a Short Physical Performance Battery (SPPB) score ≤9 and frailty/pre-frailty as the presence of at least one frailty criterion: weight loss, slow walking speed, exhaustion, low grip strength, and low physical activity. The number of vascular beds with any calcification (CAC and five ECC sites [0-6]) was calculated for a composite measure of calcification. Logistic regression was used to quantify cross-sectional associations with SPPB or frailty/pre-frailty among 1,564 ARIC participants aged 74-92 without prior CVD at visit 7 (2018-19). Results: The prevalence of low SPPB, frailty, and pre-frailty was 50%, 5%, and 56%, respectively. Highest (vs. lowest) quartile of aortic valve and mitral valve calcification was associated with low SPPB (OR 1.47 [1.15, 1.88] and 1.53 [1.19,1.97]) and frailty/pre-frailty (1.34 [1.05, 1.71] and 1.41 [1.10, 1.80]). Aortic valve ring calcification was associated with frailty/pre-frailty, and descending aorta calcification with low SPPB. The total number of calcified vascular beds demonstrated a dose-response relationship to both outcomes (Table), with 5-6 calcified vascular beds demonstrating ~2-fold higher odds. Conclusions: Cardiovascular calcification, especially aortic valve and mitral valve calcification, was robustly associated with higher risk of poor physical function and frailty/pre-frailty, suggesting the potential etiological link between cardiovascular calcification and functional decline at older age.

Introduction: Lipoprotein (a) (Lp(a)) and inflammation, as represented by elevated high-sensitivity C-reactive protein (hsCRP) concentration, are both considered as risk-enhancers in the 2018 AHA/ACC Cholesterol guidelines. However, little is known as to whether the association of Lp(a) with atherosclerotic cardiovascular disease (ASCVD) risk is modified by inflammation. Objective: We assessed whether hsCRP modifies the association of Lp(a) with ASCVD risk. Methods: MESA participants with baseline hsCRP and Lp(a) levels were included. Incident ASCVD events were ascertained from baseline through 2017. Time to incident ASCVD was analyzed using Kaplan Meir curves. Cox proportional hazards models were used to assess the association between Lp(a), hsCRP, and time to ASCVD events adjusting for covariates. Results: The study included 4,654 participants with mean age of 62 and 52.5% females (1,702 Caucasians, 557 Chinese Americans, 1,336 African Americans and 1,059 Hispanics). With a mean 13.6-year follow-up, 676 ASCVD events occurred among 4,609 participants (Figure 1). In participants with hsCRP Conclusions: Lp(a)-related ASCVD risk is modified by hsCRP levels. The findings of this analysis suggest that Lp(a) may serve as a risk enhancing factor in individuals with hsCRP level ≥2mg/L. Future studies are needed to determine whether Lp(a) is associated with risk of ASCVD in the absence of subclinical inflammation.

Background: Psychosocial factors are associated with atherosclerotic disease. However, their link to “healthy cardiovascular aging” is unknown. Aim: We aimed to comprehensively investigate the association of psychosocial factors at middle age with zero coronary artery calcium (CAC) or extra-coronary calcium (ECC) at age ≥75 years in the ARIC study. Methods: We studied 1,935 participants free of coronary heart disease history, who completed a psychosocial evaluation in 1990-1992 (mean age 53 [SD 4] years) and a cardiac computed tomography scan in 2018-2019. We assessed trait anger by the Spielberger Trait Anger Scale, depressive symptoms by the Maastricht Questionnaire, social support by the Interpersonal Support Evaluation List, and social network by the Lubben Social Network Scale. CAC/ECC was quantified by the Agatston score, and ECC included aortic valve ring, aortic valve, mitral valve, and ascending and descending aorta calcium. Results: The proportion of participants with zero calcium was 10 % for coronary artery, 15 % for aortic valve ring, 54 % for aortic valve, 52 % for mitral valve, 74 % for ascending aorta, and 11 % for descending aorta. Less trait anger was independently associated with zero CAC and aortic valve calcium (odds ratios [ORs] for one SD decrement of the score, 1.21 [95%CI, 1.02-1.45] and 1.16 [95%CI, 1.05-1.28], respectively) ( Figure A ). Less depressive symptoms, more social support, and larger social network were not positively associated with zero CAC or ECC ( Figure B-D ). The associations of less trait anger with zero CAC and aortic valve calcium remained significant when we applied inverse probability weighting to account for attrition. Conclusions: Among the psychosocial factors at middle age, only less trait anger was independently associated with zero CAC and aortic valve calcium at older age. Our findings suggest that the identification of less trait anger at middle age may be important for healthy cardiovascular aging.

Introduction In patients with chronic cardiovascular, metabolic and renal disorders, potassium (K)+ homeostasis is often delicate, especially in the presence of renin-angiotensin-aldosterone system inhibition (RAASI) and/or diuretic therapies. In this context, current clinical practical guidelines for the management of these patients recommend close monitoring of renal function and K+ levels, particularly in the presence of drug titration. Nevertheless, very limited epidemiological data on their importance at a population level is available. Purpose The objectives of the present analysis are to estimate the prevalence of potassium (K+) derangements in five key chronic cardiovascular, metabolic and renal conditions at the population level, its use of RAASI medication and describe potassium derangements among RAASI users. Methods We used data from more than 375,000 individuals 55 years of age or older included in the population-based healthcare database of a public Institute of Health between 2015 and 2017. The conditions of interest were chronic heart failure (CHF), chronic kidney disease (CKD), diabetes mellitus (DM), ischemic heart disease (IHD), and hypertension (HTN). RAASI medications included angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, mineralocorticoid receptor antagonists (MRAs), and rennin inhibitors. Hyperkalemia was defined as K+ levels >5.0 mEq/L and hypokalemia as K+ Results The prevalence of chronic cardiovascular, metabolic and renal conditions was high, particularly of HTN (48.2–48.9%). The prevalence of hyperkalemia was ranging between 10% and 25% depending of the condition, more frequent in CKD and less frequent in HTN patients. In figure, we display the prevalence of hyperkalemia among individuals with each of the relevant chronic conditions, January 1st, 2016 and January 1st, 2017. Use of at least one RAASI medication was very prevalent in HTN patients (75.2–77.3%). Among RAASI users, the frequency of K+ derangements and mainly of hyperkalemia was very noticeable (12% overall), especially in patients with CKD, CHF, elderly individuals, and users of MRAs. Hypokalemia was less frequent (1%). Conclusion The high prevalence of K+ derangements and predominantly hyperkalemia among RAASI users highlights the real-world relevance of K+ derangements and the importance of close monitoring and management of K+ levels in routine clinical practice. This is likely to benefit a large number of patients, particularly those at higher risk. Figure 1. Prevalence of hyperkalemia Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Josep Comin-Colet and Miguel Cainzos-Achirica have participated in other research projects funded by unrestricted grants from Vifor Pharma

Background Prevalence of congestive heart failure (CHF) and predisposing conditions has described previously. Most of these studies evaluated centre-European or north-American populations. However, the prevalence and evolutionary changes of Heart Failure stages A, B and C has not been fully elucidated in Mediterranean cohorts. Purpose To estimate the prevalence of CHF (HF Stage C) and four additional key chronic cardiovascular, metabolic and renal conditions predisposing to the development of CHF (HF Stages A and B) at a population level in a south-European healthcare area. We analysed the evolutionary changes in the prevalence in these five conditions. Methods In a healthcare area of 1,3Millions inhabitants, we extracted health related information of all individuals ≥55 years old. We analysed data of 375,233 individuals included in the population-based healthcare database of a public Institute of Health between 2015 and 2017. The conditions of interest were CHF, chronic kidney disease (CKD), diabetes mellitus (DM), ischemic heart disease (IHD) and hypertension (HTN). Results The prevalence of chronic conditions was high, particularly of HTN (48.2–48.9%) and DM individuals (14.6–14.8%). The other conditions were less frequent, with prevalence around 2–4% for IHD, 5–9% for CKD and 2–4% for CHF (Table). However, the less frequent conditions had a striking upward trend with over 1,500 new prevalent cases per year between 2015 and 2017 for CHF (45% relative increase), more than 2,500 new prevalent cases for IHD (67% relative increase) and more than 4,000 new prevalent cases per year for CKD (44% relative increase). Conclusion In this south European cohort, there were a high prevalence of HTN and DM as risk factors and a significant trend of increasing prevalence in high cost chronic conditions such as CHF, IHD and CKD. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): The present study was funded by an unrestricted research grant from Vifor Pharma.

Background Chronic Heart Failure (CHF) and its risk factors at stage A of the disease are conditions that trends to facilitate potassium (K+) derangements, for pathophysiology mechanisms and medication use than could facilitate both hyper- and hypokalamia. Studies on the associations between potassium derangements and clinical outcomes in these patient populations have yielded mixed findings, and the implications for healthcare expenditure are unknown. Purpose The objectives of our analysis was to asses the population-based associations between hyperkalemia, hypokalemia (compared to normokalemia) and all-cause death, urgent hospitalization, emergency department visits, daycare visits, and a yearly healthcare expenditure >85th percentile, in patients with chronic heart failure, chronic kidney disease, diabetes mellitus, hypertension and ischemic heart disease. Methods Population-based, longitudinal study including up to 36,269 patients from the Public Healthcare Area with at least one of those conditions. We used three linked administrative, hospital and primary care healthcare databases with exhaustive information on sociodemographics, medical diagnoses, pharmacy dispensing and laboratory data. Participants were identified and followed between 2015 and 2017, had to be ≥55 years old and have at least one serum potassium measurement recorded; and were classified as hyperkalemic, hypokalemic or normokalemic. Four analytic designs were used to evaluate prevalent and incident disease cases as well as prevalent and incident use of renin-angiotensin-aldosterone system inhibitors Results The majority of study participants remained normokalemic during the 3 months following study entry (ranging 94%–96%) and hyperkalemia was twice as frequent as hypokalemia. In all analyses, compared to normokalemic patients those with hyperkalemia had a worse crude event-free survival for all endpoints, and the worst survival was observed for hypokalemic patients [see Figure 1: prevalent case analysis; Kaplan-Meier cumulative survivor function curves for all-cause death (upper left), hospitalization (upper right), ED visits (lower left) and daycare visits (lower right)]. In multivariable-adjusted analyses, hyperkalemia was robustly and significantly associated with an increased risk of all-cause death (hazard ratios from Cox regression models ranging 1.31–1.68) and with an increased odds of a yearly healthcare expenditure >85th percentile (odds ratios 1.21–1.29). Associations were even stronger in hypokalemic patients (hazard ratios for all-cause death 1.92–2.60; odds ratios for healthcare expenditure >percentile 85th 1.81–1.85). Conclusions Experimental studies are needed to confirm whether prevention of potassium derangements reduces mortality and healthcare expenditure in patients with these chronic conditions. Until then, our findings provide further observational evidence on the potential importance of maintaining normal potassium levels in this setting. Figure 1 Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): The present study was funded by an unrestricted research grant from Vifor Pharma.

Stroke is becoming increasingly prevalent among the non-elderly adults (65 years of age) in the United States. Using the National Health Interview Survey database from 2012 to 2018, we examined the association of traditional risk factors, sociodemographic, cardiovascular risk factor (CRF) profile, family income, and educational attainment in young (18-44 years) and middle-aged (45-64 years) adults. CRF profiles were defined by the number of traditional risk factors with "Poor" (≥4 risk factors), "Average," or "Optimal" (0-1). The study included 168,862 non-elderly adults (55% in young adults). Overall prevalence of stroke was 1.83% among the non-elderly (0.64% and 3.31% in young- and middle-aged adults, respectively). Adults with low family income, lesser education, and who were Non-Hispanic Blacks were more likely to have stroke. Those with poor CRF profiles exhibited a 3-4 times higher odds of stroke compared to those with optimal CRF profiles. Lower income status coupled with a poor CRF profile augmented the prevalence of stroke in non-elderly adults. This national survey of non-elderly US adults showed a correlation between lower income and education, both factors of SES, and stroke. When viewed together, there was an increasing stroke burden in the non-elderly with worsening CRF profile, income status, and educational attainment.

Background and Purpose: Despite declining stroke rates in the general population, stroke incidence and hospitalizations are rising among younger individuals. Awareness of and prompt response to stroke symptoms are crucial components of a timely diagnosis and disease management. We assessed awareness of stroke symptoms and response to a perceived stroke among young adults in the United States. Methods: Using data from the 2017 National Health Interview Survey, we assessed awareness of 5 common stroke symptoms and the knowledge of planned response (ie, calling emergency medical services) among young adults ( Results: Our study population included 24 769 adults, of which 9844 (39.7%) were young adults who were included in our primary analysis, and represented 107.2 million US young adults (mean age 31.3 [±7.5] years, 50.6% women, and 62.2% non-Hispanic White). Overall, 2718 young adults (28.9%) were not aware of all 5 stroke symptoms, whereas 242 individuals (2.7%; representing 2.9 million young adults in the United States) were not aware of a single symptom. After adjusting for confounders, Hispanic ethnicity (odds ratio, 1.96 [95% CI, 1.17–3.28]), non-US born immigration status (odds ratio, 2.02 [95% CI, 1.31–3.11]), and lower education level (odds ratio, 2.77 [95% CI, 1.76–4.35]), were significantly associated with lack of symptom awareness. Individuals with 5 high-risk characteristics (non-White, non-US born, low income, uninsured, and high school educated or lower) had nearly a 4-fold higher odds of not being aware of all symptoms (odds ratio, 3.70 [95% CI, 2.43–5.62]). Conclusions: Based on data from the National Health Interview Survey, a large proportion of young adults may not be aware of stroke symptoms. Certain sociodemographic subgroups with decreased awareness may benefit from focused public health interventions.

OBJECTIVES: This study sought to assess the value, in terms of sample size and cost, of using the coronary artery calcium (CAC) score to enrich the study population of primary prevention randomized controlled trials (RCTs) with participants at high absolute risk of atherosclerotic cardiovascular disease (ASCVD) events. BACKGROUND: The feasibility of RCTs assessing the efficacy of novel add-on therapies for primary prevention among high-risk individuals treated with statins may be limited by sample size and cost. METHODS: We evaluated 3,075 statin-naive participants from the Multi-Ethnic Study of Atherosclerosis with estimated 10-year ASCVD risk of ≥7.5%. CAC of >100, CAC of >400, high sensitivity C-reactive protein levels of >2 and >3 mg/l, ankle-brachial index of 175 mg/dl were each evaluated as enrichment criteria on top of estimated ASCVD risk of ≥7.5%, ≥10%, ≥15% and ≥20%. For each criterion, using the observed 5-year incidence of CVD, we projected the incidence of CVD assuming a 28% relative risk reduction with high-intensity statin therapy and after addition of novel therapy with additive relative risk reductions of 15% and 25%. Sample size and cost of a hypothetical primary prevention 5-year RCT of a novel therapy on top of statins versus statins alone were then computed by using the projected incidences. Yearly costs per included participant of $6,000 to $9,000 and of $500/$600 per screened nonparticipant were assumed. RESULTS: CAC of >400, present in 15% to 23% participants, consistently identified the subgroups with highest 5-year incident events and outperformed the other features yielding the smallest projected sample size, ranging 33% to 58% lower than using risk estimations alone for participant selection. CAC of >400 also yielded the lowest projected RCT costs, at least $40 million lower than using risk estimations alone. CAC of >100 showed the second-best performance in most scenarios. CONCLUSIONS: High CAC scores used as study entry criteria can improve the efficiency and feasibility of primary prevention RCTs evaluating the incremental efficacy of novel add-on therapies.

Currently, South Asia accounts for a quarter of the world population, yet it already claims ≈60% of the global burden of heart disease. Besides the epidemics of type 2 diabetes mellitus and coronary heart disease already faced by South Asian countries, recent studies suggest that South Asians may also be at an increased risk of heart failure (HF), and that it presents at earlier ages than in most other racial/ethnic groups. Although a frequently underrecognized threat, an eventual HF epidemic in the densely populated South Asian nations could have dramatic health, social and economic consequences, and urgent interventions are needed to flatten the curve of HF in South Asia. In this review, we discuss recent studies portraying these trends, and describe the mechanisms that may explain an increased risk of premature HF in South Asians compared with other groups, with a special focus on highly relevant features in South Asian populations including premature coronary heart disease, early type 2 diabetes mellitus, ubiquitous abdominal obesity, exposure to the world’s highest levels of air pollution, highly prevalent pretransition forms of HF such as rheumatic heart disease, and underdevelopment of healthcare systems. Other rising lifestyle-related risk factors such as use of tobacco products, hypertension, and general obesity are also discussed. We evaluate the prognosis of HF in South Asian countries and the implications of an anticipated HF epidemic. Finally, we discuss proposed interventions aimed at curbing these adverse trends, management approaches that can improve the prognosis of prevalent HF in South Asian countries, and research gaps in this important field.

Chronic inflammatory diseases including human immunodeficiency virus infection, psoriasis, rheumatoid arthritis, and systemic lupus erythematosus predispose to atherosclerotic cardiovascular disease (ASCVD). Inflammatory bowel disease (IBD) is a common chronic inflammatory condition, and the United States has the highest prevalence worldwide. IBD has so far been overlooked as a contributor to the burden of ASCVD among young and middle-age adults, but meta-analyses of cohort studies suggest that IBD is an independent risk factor for ASCVD. This review discusses the epidemiological links between IBD and ASCVD and potential mechanisms underlying these associations. ASCVD risk management of patients with IBD is challenging because of their young age and the inability of current risk scores to fully capture their increased risk. The role of IBD in current primary prevention guidelines is evaluated, and strategies for enhanced ASCVD risk reduction in patients with IBD are outlined. Finally, the authors discuss knowledge gaps and future research directions in this innovative field.

National estimates describing the overall prevalence of and disparities in influenza vaccination among patients with diabetes mellitus (DM) in United States are not well described. Therefore, we analyzed the prevalence of influenza vaccination among adults with DM, overall and by sociodemographic characteristics, using the Medical Expenditure Panel Survey database from 2008 to 2016. Associations between sociodemographic factors and lack of vaccination were examined using adjusted logistic regression. Among adults with DM, 36% lacked influenza vaccination. Independent predictors of lacking influenza vaccination included age 18 to 39 years (odds ratio [OR] 2.54; 95% confidence interval [CI], 2.14-3.00), Black race/ethnicity (OR 1.29; 95% CI, 1.14-1.46), uninsured status (OR 1.88; 95% CI, 1.59-2.21), and no usual source of care (OR 1.61; 95% CI, 1.39-1.85). Nearly 64% individuals with ≥ 4 higher-risk sociodemographic characteristics lacked influenza vaccination (OR 3.50; 95% CI 2.79-4.39). One-third of adults with DM in the United States lack influenza vaccination, with younger age, Black race, and lower socioeconomic status serving as strong predictors. These findings highlight the continued need for focused public health interventions to increase vaccine coverage and utilization among disadvantaged communities.

The incidence and prevalence of type 2 diabetes mellitus are increasing in the United States and worldwide. The individual-level risk of atherosclerotic cardiovascular disease events in primary prevention populations with type 2 diabetes mellitus is highly heterogeneous. Accurate risk stratification in this group is paramount to optimize the use of preventive therapies. Herein, we review the use of the coronary artery calcium score as a decision aid in individuals with type 2 diabetes mellitus without clinical atherosclerotic cardiovascular disease to guide the use of preventive pharmacotherapies, such as aspirin, lipid-lowering mediations, and cardiometabolic agents. The magnitude of expected risk reduction for each of these therapies must be weighed against its cost and potential adverse events. Coronary artery calcium has the potential to improve risk stratification in select individuals beyond clinical and laboratory risk factors, thus providing a more granular assessment of the expected net benefit with each therapy. In patients with diabetes mellitus and stable chest pain, coronary computed tomography angiography increases the sensitivity for coronary artery disease diagnoses compared with functional studies because of the detection of nonobstructive atherosclerosis. Most importantly, this anatomic approach may improve cardiovascular outcomes by increasing the use of evidence-based preventive therapies informed by plaque burden. We therefore provide an updated discussion of the pivotal role of coronary computed tomography angiography in the workup of stable chest pain in patients with diabetes mellitus in the context of recent landmark trials, such as PROMISE trial (Prospective Multicenter Imaging Study for Evaluation of Chest Pain), SCOT-HEART trial (Scottish Computed Tomography of the Heart), and ISCHEMIA trial (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches). Finally, we also outline the current role of coronary computed tomography angiography in acute chest pain presentations.

Background: Recent studies suggest that non-alcoholic fatty liver disease (NAFLD) in lean (BMI

Vitamin D and calcium supplements are commonly used, often together, to optimize bone health. Multiple observational studies have linked low serum 25-hydroxyvitamin D concentrations with increased cardiovascular risk. However, subsequent randomized controlled trials (RCTs) failed to demonstrate cardiovascular benefit with vitamin D supplementation. Although vitamin D supplements do not appear to be harmful for cardiovascular health, the lack of benefit in RCTs should discourage their use for this purpose, favoring optimizing vitamin D status through healthy lifestyles such as specific foods and modest sunlight exposure. Furthermore, some (but not all) observational and RCT studies of calcium supplementation have suggested potential for cardiovascular harm. Therefore, calcium supplementation should be used cautiously, striving for recommended intake of calcium predominantly from food sources. In this review, the authors examine the currently available evidence investigating whether vitamin D and calcium supplements are helpful, harmful, or neutral for cardiovascular health.

Objective: Atherosclerotic cardiovascular disease (ASCVD) and chronic obstructive pulmonary disease (COPD) are among the leading causes of morbidity, mortality, and economic burden in the United States (US). While previous reports have shown that an optimal cardiovascular risk factor (CRF) profile is associated with improved outcomes among COPD patients, the impact of ASCVD and CRF on healthcare costs and resource utilization is not well described. Methods: The Medical Expenditure Panel Survey (MEPS) database was used from 2011 to 2016 to study healthcare expenditure for COPD patients with and without ASCVD and across CRF profiles in a nationally representative population of adults in the United States. Results: The study population consisted of 14,807 adults with COPD, representing 28 million cases annually. Presence of ASCVD was associated with higher reported expenditure across the spectrum of CRF profiles among those with COPD. On average, after adjusting for confounders, presence of ASCVD represented a mean difference per capita of $5438 (95% CI $4121 - $6754; p ​