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Abstract Giant leiomyosarcoma of scrotum is a rare tumour. A case of scrotum leiomyosarcoma is presented in a 67 year old patient with scrotal filariasis which was managed successfully with total scrotectomy with bilateral orchidectomy, degloved penis reconstructed with rotation advancement supra pubic fasciocutaneous flap. We made a literature search proving the rarity of this lesion type. Only 36 cases have been described and the first case in a filarial scrotum

Abstract Background Malignant peripheral nerve sheath tumor (MPNST) is biologically an aggressive tumor for which the treatment of choice is the surgery. We reviewed the clinical profile, diagnostic methods, treatment patterns, and outcome of twenty-four MPNST patients in this study. Patients and methods A retrospective analysis of 24 MPNST patients, treated from 1994 to 2002, in the department of Surgical Oncology at All India Institute of Medical Sciences, New Delhi, was done. A combination of gross, histopathological and immunohistochemical findings, and proliferation markers (MIB1) were considered for diagnosis and grade of the MPNST. Survival analysis was done by the Kaplan-Meier method and differences were evaluated with the log-rank test. Multivariate analysis was carried out by using Cox's proportional hazards model by using SPSS (Version 9, Chicago, Illinois) software. Results MPNST constituted 12% of all soft tissue sarcomas, where 21% (5/24) of patients had associated Von Recklinghausen's disease (VRHD). A higher incidence of male preponderance and multifocal MPNST were noted in the present series. At a mean follow-up of 38 months, 13 (54 %) patients had relapse of disease and 5-year over all and disease free survival were 58% and 35% respectively. In univariate analysis, sex (p = 0.05), tumor depth (p < 0.03), and cellular differentiation (p < 0.002) were shown to be adverse prognostic factors for disease free survival and sex (p = 0.04), cellular differentiation (p < 0.0004), and tumor grade (p = 0.05) for overall survival. However, in multivariate analysis, cellular differentiation (p < 0.005) and tumor grade (p < 0.01) emerged as independent prognostic factors for both disease free and overall survival, respectively. Postoperative radiotherapy (RT) has shown a definite role in both disease free and overall survival in this study. Conclusion MPNSTs constituted a significant proportion (12%) of soft tissue sarcoma in our medical center. Heterogeneous differentiation and multifocality of the tumor were few distinct features of MPNST. Sex and cellular differentiation were noticed as the new adverse prognostic factors and adjuvant radiotherapy has been proved to be a significant treatment tool in the current series.

Abstract Background Malignant small bowel tumors are very rare and leiomyosarcoma accounts for less than 15% of the cases. Management of these tumors is challenging in view of nonspecific symptoms, unusual presentation and high incidence of metastasis. In this case report, an unusual presentation of jejunal sarcoma and management of liver metastasis with radiofrequency ablation (RFA) is discussed. Case presentation A 45-year-old male presented with anemia and features of small bowel obstruction. Operative findings revealed a mass lesion in jejunum with intussusception of proximal loop. Resection of bowel mass was performed. Histopathological findings were suggestive of leiomyosarcoma. After 3-years of follow-up, the patient developed recurrence in infracolic omentum and a liver metastasis. The omental mass was resected and liver lesion was managed with radiofrequency ablation. Conclusion Jejunal leiomyosarcoma is a rare variety of malignant small bowel tumor and a clinical presentation with intussusception is unusual. We suggest that an aggressive management approach using a combination of surgery and a newer technique like RFA can be attempted in patients with limited metastatic spread to liver to prolong the long-term survival in a subset of patients.

SUMMARY Breast conservation therapy for early breast cancer is an established but grossly under-utilized treatment option in India for various reasons. Breast conservation therapy was offered to 200 suitable breast cancer patients between June 1993 and June 1998. Fifty-one patients (25%) opted for breast conservation and the remaining preferred mastectomy. In patients agreeing to conservation therapy, surgery was performed first along with peroperative implantation of iridium-192 to deliver a boost. Whole breast irradiation of 45 Gy was delivered 3–4 weeks after the boost. Cosmesis was assessed at the end of 6 months from completion of therapy. The main reason for refusal of breast conservation therapy was fear of recurrence in the remaining breast (60%). There were no locoregional failures in our study at a median follow up of 42 months; one patient experienced a systemic relapse. Cosmesis was good to excellent in 80% of patients. Breast conservation therapy using peroperative iridium-192 implant provides excellent locoregional disease control and cosmesis. The results of our study indicate that patient preference for mastectomy is an important reason for the under-utilization of breast conservation therapy in India. [ABSTRACT FROM AUTHOR]

Congenital anomalies of the mitral valve are rare. A mitral arcade is defined as a fibrous continuity between the papillary muscles and the anterior mitral leaflet creating a hammock like suspension. We present images of a mitral anomaly that consists of a direct attachment of the anterolateral papillary muscle to the anterior mitral leaflet, which we have labeled as a "hemi-arcade." We discuss the surgical findings and review the available literature regarding a mitral "arcade". [ABSTRACT FROM AUTHOR]

Background: As future cardiovascular disease mortality trends have public health implications, we aimed to project ischemic heart disease (IHD), cerebrovascular disease (CeVD), and heart failure (HF) mortality rates for adults (40-79 years)., Methods and Results: In this population-level study, we linked the yearly mortality rates (per 100 000 US residents) (2000-2019) with IHD, CeVD, or HF as the primary cause of death from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research with the midyear US population estimates (2000-2035) for adults (40-79 years). We calculated the observed age-standardized mortality rates (2000-2019) (per 100 000 residents) (aSMR) and fitted Bayesian age-period-cohort models to project aSMR for IHD, CeVD, and HF up to 2035 in the United States. Between 2019 (last year of observed data) and 2035 (last year of projected results), the US population (40-79 years) will increase by 16% and age. The IHD aSMR will reduce from 111.9 (in 2019) to 81.8 (66.7-96.9) in 2035, an effect observed for all age groups. The CeVD aSMR will remain comparable between 2019 (37.4) and 2035 (38.6 [30.7-46.5]). The HF aSMR will increase from 16.5 in 2019 to reach 30.9 (13-48.8) in 2035; such increases were observed in all age groups., Conclusions: In the United States, between 2020 and 2035, the aSMR for IHD is expected to decrease, for CeVD will remain stable, and for HF will increase substantially. These data can inform resource allocation for future public health initiatives.

Background: Saphenous venous grafts (SVG) remain the most widely used conduits in coronary artery bypass graft surgery (CABG). Data comparing outcomes of single saphenous venous grafting (SinCABG) versus sequential venous grafting (SeqCABG), however, are limited., Methods: Between 2002 and 2012, 2,375 patients with 3-vessel coronary artery disease underwent isolated elective CABG at the Leipzig Heart Center with a left internal mammary artery graft to left anterior descending artery and ≥2 distal SVG anastomoses. Of these, 1,278 received ≥2 singular saphenous venous grafts (SinCABG) and 563 received ≥1 sequential saphenous vein grafts with >1 distal anastomoses (SeqCABG). The primary end point was long term survival. Secondary outcomes included short-term survival, early postoperative outcomes as well as early and late graft patency., Results: At 30-days, mortality was 1.3% following SinCABG as compared to 2.3% after SeqCABG (p=0.13). The postoperative complications rate did not differ between groups. Early postoperative coronary angiographies were performed in 127 patients (7%), while clinically indicated follow-up coronary angiographies were performed in 372 patients (20%) over a median follow up of 5 years (IQR 1.7-8.9). No differences in early or late patency rates were found between both grafting techniques (p=0.79 and p=0.39, respectively). The median duration of long-term clinical follow-up was 8.4 years (IQR 5.6-11.4). Long-term survival rates at 1, 5, 10 and 15 years in SinCABG versus SeqCABG were 95% versus 94%, 83% versus 82%, 63% versus 62%, and 47% versus 41%, respectively (p=0.22)., Conclusions: Short and long-term mortality as well as early and late graft patency rates did not differ in patients undergoing SinCABG as compared to patients undergoing SeqCABG., (Copyright © 2024 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Cardio-kidney-metabolic (CKM) syndrome is defined by the American Heart Association as the intersection between metabolic, renal and cardiovascular disease. Understanding the contemporary estimates of CKM related mortality and recent trends in the US is essential for developing targeted public interventions. We collected state-level and county-level CKM-associated age-adjusted premature cardiovascular mortality (aaCVM) (2010-2019) rates from the CDC Wide-ranging Online Data for Epidemiologic Research (WONDER). We linked the county-level aaCVM with a multi-component social deprivation metric: the Social Deprivation Index (SDI: range 0-100) and grouped them as follows: I: 0-25, II: 26-50, III: 51-75, and IV: 76-100. We conducted pair-wise comparison of aaCVM between SDI groups with the multiplicity adjusted Wilcoxon test; we compared aaCVM in men versus women, metropolitan versus nonmetropolitan counties, and non-hispanic white versus non-hispanic black residents. In 3101 analyzed counties in the US, the median CKM associated aaCVM was 61 [interquartile range (IQR): 45, 82]/100 000. Mississippi (99/100 000) and Minnesota (33/100 000) had the highest and lowest values respectively. CKM associated aaMR increased across SDI groups [I - 45 (IQR: 36, 55)/100 000, II- 61 (IQR: 49, 77)/100 000, III- 77 (IQR: 61, 94)/100 000, IV- 89 (IQR: 70, 110)/100 000; all pair-wise p-values < 0.001]. Men had higher rates [85 (64, 91)/100 000] than women [41 (28, 58)/100 000](p-value < 0.001), metropolitan counties [54 (40, 72)/100 000] had lower rates than non-metropolitan counties [66 (49, 90)/100 000](p-value < 0.001), and non-Hispanic Black [110 (86, 137)/100 000] had higher aaMR than non-Hispanic White residents [59 (44, 78)/100 000](p-value < 0.001). In the US, CKM mortality remains high and disproportionately occurs in more socially deprived counties and non-metropolitan counties. Our inability to reduce CKM mortality rates over the study period highlights the need for targeted policy interventions to curb the ongoing high burden., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Objectives: Cardiovascular diseases (CVDs) are the leading causes of global mortality. Modifiable behavioural and metabolic risk factors significantly contribute to the burden of CVD. Given the vast socio-demographic and health outcome heterogeneity in Latin America, similar southern Latin American countries (Argentina, Chile, and Uruguay) were analysed as a distinct group to describe the CVD death rates related to metabolic and behavioural risk factors., Study Design: An ecological study was performed using data from the Global Burden of Disease Study 2019., Methods: Metabolic and behavioural risk factors-related CVD death were examined by analysing age-standardised rates per 100,000 individuals in the three countries between 1990 and 2019., Results: While exposure to behavioural risk is decreasing, an upwards trend was observed in metabolic risks. Among the assessed risk factors, metabolic factors emerged as the primary contributors to deaths. High fasting plasma glucose exhibited a remarkable increase in relative importance across most studied contexts. Dietary risks stood out among behavioural factors due to their complexity and substantial changes observed. Although mortality rates have declined for overall CVD, peripheral artery disease mortality is rising., Conclusion: Modifiable behavioural and metabolic risk factors significantly influence CVD mortality in Southern Latin America. Despite the increasing exposure to metabolic risks, advancements in prevention and treatment are evidenced in the decline of mortality rates for most CVD. These findings emphasise the need for targeted interventions and comprehensive strategies to address their impact on cardiovascular health, advocating for healthy lifestyle behaviours to mitigate the progression and CVD development., (Copyright © 2024 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Importance: It is not well understood if and how various social and environmental determinants of health (SEDoH) are associated with mortality rates related to cardio-kidney-metabolic syndrome (CKM) across the US., Objective: To study the magnitude of the association strength of SEDoH with CKM-related mortality at the county level across the US., Design, Setting, and Participants: This cross-sectional, retrospective, population-based study used aggregate county-level data from the US Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (WONDER) data portal from 2010-2019. Data analysis occurred from September 2023 to January 2024., Exposures: A total of 7 diverse SEDoH were chosen, including median annual household income, percentage of racial and ethnic minority residents per county, fine particulate air pollution (PM2.5) concentrations, high-school completion rate, primary health care access, food insecurity, and rurality rate., Main Outcomes and Measures: The primary outcome was county-level age-adjusted mortality rate (aaMR) attributable to CKM. The association of county-level CKM-related aaMR with the 7 SEDoH was analyzed using geographically weighted models and the model median coefficients for each covariate studied., Results: Data from 3101 of 3243 counties (95.6%) were analyzed. There was substantial variation in SEDoH between states and counties. The overall pooled median (IQR) aaMR (2010-2019) in the US was 505.5 (441.3-578.9) per 100 000 residents. Most counties in the lower half of the US had rates much higher than the pooled median (eg, Southern US median [IQR] aaMR, 537.3 [466.0-615.9] per 100 000 residents). CKM-related mortality was positively associated with the food insecurity rate (median [IQR] β = 6.78 [2.78-11.56]) and PM2.5 concentrations (median [IQR] β = 5.52 [-11.06 to 19.70]), while it was negatively associated with median annual household income (median [IQR] β = -0.002 [-0.003 to -0.001]), rurality (median [IQR] β = -0.32 [-0.67 to 0.02]), high school completion rate (median [IQR] β = -1.89 [-4.54 to 0.10]), racial and ethnic minority rate (median [IQR] β = -0.66 [-1.85 to 0.89]), and primary health care access rate (median [IQR] β = -0.18 [-0.35 to 0.07])., Conclusions and Relevance: In this cross-sectional study of county-level data across the US, there were substantial geographical differences in the magnitude of the association of SEDoH with CKM-related aaMR. These findings may provide guidance for deciding local health care policy.

Purpose of Review: Current guidelines for primary and secondary prevention of cardiovascular events in adults up to age 75 years are well-established. However, recommendations for lipid-lowering therapies (LLT), particularly for primary prevention, are inconclusive after age 75. In this review, we focus on adults ≥ 75 years to assess low-density lipoprotein-cholesterol (LDL-C) as a marker for predicting atherosclerotic cardiovascular disease (ASCVD) risk, review risk assessment tools, highlight guidelines for LLT, and discuss benefits, risks, and deprescribing strategies., Recent Findings: The relationship between LDL-C and all-cause mortality and cardiovascular outcomes in older adults is complex and confounded. Current ASCVD risk estimators heavily depend on age and lack geriatric-specific variables. Emerging tools may reclassify individuals based on biologic rather than chronologic age, with coronary artery calcium scores gaining popularity. After initiating LLT for primary or secondary prevention, target LDL-C levels for older adults are lacking, and non-statin therapy thresholds remain unknown, relying on evidence from younger populations. Shared decision-making is crucial, considering therapy's time to benefit, life expectancy, adverse events, and geriatric syndromes. Deprescribing is recommended in end-of-life care but remains unclear in fit or frail older adults. After an ASCVD event, LLT is appropriate for most older adults, and deprescribing can be considered for those approaching the last months of life. Ongoing trials will guide statin prescription and deprescribing among older adults free of ASCVD. In the interim, for adults ≥ 75 years without a limited life expectancy who are free of ASCVD, an LLT approach that includes both lifestyle and medications, specifically statins, may be considered after shared decision-making., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Aim: Elevated C-reactive protein (CRP), a marker of inflammation, is common in many chronic conditions. We aimed to examine to what extent elevated CRP in chronic conditions could be explained by concurrent adiposity., Materials and Methods: This cross-sectional study analysed UK Biobank data on 10 chronic conditions reported at baseline. Linear regression models explored the extent to which CRP concentrations were elevated in each condition, unadjusted; adjusted for sociodemographic confounders and lifestyle and body mass index (BMI) in a series of models; or adjusted for BMI and waist circumference together or for adiposity alone., Results: After exclusion of participants with a potential acute infection at baseline, we tested the association in 292 772 UK Biobank participants. Linear regression showed that elevated CRP concentration was associated with all included conditions. After adjustment for sociodemographic confounders, lifestyle and BMI, chronic kidney disease, heart failure, liver disease, psoriasis, rheumatoid arthritis and chronic obstructive pulmonary disease were still associated with elevated CRP. In contrast, the association between prevalent diabetes, prior myocardial infarction (MI), hypertension and sleep apnoea and CRP could be mostly explained by adiposity alone. For example, the 42% higher CRP concentrations in diabetes compared to those without diabetes in the unadjusted model (lnCRP β: 0.35; 95% confidence interval [CI]: 0.32-0.37, p < 0.001) were completely attenuated after adjustment for BMI (lnCRP β: -0.07; 95% CI: -0.09-0.05, p < 0.001)., Conclusions/interpretation: In diabetes, MI, hypertension and sleep apnoea and elevated CRP appears to be accounted for by the greater adiposity typically evident in these conditions. However, for the other conditions, systemic inflammation cannot be explained by excess adiposity alone., (© 2024 The Author(s). Diabetes, Obesity and Metabolism published by John Wiley & Sons Ltd.)

Background: Exposure to fine particulate matter (<2.5 um, particulate matter with an aerodynamic diameter <2.5 microns [PM 2.5 ]) has been implicated in atherogenesis. Limited data in animal studies suggest that PM 2.5 exposure leads to myocardial fibrosis and increased incidence of heart failure (HF). Whether PM 2.5 is associated with adverse outcomes in patients with preexisting HF has not been widely studied., Methods and Results: In this retrospective cohort study, Medicare patients hospitalized with first HF between 2013 and 2020 were identified from the Medicare Provider Analysis and Review Part A 100% files. Patients were linked with integrated estimates of ambient PM 2.5 obtained at 1×1 km using the zip code of participants' residence. The study outcomes were all-cause death, HF, and all-cause readmissions burden. A total of 2 599 525 patients were included in this study, with 6 321 731 person-years of follow-up. Mean PM 2.5 was 7.3±1.7 μg/m 3 . Each interquartile range of PM 2.5 was associated with 0.9% increased hazard of all-cause death, 4.5% increased hazard of first HF readmission, 3.1% increased risk of HF hospitalization burden, and 5.2% increase in all-cause readmission burden, after adjusting for 11 sociodemographic and medical factors. Subgroup analyses showed that the effects were more pronounced at levels <7 μg/m 3 and in patients aged <75 years, Asians, and those residing in rural areas., Conclusions: Ambient air pollution is associated with higher risk of adverse events in Medicare beneficiaries with established HF. These associations persist below the National Air Quality Standards (12 μg/m 3 ), supporting that no threshold effect exists for health effects of air pollution exposure.

Background:  The optimal timing of surgical revascularization after ST-elevation myocardial infarction (STEMI) is controversial, with some suggesting higher mortality rates in patients undergoing early surgery. The aim of the study is to determine the effect of the timing of surgical revascularization on 30-day mortality and long-term outcomes in these patients., Methods:  Retrospective single-center analysis of patients with STEMI undergoing coronary artery bypass grafting (CABG) between January 2008 and December 2019 at our institution. The cohort was split into three groups based on time from symptom onset until surgical revascularization (Group 1: <12 hours, Group 2: 12-72 hours, Group 3: >72 hours). Statistical analyses were performed with and without patients in cardiogenic shock. Primary outcomes were 30-day mortality and 10-year survival., Results:  During the study period, 437 consecutive patients underwent surgical revascularization in the setting of STEMI. The mean age was 67.0 years, 96 (22.0%) patients were female, and 281 (64.3%) patients underwent off-pump CABG. The overall 30-day mortality including patients with cardiogenic shock was 12.8%. The 30-day mortality was 16.1, 13.9, and 9.3% in Groups 1, 2, and 3 ( p  = 0.31), whereas 10-year survival was 48.5, 57.3, and 54.9% (log-rank: p  = 0.40). After exclusion of patients in cardiogenic shock, there was no difference between the three groups in 30-day and 10-year mortality. Timing of surgery had no influence on early- and long-term survival., Conclusion:  In patients with STEMI, early surgical revascularization achieved similar early- and long-term survival rates compared with a delayed surgical revascularization strategy. Hence, when indicated, an early CABG strategy has no disadvantages in comparison to a delayed strategy., Competing Interests: None declared., (Thieme. All rights reserved.)

Lead exposure has been linked to a myriad of cardiovascular diseases. Utilizing data from the 2019 Global Burden of Disease Study, we quantified age-standardized lead exposure-related mortality and disability-adjusted life years (DALYs) in the United States between 1990 and 2019. Our analysis revealed a substantial reduction in age-standardized cardiovascular disease (CVD) mortality attributable to lead exposure by 60 % (from 7.4 to 2.9 per 100,000), along with a concurrent decrease in age-standardized CVD DALYs by 66 % (from 143.2 to 48.7 per 100,000)., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

We used machine learning methods to explore sociodemographic and environmental determinants of health (SEDH) associated with county-level stroke mortality in the USA. We conducted a cross-sectional analysis of individuals aged ≥15 years who died from all stroke subtypes between 2016 and 2020. We analyzed 54 county-level SEDH possibly associated with age-adjusted stroke mortality rates/100,000 people. Classification and Regression Tree (CART) was used to identify specific county-level clusters associated with stroke mortality. Variable importance was assessed using Random Forest analysis. A total of 501,391 decedents from 2397 counties were included. CART identified 10 clusters, with 77.5% relative increase in stroke mortality rates across the spectrum (28.5 vs 50.7 per 100,000 persons). CART identified 8 SEDH to guide the classification of the county clusters. Including, annual Median Household Income ($), live births with Low Birthweight (%) , current adult Smokers (%), adults reporting Severe Housing Problems (%), adequate Access to Exercise (%) , adults reporting Physical Inactivity (%), adults with diagnosed Diabetes (%), and adults reporting Excessive Drinking (%) . In conclusion, SEDH exposures have a complex relationship with stroke. Machine learning approaches can help deconstruct this relationship and demonstrate associations that allow improved understanding of the socio-environmental drivers of stroke and development of targeted interventions., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The Global Burden of Disease assessment estimates that 20% of global type 2 diabetes cases are related to chronic exposure to particulate matter (PM) with a diameter of 2·5 μm or less (PM 2·5 ). With 99% of the global population residing in areas where air pollution levels are above current WHO air quality guidelines, and increasing concern in regard to the common drivers of air pollution and climate change, there is a compelling need to understand the connection between air pollution and cardiometabolic disease, and pathways to address this preventable risk factor. This Review provides an up to date summary of the epidemiological evidence and mechanistic underpinnings linking air pollution with cardiometabolic risk. We also outline approaches to improve awareness, and discuss personal-level, community, governmental, and policy interventions to help mitigate the growing global public health risk of air pollution exposure., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Patients with type 2 diabetes are at risk of heart failure hospitalization. As social determinants of health are rarely included in risk models, we validated and recalibrated the WATCH-DM score in a diverse patient-group using their social deprivation index (SDI)., Methods: We identified US Veterans with type 2 diabetes without heart failure that received outpatient care during 2010 at Veterans Affairs medical centers nationwide, linked them to their SDI using residential ZIP codes and grouped them as SDI <20%, 21% to 40%, 41% to 60%, 61% to 80%, and >80% (higher values represent increased deprivation). Accounting for all-cause mortality, we obtained the incidence for heart failure hospitalization at 5 years follow-up; overall and in each SDI group. We evaluated the WATCH-DM score using the C statistic, the Greenwood Nam D'Agostino test χ 2 test and calibration plots and further recalibrated the WATCH-DM score for each SDI group using a statistical correction factor., Results: In 1 065 691 studied patients (mean age 67 years, 25% Black and 6% Hispanic patients), the 5-year incidence of heart failure hospitalization was 5.39%. In SDI group 1 (least deprived) and 5 (most deprived), the 5-year heart failure hospitalization was 3.18% and 11%, respectively. The score C statistic was 0.62; WATCH-DM systematically overestimated heart failure risk in SDI groups 1 to 2 (expected/observed ratios, 1.38 and 1.36, respectively) and underestimated the heart failure risk in groups 4 to 5 (expected/observed ratios, 0.95 and 0.80, respectively). Graphical evaluation demonstrated that the recalibration of WATCH-DM using an SDI group-based correction factor improved predictive capabilities as supported by reduction in the χ 2 test results (801-27 in SDI groups I; 623-23 in SDI group V)., Conclusions: Including social determinants of health to recalibrate the WATCH-DM score improved risk prediction highlighting the importance of including social determinants in future clinical risk prediction models., Competing Interests: Disclosures N. Sattar reports personal fees from Afimmune, Amgen, AstraZeneca, Boehringer Ingelheim, Eli Lilly, Hanmi Pharmaceuticals, Merck Sharp & Dohme, Novartis, Novo Nordisk, Pfizer, and Sanofi and grant funding paid to his university from AstraZeneca, Boehringer Ingelheim, Novartis, and Roche Diagnostics outside the submitted work. Dr Al-Kindi reports support from the National Institute of Minority Health. Dr Deo reports funding from Johnson & Johnson outside the submitted work. The other authors report no conflicts.

Background: Heart failure (HF) has unique aspects that vary by biological sex. Thus, understanding sex-specific trends of HF in the US population is crucial to develop targeted interventions. We aimed to analyze the burden of HF in female and male patients across the US, from 1990 to 2019., Methods: Using the Global Burden of Disease (GBD) study data from 2019, we performed an analysis of the burden of HF from 1990-2019, across US states and regions. The GBD defined HF through studies that used symptom-based criteria and expressed the burden of HF as the age-adjusted prevalence and years lived with disability (YLDs) rates per 100,000 individuals., Results: The age-adjusted prevalence of HF for the US in 2019 was 926.2 (95% UI [799.6, 1,079.0]) for females and 1,291.2 (95% UI [1,104.1, 1,496.8]) for males. Notably, our findings also highlight cyclic fluctuations in HF prevalence over time, with peaks occurring in the mid-1990s and around 2010, while reaching their lowest points in around 2000 and 2018. Among individuals >70 years of age, the absolute number of individuals with HF was higher in females, and this age group doubled the absolute count between 1990 and 2019. Comparing 1990-1994 to 2015-2019, 10 states had increased female HF prevalence, while only 4 states increased male prevalence. Overall, Western states had the greatest relative decline in HF burden, in both sexes., Conclusion: The burden of HF in the US is high, although the magnitude of this burden varies according to age, sex, state, and region. There is a significant increase in the absolute number of individuals with HF, especially among women >70 years, expected to continue due to the aging population., Competing Interests: Disclosures All authors declare no competing interests., (Copyright © 2023. Published by Elsevier Inc.)

Background: Increased particulate matter <2.5 μm (PM 2.5 ) air pollution is associated with adverse cardiovascular outcomes. However, its impact on patients with prior coronary artery bypass grafting (CABG) is unknown., Objectives: The purpose of this study was to evaluate the association between major adverse cardiovascular events (MACE) (defined as myocardial infarction, stroke, or cardiovascular death) and air pollution after CABG., Methods: We linked 26,403 U.S. veterans who underwent CABG (2010-2019) nationally with average annual ambient PM 2.5 estimates using residential address. Over a 5-year median follow-up period, we identified MACE and fit a multivariable Cox proportional hazard model to determine the risk of MACE as per PM 2.5 exposure. We also estimated the absolute potential reduction in PM 2.5 attributable MACE simulating a hypothetical PM 2.5 lowered to the revised World Health Organization standard of 5 μg/m 3 ., Results: The observed median PM 2.5 exposure was 7.9 μg/m 3 (IQR: 7.0-8.9 μg/m 3 ; 95% of patients were exposed to PM 2.5 above 5 μg/m 3 ). Increased PM 2.5 exposure was associated with a higher 10-year MACE rate (first tertile 38% vs third tertile 45%; P  < 0.001). Adjusting for demographic, racial, and clinical characteristics, a 10 μg/m 3 increase in PM 2.5 resulted in 27% relative risk for MACE (HR: 1.27, 95% CI: 1.10-1.46; P  < 0.001). Currently, 10% of total MACE is attributable to PM 2.5 exposure. Reducing maximum PM 2.5 to 5 μg/m 3 could result in a 7% absolute reduction in 10-year MACE rates., Conclusions: In this large nationwide CABG cohort, ambient PM 2.5 air pollution was strongly associated with adverse 10-year cardiovascular outcomes. Reducing levels to World Health Organization-recommended standards would result in a substantial risk reduction at the population level., Competing Interests: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Background We tested the potential of the Secondary Manifestations of Arterial Disease (SMART2) risk score for use in patients undergoing coronary artery bypass grafting. Methods and Results We conducted an external validation of the SMART2 score in a racially diverse high-risk national cohort (2010-2019) that underwent isolated coronary artery bypass grafting. We calculated the preoperative SMART2 score and modeled the 5-year major adverse cardiovascular event (cardiovascular mortality+myocardial infarction+stroke) incidence. We evaluated SMART2 score discrimination at 5 years using c-statistic and calibration with observed/expected ratio and calibration plots. We analyzed the potential clinical benefit using decision curves. We repeated these analyses in clinical subgroups, diabetes, chronic kidney disease, and polyvascular disease, and separately in White and Black patients. In 27 443 (mean age, 65 years; 10% Black individuals) US veterans undergoing coronary artery bypass grafting (2010-2019) nationwide, the 5-year major adverse cardiovascular event rate was 25%; 27% patients were in high predicted risk (>30% 5-year major adverse cardiovascular events). SMART2 score discrimination (c-statistic: 64) was comparable to the original study (c-statistic: 67) and was best in patients with chronic kidney disease (c-statistic: 66). However, it underpredicted major adverse cardiovascular event rates in the whole cohort (observed/expected ratio, 1.45) as well as in all studied subgroups. The SMART2 score performed better in White than Black patients. On decision curve analysis, the SMART2 score provides a net benefit over a wide range of risk thresholds. Conclusions The SMART2 model performs well in a racially diverse coronary artery bypass grafting cohort, with better predictive capabilities at the upper range of baseline risk, and can therefore be used to guide secondary preventive pharmacotherapy.

Objectives: Fine particulate matter <2.5 microns (PM 2.5 ) is the most studied air pollutant. Both short- and long-term exposure to PM 2.5 have been linked to cardiovascular disease (CVD). Studies evaluating air pollution in South America are scarce. Therefore, the impact of exposure to PM 2.5 , household air pollution (HAP), and ambient air pollution (AAP) on CVD mortality and CVD disability-adjusted life years (DALYs) in South American countries from 1990 to 2019 was explored., Study Design and Methods: The Global Burden of Disease initiative exposure-response function was used to analyze the total PM 2.5 , ambient PM 2.5 , and household PM 2.5 -related CVD deaths and DALYs rates, per 100,000 individuals, in 12 South American countries between 1990 and 2019. The relative change in burden was also assessed by comparing the 1990-1994 to 2015-2019 periods., Results: In 2019, 70,668 deaths and 1,736,414 DALYs due to CVD were attributed to total PM 2.5 exposure in South America. Substantial regional heterogeneity was observed concerning the absolute change in PM 2.5 concentration levels comparing 1990 to 2019. All South American countries observed a relative decline in CVD deaths and DALYs comparing the 1990-1994 to 2015-2019 periods. No country was able to reach the current World Health Organization 5 μg/m 3 recommended limit in 2019. Predominantly, AAP was the greatest contributor to the CVD burden., Conclusion: Air pollution substantially impacted CVD in South America; however, this impact was heterogenous, and the relative reduction of HAP and AAP burden was also not uniform. Recognizing PM 2.5 importance is key for developing target population and individual-level interventions, which could ultimately alleviate its burden., (Copyright © 2023 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Background: The importance of type 2 diabetes mellitus (T2D) in heart failure hospitalizations (HFH) is acknowledged. As information on the prevalence and influence of social deprivation on HFH is limited, we studied this issue in a racially diverse cohort., Methods: Linking data from US Veterans with stable T2D (without prevalent HF) with a zip-code derived population-level social deprivation index (SDI), we grouped them according to increasing SDI as follows: SDI: group I: ≤20; II: 21-40; III: 41-60; IV: 61-80; and V (most deprived) 81-100. Over a 10-year follow-up period, we identified the total (first and recurrent) number of HFH episodes for each patient and calculated the age-adjusted HFH rate [per 1000 patient-years (PY)]. We analysed the incident rate ratio between SDI groups and HFH using adjusted analyses., Results: In 1 012 351 patients with T2D (mean age 67.5 years, 75.7% White), the cumulative incidence of first HFH was 9.4% and 14.2% in SDI groups I and V respectively. The 10-year total HFH rate was 54.8 (95% CI: 54.5, 55.2)/1000 PY. Total HFH increased incrementally from SDI group I [43.3 (95% CI: 42.4, 44.2)/1000 PY] to group V [68.6 (95% CI: 67.8, 69.9)/1000 PY]. Compared with group I, group V patients had a 53% higher relative risk of HFH. The negative association between SDI and HFH was stronger in Black patients (SDI × Race p interaction  < .001)., Conclusions: Social deprivation is associated with increased HFH in T2D with a disproportionate influence in Black patients. Strategies to reduce social disparity and equalize racial differences may help to bridge this gap., (© 2023 The Authors. Diabetes, Obesity and Metabolism published by John Wiley & Sons Ltd.)

Background: Partial intraluminal thrombosis of the frozen elephant trunk (FET) stent graft is a poorly described but not infrequent complication after aortic arch surgery. This study aims to describe and analyze the occurrence of early FET stent graft thrombosis., Methods: Retrospective single-center analysis including patients who underwent aortic arch replacement with FET technique between 2006 and 2020. Stent graft thrombosis was diagnosed through computed tomography scan. Several computed tomography scan parameters and clinical variables were analyzed as predictors of this event., Results: A total of 125 patients were included for analysis. Among these, 21 (16.8%) patients developed early postoperative FET stent graft thrombosis. Mean volumetric size of the aorta was 12.2 ± 2.0 mL in patients with FET stent graft thrombosis and 10.1 ± 2.8 mL in patients without thrombosis (P < .01). Thrombosis occurred more frequently among patients requiring thoracic endovascular aortic repair completion (15 of 21 [71.4%] patients) than in patients with completely excluded aneurysms (6 of 21 [28.6%] patients) (P = .01). Mean stent-to-aneurysm diameter ratio was 0.8 ± 0.2 among patients with thrombosis and 1.0 ± 0.2 among patients without thrombosis (P < .01). Thrombosis was more frequently observed among patients with conservative management of postoperative bleeding (P = .04). Patients with early FET thrombosis had a nonsignificantly higher in-hospital all-cause mortality than patients without thrombosis (19.0% vs 8.7%; P = .3)., Conclusions: Early postoperative intraluminal thrombosis is a frequent complication post FET surgery. Smaller stent graft sizes, larger or partially covered aneurysms, and major bleeding are associated with early thrombosis. Slight FET oversizing, prompt thoracic endovascular aortic repair completion, and early reintervention for major bleeding may prevent early thrombosis., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Contemporary guidelines emphasize the value of incorporating frailty into clinical decision-making regarding revascularization strategies for coronary artery disease. Yet, there are limited data describing the association between frailty and longer-term mortality among coronary artery bypass grafting (CABG) patients., Methods: We conducted a retrospective cohort study (2016-2020, 40 VA medical centers) of US veterans nationwide that underwent coronary artery bypass grafting (CABG). Frailty was quantified by the Veterans Administration Frailty Index (VA-FI), which applies the cumulative deficit method to render a proportion of 30 pertinent diagnosis codes. Patients were classified as non-frail (VA-FI ≤ 0.1), pre-frail (0.1 < VA-FI ≤ 0.2), or frail (VA-FI > 0.2). We used Cox proportional hazards models to ascertain the association of frailty with all-cause mortality. Our primary study outcome was 5-year all-cause mortality; the co-primary outcome was days alive and out of the hospital within the first postoperative year., Results: There were 13,554 CABG patients (median 69 years, 79% White, 1.5% women). The mean pre-operative VA-FI was 0.21 (SD: 0.11); 31% were pre-frail (VA-FI: 0.17) and 47% were frail (VA-FI: 0.31). Frail patients were older and had higher co-morbidity burdens than pre-frail and non-frail patients. Compared with non-frail patients (13.0% [11.4, 14.7]), there was a significant association between frail and pre-frail patients and increased cumulative 5-year all-cause mortality (frail: 24.8% [23.3, 26.1]; HR: 1.75 [95% CI 1.54, 2.00]; pre-frail 16.8% [95% CI 15.3, 18.4]; HR 1.2 [1.08,1.34]). Compared with non-frail patients (mean 362[SD 12]), pre-frail (mean 361 [SD 14]; p < 0.01) and frail patients (mean 358[SD 18]; p < 0.01) spent fewer days alive and out of the hospital in the first postoperative year., Conclusions: Pre-frailty and frailty were prevalent among US veterans undergoing CABG and associated with worse mid-term outcomes. Given the high prevalence of frailty with attendant adverse outcomes, there may be an opportunity to improve outcomes by identifying and mitigating frailty before surgery., (© 2023 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.)

Importance: In the 1930s, the government-sponsored Home Owners' Loan Corporation (HOLC) established maps of US neighborhoods that identified mortgage risk (grade A [green] characterizing lowest-risk neighborhoods in the US through mechanisms that transcend traditional risk factors to grade D [red] characterizing highest risk). This practice led to disinvestments and segregation in neighborhoods considered redlined. Very few studies have targeted whether there is an association between redlining and cardiovascular disease., Objective: To evaluate whether redlining is associated with adverse cardiovascular outcomes in US veterans., Design, Setting, and Participants: In this longitudinal cohort study, US veterans were followed up (January 1, 2016, to December 31, 2019) for a median of 4 years. Data, including self-reported race and ethnicity, were obtained from Veterans Affairs medical centers across the US on individuals receiving care for established atherosclerotic disease (coronary artery disease, peripheral vascular disease, or stroke). Data analysis was performed in June 2022., Exposure: Home Owners' Loan Corporation grade of the census tracts of residence., Main Outcomes and Measures: The first occurrence of major adverse cardiovascular events (MACE), comprising myocardial infarction, stroke, major adverse extremity events, and all-cause mortality. The adjusted association between HOLC grade and adverse outcomes was measured using Cox proportional hazards regression. Competing risks were used to model individual nonfatal components of MACE., Results: Of 79 997 patients (mean [SD] age, 74.46 [10.16] years, female, 2.9%; White, 55.7%; Black, 37.3%; and Hispanic, 5.4%), a total of 7% of the individuals resided in HOLC grade A neighborhoods, 20% in B neighborhoods, 42% in C neighborhoods, and 31% in D neighborhoods. Compared with grade A neighborhoods, patients residing in HOLC grade D (redlined) neighborhoods were more likely to be Black or Hispanic with a higher prevalence of diabetes, heart failure, and chronic kidney disease. There were no associations between HOLC and MACE in unadjusted models. After adjustment for demographic factors, compared with grade A neighborhoods, those residing in redlined neighborhoods had an increased risk of MACE (hazard ratio [HR], 1.139; 95% CI, 1.083-1.198; P < .001) and all-cause mortality (HR, 1.129; 95% CI, 1.072-1.190; P < .001). Similarly, veterans residing in redlined neighborhoods had a higher risk of myocardial infarction (HR, 1.148; 95% CI, 1.011-1.303; P < .001) but not stroke (HR, 0.889; 95% CI, 0.584-1.353; P = .58). Hazard ratios were smaller, but remained significant, after adjustment for risk factors and social vulnerability., Conclusions and Relevance: In this cohort study of US veterans, the findings suggest that those with atherosclerotic cardiovascular disease who reside in historically redlined neighborhoods continue to have a higher prevalence of traditional cardiovascular risk factors and higher cardiovascular risk. Even close to a century after this practice was discontinued, redlining appears to still be adversely associated with adverse cardiovascular events.

Competing Interests: No funding was received for this work.

Objective: During a transcatheter aortic valve implant (TAVI) procedure, intraprocedural complications that are manageable only by conversion to emergency open-heart surgery (E-OHS) occasionally occur. Contemporary data on the incidence and outcome of TAVI patients undergoing E-OHS are scarce. This study aimed to evaluate early and midterm outcomes following E-OHS of patients undergoing TAVI in a large tertiary care centre with immediate surgical backup availability for all TAVI procedures over a 15-year period., Methods: Data from all patients undergoing transfemoral TAVI between 2006 and 2020 at the Heart Centre Leipzig were analysed. The study time was divided into 3 periods: 2006-2010 (P1), 2011-2015 (P2) and 2016-2020 (P3). Patients were grouped according to their surgical risk (high risk: EuroSCORE II ≥ 6%; low/intermediate risk: EuroSCORE II <6%). Primary outcomes were intraprocedural and in-hospital death and 1-year survival., Results: During the study period, a total of 6903 patients underwent transfemoral TAVI. Among them, 74 (1.1%) required E-OHS [high risk, n = 66 (89.2%); low/intermediate risk, n = 8 (10.8%)]. The rate of patients requiring E-OHS was 3.5% (20/577 patients), 1.8% (35/1967 patients) and 0.4% (19/4359 patients) in study periods P1 to P3, respectively (P < 0.001). The proportion of patients who had E-OHS who were low/intermediate risk increased considerably over time (P1:0%; P28.6%; P3:26.3%; P = 0.077). Intraprocedural deaths occurred in 10 patients (13.5%), all of whom were high-risk. In-hospital mortality was 62.1% in high-risk patients and 12.5% in low/intermediate risk patients (P = 0.007). One-year survival was 37.8% in all patients undergoing E-OHS, 31.8% in high-risk patients and 87.5% in low/intermediate risk patients (log-rank P = 0.002)., Conclusions: In-hospital and 1-year survival rates following E-OHS are higher in low/intermediate risk than in high-risk patients undergoing TAVI. An on-site cardiac surgical department with immediately available E-OHS capabilities is an important component of the TAVI team., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Residents living in a "food desert" are known to be at a higher risk for developing cardiovascular disease (CVD). However, national-level data regarding the influence of residing in a food desert in patients with established CVD is lacking. Data from veterans with established atherosclerotic CVD who received outpatient care in the Veterans Health Administration system between January 2016 and December 2021 were obtained, with follow-up information collected until May 2022 (median follow-up: 4.3 years). A food desert was defined using the United States Department of Agriculture criteria, and census tract data were used to identify Veterans in these areas. All-cause mortality and the occurrence of major adverse cardiovascular events (MACEs; a composite of myocardial infarction/stroke/heart failure/all-cause mortality) were evaluated as the co-primary end points. The relative risk for MACE in food desert areas was evaluated by fitting multivariable Cox models adjusted for age, gender, race, ethnicity, and median household income, with food desert status as the primary exposure. Of the 1,640,346 patients (mean age 72 years, women 2.7%, White 77.7%, Hispanic 3.4%), 25,7814 (15.7%) belonged to the food desert group. Patients residing in food deserts were younger; more likely to be Black (22% vs 13%)or Hispanic (4% vs 3.5%); and had a higher prevalence of diabetes mellitus (52.7% vs 49.8%), chronic kidney disease (31.8% vs 30.4%,) and heart failure (25.6% vs 23.8%). Adjusted for covariates, food desert patients had a higher risk of MACE (hazard ratio 1.040 [1.033 to 1.047]; p <0.001) and all-cause mortality (hazard ratio 1.032 [1.024 to 1.039]; p <0.001). In conclusion, we observed that a large proportion of US veterans with established atherosclerotic CVD reside in food desert census tracts. Adjusting for age, gender, race, and ethnicity, residing in food deserts was associated with a higher risk of adverse cardiac events and all-cause mortality., Competing Interests: Disclosures The authors have no conflicts of interest to declare., (Published by Elsevier Inc.)

Open access journals (OAJ) in biomedicine are promoted to improve the reach and distribution of global health research (GHR). However, in the last 20 years, article publishing charge (APC) is attracting and publishing the vast majority of papers from high-income countries (HIC) in "oncology" journals under OAJ. This paper outlines the impediments for cancer research and publication from low-and middle-income countries (LMIC): (a) existing disparities in cancer care facilities and survival outcomes between HIC and LMIC, (b) more than 70 % of OAJ in 'oncology' subject levy APC, becoming unaffordable for scientists and clinicians from LMIC, (c) impactful OAJ in oncology engage less than 10 % of members from LMIC in editorial board or as peer reviewer, whereas two-third of cancer diagnosis and management occur in these countries. Peer review serves the editors by recommending the relevant papers. Thus, peer reviewers from developing countries working for the OAJs in "oncology" can increase the diversity in publication, improving the GHR in cancer management. The cancer research and clinical trials which can bring to notice the challenges and hurdles faced by researchers, clinicians and cancer patients in LMIC will be served to some measure by engaging peer reviewers from those countries who understand the ecosystem., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Effective lipid lowering is essential in patients with peripheral arterial disease (PAD) and cerebrovascular disease (CeVD). Proprotein convertase subtilsin/kexin type 9 inhibitors (PCSK9i) efficiently lower low-density lipoprotein (LDL) levels; however, use in PAD and CeVD patients is limited. Therefore, our aim was to evaluate the use of PCSK9i among US Veterans and compare rates between patients with PAD, CeVD, and coronary artery disease (CAD)., Methods: We evaluated PCSK9i initiation (2016-2019) in US Veterans with CAD, PAD, or CeVD treated at 124 Veterans Affairs (VA) hospitals. We fit a hierarchical logistic regression model to evaluate the association of the patient's primary diagnosis, baseline low-density lipoprotein cholesterol (LDL-C) levels, socioeconomic indicators, and the Department of Veterans Affairs medical center enrollment with PCSK9i initiation., Results: Of 519,566 patients with atherosclerotic vascular disease, 337,766 (65%), 79,926 (15%) and 101,874 (20%) had CAD, PAD, and CeVD, respectively. Among 2115/519,566 (0.4%) initiated on PCSK9i therapy, 84.3% had CAD, while only 7.2% and 8.5% had PAD and CeVD, respectively. Compared with CAD patients, PAD {odds ratio [OR] 0.50 (0.36-0.70)} and CeVD [OR 0.24 (0.15-0.37)] patients were less likely to receive PCSK9i. Relative to under $40K per year, PCSK9i initiation was higher if earning $40,000-$80,000 [OR 1.13 (1.01-1.27)] or > $80,000 [OR 1.41 (1.14-1.75)]. Even moderate community deprivation [OR 0.87 (0.77-0.97)] was associated with lower PCSK9i therapy., Conclusions: Adjusted for LDL-C levels, PAD and CeVD patients are much less likely to receive PCSK9i therapy. Despite low co-pay, PCSK9i initiation rates among US veterans, nationwide, is low, with household income and community deprivation appearing to predict PCSK9i use., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Neighborhood walkability may be associated with increased physical activity and thus may confer protection against cardiovascular disease and associated risk factors. We sought to characterize the association between neighborhood-level cardiovascular diseases and risk factors with neighborhood walkability across US census tracts.We linked the Centers for Disease Control and Prevention (CDC) PLACES dataset which provided census-tract level prevalence of coronary artery disease (CAD) and cardiovascular risk factors (hypertension, high cholesterol, obesity, and diabetes), with census tract population-weighted national walkability index (NWI) from the US Environmental Protection Agency (EPA). We calculated the mean prevalence of each cardiovascular health indicator per quartile of the walkability score. We also fit a multivariable linear regression model to estimate the association between walkability index and the prevalence of CAD adjusting for age, sex, race, and the CDC'S social vulnerability index, an integrated metric of socioeconomic position. We additionally performed mediation analyses to understand the mediating effects of CAD risk factors on the relationship between NWI and CAD prevalence. A total of 70,123 census tracts were analyzed nationwide. Across walkability quartiles Q1 (least walkable) through Q4 (most walkable), we found statistically significant decrease in the prevalence of CAD (7.0% to 5.4%), and risk factors including hypertension (35.5% to 29.7%), high cholesterol (34.5% to 29.2%), obesity (35.0% to 30.2%), and diabetes (11.6% to 10.6%). After multivariable adjustment, continuous walkability index was negatively and significantly associated with the prevalence of CAD (β = -0.09, P<0.0001). The relationship between NWI and CAD is partially mediated by the risk factors. High cholesterol accounted for 45%, high blood pressure 41% and diabetes 10% of the total effect of walkability on CAD. While direct relationship between walkability and CAD accounted for 9% of the total effect. This nationwide analysis demonstrates that neighborhood walkability is associated with a lower prevalence of cardiovascular risk factors and CAD. The association between NWI and CAD seems to be partly mediated by prevalence of traditional risk factors., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Fine particulate matter (PM 2.5 ) promotes atherosclerosis progression and plaque vulnerability. Consequently, patients with a high atherosclerotic burden may be at especially increased risk when exposed to air pollution., Objectives: The purpose of this study was to examine the relationship between chronic ambient PM 2.5 exposure and adverse outcomes after percutaneous coronary interventions (PCI)., Methods: Baseline clinical and procedural data from U.S. veterans undergoing elective PCI (2005-2018) were linked to annual ambient PM 2.5 exposure. The association between PM 2.5 exposure and major adverse cardiovascular events (MACEs) (myocardial infarction, stroke, or all-cause mortality) was determined using time-varying Cox regression models. Using flexible parametric models, we also evaluated the average life months lost for specific PM 2.5 levels over the 15-year period., Results: In the 73,425 veterans that underwent an elective PCI, the mean annual PM 2.5 exposure was 8.4 ± 1.8 μg/m 3 (median follow-up 6.75 years). The incidence of MACE was 28%, 48%, and 65% at 5, 10, and 15 years, respectively. In adjusted models, each 1-μg/m 3 increase in PM 2.5 exposure was associated with an 8.7% (95% CI: 8.4%-8.9%; P  < 0.001) increase in MACE. Compared to patients exposed to 5 μg/m 3 , those exposed to 10 μg/m 3 lost 1.1, 3.8, and 7.6 months of life at 5, 10, and 15 years of exposure, respectively., Conclusions: Veterans undergoing elective PCI are at increased risk of MACE and significant life years lost with long-term exposure to fine particulate matter pollution, even at the current low levels in the United States. These findings emphasize the need for improved air quality standards and patient interventions to better protect vulnerable populations., Competing Interests: This work was partly funded by the 10.13039/100006545National Institute on Minority Health and Health Disparities Award #P50MD017351. The authors have reported that they have no relationships relevant to the contents of this article to disclose., (© 2023 The Authors.)