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There has been an increase in the use of smokeless tobacco recently. Whether smokeless tobacco use may predispose individuals to use other addictive substances is unknown. The use of multiple addictive substances may compound an individual's adverse health effects.In a cross-sectional analysis, we used the 2016-2017 Behavioral Risk Factor Surveillance System (BRFSS) survey database to identify all individuals who reported the use of smokeless tobacco and extracted data regarding baseline and demographic patterns, as well as information regarding the use of other addictive substances. Weighted multivariable logistic regression models adjusting for age, gender, race/ethnicity, poverty level, education, employment status, and marital status were used to determine the odds ratios (ORs) for use of alcohol, cigarettes, e-cigarettes, and marijuana among smokeless tobacco users.We identified 30,395 (3.38%) individuals in our study population who reported smokeless tobacco use. Compared with non-users, smokeless tobacco users were more likely to be unmarried, male, Caucasian, belonging to the lower socioeconomic strata, and did not have a formal college education (P0.01). In multivariable analyses, smokeless tobacco use was associated with a higher likelihood of cigarettes use (OR: 1.76 [95% confidence interval {CI}: 1.66-1.86, P0.01]), e-cigarette use (OR: 1.61 [95% CI: 1.52-1.71, P0.01]), and heavy alcohol consumption (OR:2.36 [95% CI: 2.17-2.56, P0.01]) but not marijuana use (OR: 1.11 [95% CI: 0.90-1.38, P = 0.33]).In a large, nationally representative sample, smokeless tobacco use was associated with the increased use of cigarettes, e-cigarettes, and alcohol. Simultaneous use of these substances may compound the adverse health effects of smokeless tobacco use. Public health interventions addressing this concerning trend are warranted.

Ty J. Gluckman, MD, FACC, Chair Niti R. Aggarwal, MD, FACC Nicole M. Bhave, MD, FACC Gregory J. Dehmer, MD, MACC Olivia N. Gilbert, MD, MSc, FACC Chayakrit Krittanawong, MD Dharam J. Kumbhani, MD, SM, FACC Andrea L. Price, CPHQ, RCIS, AACC Javier A. Sala-Mercado, MD, PhD David E.

Engagement in healthy lifestyle behaviors is suboptimal. The vast majority of the US population does not meet current recommendations. A healthy lifestyle is defined by consuming a healthy dietary pattern, engaging in regular physical activity, avoiding exposure to tobacco products, habitually attaining adequate amounts of sleep, and managing stress levels. For all these health behaviors there are well-established guidelines; however, promotion in clinical settings can be challenging. It is critical to overcome these challenges because greater promotion of heathy lifestyle practices in clinical settings effectively motivates and initiates patient behavior change. The 5A Model (assess, advise, agree, assist, and arrange) was developed to provide a framework for clinical counseling with requisite attention to the demands of clinical settings. In this science advisory, we present strategies, based on the 5A Model, that clinicians and other health care professionals can use for efficient lifestyle-related behavior change counseling in patients at all levels of cardiovascular disease risk at every visit. In addition, we discuss the underlying role of psychological health and well-being in lifestyle-related behavior change counseling, and how clinicians can leverage health technologies when providing brief patient-centered counseling. Greater attention to healthy lifestyle behaviors during routine clinician visits will contribute to promoting cardiovascular health.

At a population level, engagement in healthy lifestyle behaviors is suboptimal in the United States. Moreover, marked disparities exist in healthy lifestyle behaviors and cardiovascular risk factors as a result of social determinants of health. In addition, there are specific challenges to engaging in healthy lifestyle behaviors related to age, developmental stage, or major life circumstances. Key components of a healthy lifestyle are consuming a healthy dietary pattern, engaging in regular physical activity, avoiding use of tobacco products, habitually attaining adequate sleep, and managing stress. For these health behaviors, there are guidelines and recommendations; however, promotion in clinical settings can be challenging, particularly in certain population groups. These challenges must be overcome to facilitate greater promotion of healthy lifestyle practices in clinical settings. The 5A Model (assess, advise, agree, assist, and arrange) was developed to provide a framework for clinical counseling with consideration for the demands of clinical settings. In this science advisory, we summarize specific considerations for lifestyle-related behavior change counseling using the 5A Model for patients across the life span. In all life stages, social determinants of health and unmet social-related health needs, as well as overweight and obesity, are associated with increased risk of cardiovascular disease, and there is the potential to modify this risk with lifestyle-related behavior changes. In addition, specific considerations for lifestyle-related behavior change counseling in life stages in which lifestyle behaviors significantly affect cardiovascular disease risk are outlined. Greater attention to healthy lifestyle behaviors during every clinician visit will contribute to improved cardiovascular health.

Key Points Question What is the accuracy of low-density lipoprotein cholesterol (LDL-C) estimation when comparing the Friedewald, extended Martin/Hopkins, and Sampson equations with LDL-C measured through ultracentrifugation at triglyceride levels of 400 to 799 mg/dL? Findings In this cross-sectional study of 111 939 patients, across all individual guideline LDL-C classes from, Importance Low-density lipoprotein cholesterol (LDL-C) is typically estimated with the Friedewald or Martin/Hopkins equation; however, if triglyceride levels are 400 mg/dL or greater, laboratories reflexively perform direct LDL-C (dLDL-C) measurement. The use of direct chemical LDL-C assays and estimation of LDL-C via the National Institutes of Health Sampson equation are not well validated, and data on the accuracy of LDL-C estimation at higher triglyceride levels are limited. Objective To compare an extended Martin/Hopkins equation for triglyceride values of 400 to 799 mg/dL with the Friedewald and Sampson equations. Design, Setting, and Participants This cross-sectional study evaluated consecutive patients at clinical sites across the US with patient lipid distributions representative of the US population in the Very Large Database of Lipids from January 1, 2006, to December 31, 2015, with triglyceride levels of 400 to 799 mg/dL. Data analysis was performed from November 9, 2020, to March 23, 2021. Main Outcomes and Measures Accuracy in LDL-C classification according to guideline-based categories and absolute errors between estimated LDL-C and dLDL-C levels. Patients were randomly assigned 2:1 to derivation and validation data sets. Levels of dLDL-C were measured by vertical spin-density gradient ultracentrifugation. The LDL-C levels were estimated using the Friedewald method, with a fixed ratio of triglycerides to very low-density lipoprotein cholesterol (VLDL-C ratio of 5:1), extended Martin/Hopkins equation with a flexible ratio, and Sampson equation with VLDL-C estimation by multiple least-squares regression. Results A total of 111 939 patients (mean [SD] age, 52 [13] years; 65.0% male) with triglyceride levels of 400 to 799 mg/dL were included, representing 2.2% of 5 081 680 patients in the database. Across all individual guideline LDL-C classes (, This cross-sectional study of patients with lipid distributions representative of the US population compares the accuracy of 3 low-density lipoprotein level estimation methods with triglyceride levels of 400 to 799 mg/dL.

Although significant progress has been made to reduce the global burden of cardiovascular disease, efforts have focused primarily on treatment of manifest disease rather than on prevention of events. An enormous opportunity exists to transition focus from intervention to providing equal attention to prevention of cardiovascular disease. The nascent specialty of "preventive cardiology" is emerging from the background of long-established services such as lipid, diabetes, hypertension, and general cardiology clinics. It is incumbent on the cardiology community to invest in cardiovascular prevention because past gains are threatened with the rising tide of obesity and diabetes. Now is the time to establish a dedicated preventive cardiology subspecialty to train the clinicians of the future. This American College of Cardiology Council Perspective aims to define the need for preventive cardiology as a unique subspecialty, broaches controversies, provides a structure for future training and education, and identifies possible paths forward to professional certification.

Ty J. Gluckman, MD, FACC, Chair Niti R. Aggarwal, MD, FACC Nicole Martin Bhave, MD, FACC Gregory J. Dehmer, MD, MACC Olivia N. Gilbert, MD, MSc, FACC Dharam J. Kumbhani, MD, SM, FACC Andrea L. Price, MS, CPHQ, RCIS, AACC David E. Winchester, MD, FACC Martha Gulati, MD, MD, FACC—Ex Officio

Ty J. Gluckman, MD, FACC, Chair Niti R. Aggarwal, MD, FACC Nicole Martin Bhave, MD, FACC Gregory J. Dehmer, MD, MACC Olivia N. Gilbert, MD, MSc, FACC Dharam J. Kumbhani, MD, SM, FACC Andrea L. Price , MS, CPHQ, RCIS, AACC David E. Winchester, MD, FACC Martha Gulati, MD, MD, FACC–Ex

James L. Januzzi, Jr, MD, FACC, Chair Tariq Ahmad, MD, MPH, FACC Brendan Everett, MD, FACC William Hucker, MD, PHD Dharam J. Kumbhani, MD, SM, FACC Joseph E. Marine, MD, FACC Pamela B. Morris, MD, FACC Robert N. Piana, MD, FACC Sunil V. Rao, MD, FACC Marielle Scherrer-Crosbie, MD, PhD

James L. Januzzi Jr, MD, FACC, Chair Tariq Ahmad, MD, MPH, FACC Brendan Everett, MD, FACC William Hucker, MD, PhD Dharam J. Kumbhani, MD, SM, FACC Joseph E. Marine, MD, FACC Pamela B. Morris, MD, FACC Robert N. Piana, MD, FACC Sunil V. Rao, MD, FACC Marielle Scherrer-Crosbie, MD, PhD

Despite dramatic declines in total cardiovascular disease (CVD) mortality among women in the USA, CVD remains the #1 killer of women, causing almost one out of three female deaths in 2016. Hypercholesterolemia is causal in the development of coronary atherosclerosis and incident atherosclerotic cardiovascular disease (ASCVD) events in women, as it is in men. Statins lower atherogenic lipoproteins to a similar degree in both sexes. Meta-analyses demonstrate that women and men at similar risk of major vascular events achieve similar proportional and absolute benefits from statin therapy, even in primary prevention and among individuals at low baseline risk. The evidence for prevention of ASCVD in women with the use of non-statin drugs is limited as no large randomized controlled trials have been adequately powered to evaluate sex differences in response to non-statin therapies. However, current guidelines for the use of non-statin therapies for management of dyslipidemia for women are the same as those for men. Clinically significant adverse drug effects and self-reported drug allergies have been reported to occur more frequently among women than men for a number of drug classes, and clinicians should be aware of potential sex differences in adverse events. There are important considerations in management of dyslipidemia in women across the lifespan, particularly during conception, pregnancy, and lactation.

The potential cardiovascular (CV) benefits of many trending foods and dietary patterns are still incompletely understood, and scientific inquiry continues to evolve. In the meantime, howeve...

for the 2017 Focused Update to the 2016 Expert Consensus Decision Pathway In 2016, the American College of Cardiology published the first expert consensus decision pathway (ECDP) on the role of non-statin therapies for low-density lipoprotein (LDL)–cholesterol lowering in the management of atherosclerotic cardiovascular disease (ASCVD) risk. Since the publication of that document, additional evidence and perspectives have emerged from randomized clinical trials and other sources, particularly considering the longer-term efficacy and safety of proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors in secondary prevention of ASCVD. Most notably, the FOURIER (Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk) trial and SPIRE-1 and -2 (Studies of PCSK9 Inhibition and the Reduction of Vascular Events), assessing evolocumab and bococizumab, respectively, have published final results of cardiovascular outcomes trials in patients with clinical ASCVD and in a smaller number of high-risk primary prevention patients. In addition, further evidence on the types of patients most likely to benefit from the use of ezetimibe in addition to statin therapy after acute coronary syndrome has been published. Based on results from these important analyses, the ECDP writing committee judged that it would be desirable to provide a focused update to help guide clinicians more clearly on decision making regarding the use of ezetimibe and PCSK9 inhibitors in patients with clinical ASCVD with or without comorbidities. In the following summary table, changes from the 2016 ECDP to the 2017 ECDP Focused Update are highlighted, and a brief rationale is provided. The content of the full document has been changed accordingly, with more extensive and detailed guidance regarding decision making provided both in the text and in the updated algorithms. Revised recommendations are provided for patients with clinical ASCVD with or without comorbidities on statin therapy for secondary prevention. The ECDP writing committee judged that these new data did not warrant changes to the decision pathways and algorithms regarding the use of ezetimibe or PCSK9 inhibitors in primary prevention patients with LDL-C

The purpose of the current study is to investigate whether breast cancer survivors after radiation therapy have a higher burden of coronary artery calcium as a potential surrogate of radiation-induced accelerated coronary artery disease. 333 patients were included. 54 patients underwent chest CT ae 6 months after the start of radiation therapy (radiation therapy group), while 279 patients had a CT scan either prior to or without undergoing radiation therapy (RT). Coronary artery calcium was quantified from CT by applying a threshold-based automated algorithm. Mean age at diagnosis was similar (p = 0.771) between RT (57.4 +/- 13.1 years) and NoRT (58.0 +/- 11.9 years). Median time between radiation therapy and CT was 2 years. The groups showed no significant differences in race, smoking history, cancer laterality, or cancer stage. 39 (72.2%) of RT patients had a coronary artery calcium score of 0, compared to 201 (72.0%) in patients without radiation therapy. Median coronary artery calcium burden for both groups was not significantly different (p = 0.982), nor when comparing patients who underwent left- versus right-sided radiation therapy (p = 0.453). When adjusting for the time between diagnosis and CT, radiation therapy patients had a significantly lower risk of a positive coronary artery calcium score. In conclusion, breast cancer survivors after radiation therapy are not more likely to show coronary artery calcium on follow-up CT imaging. Our results thus do not support radiation-induced accelerated coronary artery disease as an explanation for higher rates of heart disease in this group.

The measurement of cholesterol and triglycerides as indicators of metabolic disorders and most particularly of vascular disease risk has been of growing importance to physicians and epidemiologists over the past century. This was refocused on the lipoproteins, the specific packages in blood that carry these lipids, by John Gofman, MD, PhD, and Don Fredrickson, MD, more than 50 years ago. We continue to learn about the metabolism of these large molecular structures and their relationship to arteriosclerosis as new genetic and interventional studies are published. The clinical laboratory has evolved to provide more focused information with measures that can help us assess risk and target our therapy more effectively. In this roundtable discussion, I had the opportunity to talk with physicians who consider lipoprotein management to be central features of their practice every day. They personally care for patients with metabolic disorders in which the lipoproteins have caused disease or are predicted to do so. They are well-versed on the way that science is leading us in our field. I believe that you will learn from their view of current needs regarding lipoprotein measures and the changes that may derive from ongoing scientific studies in our field.

The potential cardiovascular benefits of several trending foods and dietary patterns are still incompletely understood, and nutritional science continues to evolve. However, in the meantime, a number of controversial dietary patterns, foods, and nutrients have received significant media exposure and are mired by hype. This review addresses some of the more popular foods and dietary patterns that are promoted for cardiovascular health to provide clinicians with accurate information for patient discussions in the clinical setting.

Although significant progress has been made to reduce the global burden of cardiovascular disease, efforts have focused primarily on treatment of manifest disease rather than on prevention of events. An enormous opportunity exists to transition focus from intervention to providing equal attention to prevention of cardiovascular disease. The nascent specialty of "preventive cardiology" is emerging from the background of long-established services such as lipid, diabetes, hypertension, and general cardiology clinics. It is incumbent on the cardiology community to invest in cardiovascular prevention because past gains are threatened with the rising tide of obesity and diabetes. Now is the time to establish a dedicated preventive cardiology subspecialty to train the clinicians of the future. This American College of Cardiology Council Perspective aims to define the need for preventive cardiology as a unique subspecialty, broaches controversies, provides a structure for future training and education, and identifies possible paths forward to professional certification.

Background: Maternal pregnancy complications, particularly preeclampsia and gestational diabetes mellitus, are described to increase the risk for subsequent coronary artery disease (CAD). In addition, black women are at higher risk for CAD. The objective of this study was to compare the prevalence and extent of CAD as detected by coronary computed tomographic angiography (CCTA) in black women with and without a history of prior pregnancy complications. Methods: We retrospectively evaluated patient characteristics and CCTA findings in groups of black women with a prior history of preterm delivery (n=154), preeclampsia (n=137), or gestational diabetes mellitus (n=148), and a matched control group of black women who gave birth without such complications (n=445). Univariate and multivariate analyses were performed to assess risk factors of CAD. Results: All groups with prior pregnancy complications showed higher rates of any (≥20% luminal narrowing) and obstructive (≥50% luminal narrowing) CAD (preterm delivery: 29.2% and 9.1%; preeclampsia: 29.2% and 7.3%; and gestational diabetes mellitus: 47.3% and 15.5%) compared with control women (23.8% and 5.4%). After accounting for confounding factors at multivariate analysis, gestational diabetes mellitus remained a strong risk factor of any (odds ratio, 3.26; 95% CI, 2.03–5.22; P P Conclusions: Black women with a history of pregnancy complications, particularly gestational diabetes mellitus, have a higher prevalence of CAD on CCTA while only a history of gestational diabetes mellitus was independently associated with any and obstructive CAD on CCTA.

The 2018 American Heart Association/American College of Cardiology Multisociety Cholesterol Guidelines [(1)][1] recommend risk stratification among patients with atherosclerotic cardiovascular disease (ASCVD) to identify “very high-risk ASCVD patients.” These patients have characteristics

The roundtable discussion in this issue will focus on the problems faced by young women with lipid disorders. This is often the source of confusion for the patient and physician because the myth continues that young women do not have complications of atherosclerosis as a result of elevated blood cholesterol. The essential role of women in bearing children during the early years of adulthood also produces difficult decisions because the mother and fetus are usually experiencing similar exposure to therapeutic regimens. We are joined in this discussion by Drs. Pamela Morris of the Medical University of South Carolina and Robert Wild of the University of Oklahoma Health Sciences Center. Dr Morris is an Internist, and Dr Wild is an Obstetrician and Gynecologist. Both are board certified in clinical lipidology and are actively publishing in this field. We have recorded this roundtable discussion during the National Lipid Association Scientific Sessions held in New Orleans during May 2016.

James L. Januzzi, Jr, MD, FACC, Chair Luis C. Afonso, MBBS, FACC Anthony Bavry, MD, FACC Brendan M. Everett, MD, FACC Jonathan Halperin, MD, FACC Adrian Hernandez, MD, FACC Hani Jneid, MD, FACC Dharam J. Kumbhani, MD, SM, FACC Eva M. Lonn, MD, FACC James K. Min, MD, FACC Pamela B. Morris

In the FOURIER trial (Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk),1 treatment with evolocumab resulted in a 15% relative (1.5% absolute) risk reduction of major cardiovascular events in patients with atherosclerotic cardiovascular disease (ASCVD) at a median follow-up of 2.2 years. This trial included patients with low-density lipoprotein cholesterol (LDL-C) ≥70 mg/dL or non–high-density lipoprotein cholesterol ≥100 mg/dL on at least moderate-intensity statins. It is not known what proportion of patients with ASCVD would qualify for evolocumab on the basis of FOURIER entry criteria and how eligibility would change if maximal doses of evidence-based lipid-lowering therapies were required. We assessed the number and proportion of US veterans with ASCVD who would qualify for evolocumab on the basis of FOURIER trial entry criteria and how these figures would change if high-intensity statins, ezetimibe, or the combination of both agents were used. Using a cohort of veterans with ASCVD (myocardial infarction, ischemic stroke, or peripheral arterial disease) receiving care in the Veterans Affairs (VA) system between October 2013 and September 2014, we identified all patients with ASCVD 40 to 85 years of age (n=631 855) using previously described algorithms with a positive predictive value of 88% in correctly identifying patients with ASCVD.2 We identified patients meeting 1 major or 2 minor FOURIER protocol criteria and excluded patients with LDL-C 400 mg/dL, and those meeting other FOURIER exclusions.1 Among patients meeting FOURIER inclusion and exclusion criteria, we determined proportions receiving moderate-intensity statins (30%–

Background: Patients with low-density lipoprotein cholesterol (LDL-C) ≥190 mg/dL are at high risk of atherosclerotic cardiovascular disease events. Treatment guidelines recommend intensive treatment in these patients. Variation in the use of lipid-lowering therapies (LLTs) in these patients in a national sample of cardiology practices is not known. Methods and Results: Using data from the American College of Cardiology National Cardiovascular Data Registry–Practice Innovation and Clinical Excellence registry, we assessed the proportion of patients with LDL-C ≥190 mg/dL (n=49 447) receiving statin, high-intensity statin, LLT associated with ≥50% LDL-C lowering, ezetimibe, or a PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitor between January 2013 and December 2016. We assessed practice-level rates and variation in LLT use using median rate ratio (MRR) adjusted for patient and practice characteristics. MRRs represent the likelihood that 2 random practices would differ in treatment of identical patients with LDL-C ≥190 mg/dL. The proportion of patients receiving a statin, high-intensity statin, LLT associated with ≥50% LDL-C reduction, ezetimibe, or PCSK9 inhibitor were 58.5%, 31.9%, 34.6%, 8.5%, and 1.5%, respectively. Median practice-level rates and adjusted MRR for statin (56% [interquartile range, 47.3%–64.8%]; MRR, 1.20 [95% confidence interval [CI], 1.17–1.23]), high-intensity statin (30.2% [interquartile range, 12.1%–41.1%]; MRR, 2.31 [95% CI, 2.12–2.51]), LLT with ≥50% LDL-C lowering (31.8% [interquartile range, 15.3%–45.5%]; MRR, 2.12 [95% CI, 1.95–2.28]), ezetimibe (5.8% [interquartile range, 2.8%–9.8%]; MRR, 2.42 [95% CI, 2.21–2.63]), and PCSK9 inhibitors (0.16% [interquartile range, 0%–1.9%]; MRR, 2.38 [95% CI, 2.04–2.72]) indicated significant gaps and >200% variation in receipt of several of these medications for patients across practices. Among those without concomitant atherosclerotic cardiovascular disease, even larger treatment gaps were noted (proportion of patients on a statin, high-intensity statin, LLT with ≥50% LDL-C reduction, ezetimibe, or PCSK9 inhibitor were 50.8%, 25.25%, 26.8%, 4.9%, and 0.74%, respectively). Conclusions: Evidence-based LLT use remains low among patients with elevated LDL-C with significant variation in care. System-level interventions are needed to address these gaps and reduce variation in care of these high-risk patients.

The 2013 American College of Cardiology/American Heart Association cholesterol guideline recommends moderate to high-intensity statin therapy in patients with peripheral artery disease (PAD) and ischemic cerebrovascular disease (ICVD). We examined frequency and facility-level variation in any statin prescription and in guideline-concordant statin prescriptions in patients with PAD and ICVD receiving primary care in 130 facilities across the Veterans Affairs (VA) health care system between October 2013 and September 2014. Guideline-concordant statin intensity was defined as the prescription of high-intensity statins in patients with PAD or ICVD ≤75 years and at least moderate-intensity statins in those >75 years. We calculated median rate ratios (MRR) after adjusting for patient demographic factors to assess the magnitude of facility-level variation in statin prescribing patterns independent of patient characteristics. Among 194,151 PAD patients, 153,438 patients (79.0%) were prescribed any statin and 79,435 (40.9%) were prescribed a guideline-concordant intensity of statin. PAD patients without ischemic heart disease were prescribed any statin and a guideline-concordant intensity of statin therapy less frequently (69.1% and 28.9%, respectively). Among 339,771 ICVD patients, 265,491 (78.1%) were prescribed any statin and 136,430 (40.2%) were prescribed a guideline-concordant intensity of statin. ICVD patients without ischemic heart disease were prescribed any statin and a guideline-concordant intensity of statin less frequently (70.9% and 30.5%, respectively). MRRs for both PAD and ICVD patients demonstrated a 20% and 28% variation among two facilities in treating two identical patients with statin therapy and guideline-concordant intensity of statin therapy, respectively. The prescription of statins, especially guideline-recommended intensity of statin therapy, is suboptimal in PAD and ICVD patients, with significant facility-level variation not explained by patient-level factors.

The potential cardiovascular (CV) benefits of many trending foods and dietary patterns are still incompletely understood, and scientific inquiry continues to evolve. In the meantime, however, a number of controversial dietary patterns, foods, and nutrients have received significant media attention and are mired by "hype." This second review addresses some of the more recent popular foods and dietary patterns that are recommended for CV health to provide clinicians with current information for patient discussions in the clinical setting. Specifically, this paper delves into dairy products, added sugars, legumes, coffee, tea, alcoholic beverages, energy drinks, mushrooms, fermented foods, seaweed, plant and marine-derived omega-3-fatty acids, and vitamin B12.

Objective: Accumulating data on predominantly Caucasian women suggests an association between breast arterial calcification (BAC) and coronary artery disease (CAD). We sought to comprehensively examine the correlation between mammographic BAC and CAD endpoints detected by cardiac computed tomography (CCT) in African American (AA) women.Methods: Consecutive AA women who underwent digital screening mammography and CCT were identified. In blinded fashion, mammographic and CCT studies were reviewed. Patient-related pertinent covariates were assessed.Results: Two-hundred-four AA women (median age, 52.5 years) were included. BAC was present in 42 women (20.6%). BAC was significantly associated with coronary artery calcium score >100 (odds ratio [OR], 7.66; 95% confidence interval [CI], 2.75-21.29; P 50% (OR, 5.48; CI, 1.97-15.23; P = 0.001) by CCT.Conclusion: In AA women, BAC is associated with increased probability of coronary calcification, atherosclerosis, and CAD on CCT. (C) 2015 Elsevier Ireland Ltd. All rights reserved.

Cardiovascular morbidity and mortality as a result of inhaled tobacco products continues to be a global healthcare crisis, particularly in low- and middle-income nations lacking the infrastructure to develop and implement effective public health policies limiting tobacco use. Following initiation of public awareness campaigns 50 years ago in the United States, considerable success has been achieved in reducing the prevalence of cigarette smoking and exposure to secondhand smoke. However, there has been a slowing of cessation rates in the United States during recent years, possibly caused by high residual addiction or fatigue from cessation messaging. Furthermore, tobacco products have continued to evolve faster than the scientific understanding of their biological effects. This review considers selected updates on the genetics and epigenetics of smoking behavior and associated cardiovascular risk, mechanisms of atherogenesis and thrombosis, clinical effects of smoking and benefits of cessation, and potential impact of electronic cigarettes on cardiovascular health.

In 2016, the American College of Cardiology published the first expert consensus decision pathway (ECDP) on the role of non-statin therapies for low-density lipoprotein (LDL)-cholesterol lowering in the management of atherosclerotic cardiovascular disease (ASCVD) risk. Since the publication of that document, additional evidence and perspectives have emerged from randomized clinical trials and other sources, particularly considering the longer-term efficacy and safety of proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors in secondary prevention of ASCVD. Most notably, the FOURIER (Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk) trial and SPIRE-1 and -2 (Studies of PCSK9 Inhibition and the Reduction of Vascular Events), assessing evolocumab and bococizumab, respectively, have published final results of cardiovascular outcomes trials in patients with clinical ASCVD and in a smaller number of high-risk primary prevention patients. In addition, further evidence on the types of patients most likely to benefit from the use of ezetimibe in addition to statin therapy after acute coronary syndrome has been published. Based on results from these important analyses, the ECDP writing committee judged that it would be desirable to provide a focused update to help guide clinicians more clearly on decision making regarding the use of ezetimibe and PCSK9 inhibitors in patients with clinical ASCVD with or without comorbidities. In the following summary table, changes from the 2016 ECDP to the 2017 ECDP Focused Update are highlighted, and a brief rationale is provided. The content of the full document has been changed accordingly, with more extensive and detailed guidance regarding decision making provided both in the text and in the updated algorithms. Revised recommendations are provided for patients with clinical ASCVD with or without comorbidities on statin therapy for secondary prevention. The ECDP writing committee judged that these new data did not warrant changes to the decision pathways and algorithms regarding the use of ezetimibe or PCSK9 inhibitors in primary prevention patients with LDL-C 190 mg/dL with or without diabetes mellitus or patients without ASCVD and LDL-C ≥190 mg/dL not due to secondary causes. Based on feedback and further deliberation, the ECDP writing committee down-graded recommendations regarding bile acid sequestrant use, recommending bile acid sequestrants only as optional secondary agents for consideration in patients intolerant to ezetimibe. For clarification, the writing committee has also included new information on diagnostic categories of heterozygous and homozygous familial hypercholesterolemia, based on clinical criteria with and without genetic testing. Other changes to the original document were kept to a minimum to provide consistent guidance to clinicians, unless there was a compelling reason or new evidence, in which case justification is provided.

The measurement of cholesterol and triglycerides as indicators of metabolic disorders and most particularly of vascular disease risk has been of growing importance to physicians and epidemiologists over the past century. This was refocused on the lipoproteins, the specific packages in blood that carry these lipids, by John Gofman, MD, PhD, and Don Fredrickson, MD, more than 50 years ago. We continue to learn about the metabolism of these large molecular structures and their relationship to arteriosclerosis as new genetic and interventional studies are published. The clinical laboratory has evolved to provide more focused information with measures that can help us assess risk and target our therapy more effectively. In this roundtable discussion, I had the opportunity to talk with physicians who consider lipoprotein management to be central features of their practice every day. They personally care for patients with metabolic disorders in which the lipoproteins have caused disease or are predicted to do so. They are well-versed on the way that science is leading us in our field. I believe that you will learn from their view of current needs regarding lipoprotein measures and the changes that may derive from ongoing scientific studies in our field.

Morbidity and mortality from peripheral arterial disease (PAD) continues to increase. Traditional cardiovascular risk factors are implicated in the development of PAD, yet the extent to which those risk factors correlate with mortality in such patients remains insufficiently assessed. Using data from the 1999 to 2004 National Health and Nutrition Examination Survey, Cox proportional hazards models were used to examine the association of cardiovascular risk factors and all-cause and cardiovascular mortality. A total of 647 individuals ≥40 years old with PAD (i.e., ankle-brachial index [ABI] ≤ 0.9) were followed for a median of 7.8 years. There were 336 deaths, of which 98 were attributable to cardiovascular disease. Compared with never smokers, current (hazard ratio [HR] 2.45, 95% confidence interval [CI] 1.62 to 3.71) and former (HR 1.62, 95% CI 1.14 to 2.29) smokers with PAD had higher rates of death. Moderate or vigorous physical activity of ≥10 minutes monthly was associated with lower death rates (HR 0.63, 95% CI 0.44 to 0.91). Also associated with increased rates of cardiovascular death were an ABI of0.5 (HR 2.56, 95% CI 1.28 to 5.15, compared with those with an ABI of 0.7 to 0.9) and diabetes mellitus (HR 2.50, 95% CI 1.33 to 4.73). Neither C-reactive protein nor body mass index was associated with mortality. In conclusion, tobacco use increased the risk of all-cause and cardiovascular death, whereas physical activity was associated with a decreased mortality risk. A low ABI and diabetes were also predictive of cardiovascular death.

Background: The 2013 ACC/AHA cholesterol guideline recommends high-intensity statin therapy in patients 75 or younger and moderate-intensity statins in patients > 75 years with atherosclerotic cardiovascular disease including those with ischemic cerebrovascular disease (ICVD). Statin prescribing patterns and their facility-level variation in patients with ICVD are unknown. Methods: We examined the frequency and facility-level variation in the use of any and correct intensity statins in patients with ICVD (ischemic stroke or carotid arterial disease) who received primary care in 130 facilities across the Veterans Affairs (VA) health care system with or without concomitant ischemic heart disease (IHD) or peripheral artery disease (PAD). We then calculated median rate ratios (MRR) adjusted for patient demographic factors to assess the magnitude of facility-level variation in statin prescribing patterns for comparable patients. Results: Among 339,771 ICVD patients, 182,231 (53.6%) had ICVD without IHD (with or without PAD) and 163,730 (48.2%) had ICVD without IHD or PAD. Rates of statin use in the entire ICVD group, patients with ICVD without IHD, and ICVD alone were 78.1%, 70.9% and 69.9%, respectively. Median facility-level rates of any statin use were 78.1% (IQR 75.5-80.7), 70.7% (67.9-73.8) and 69.9% (66.9-73.1), respectively. Correct intensity statins were prescribed among 40.2% of the entire ICVD group, 30.5% with ICVD without IHD, and 29.6% with ICVD alone. Median facility-level rate of correct statin use in all ICVD patients was 39.1% (35.8-43.9), 29.9% (26.0-34.6) for patients with ICVD without IHD and 29.0% (25.4-33.7) in those with ICVD alone.Calculated MRRs reflect approximately 22% variation among two facilities treating two identical ICVD patients with statin therapy and a 27-28% variation in identical ICVD patients for correct statin intensity (Table). Conclusions: The use of statin and especially guideline-recommended statin intensity is suboptimal in ICVD patients, especially patients without concomitant IHD or PAD. There is significant facility-level variation in receipt of guideline directed statin therapy in ICVD patients. Interventions are needed to improve guideline directed moderate to high-intensity statin use and reduce variation in care in this high risk group.

Cardiovascular mortality remains high due to insufficient progress made in managing cardiovascular risk factors such as diabetes mellitus, physical inactivity, and smoking. Healthy lifestyle choices play an important role in the management of these modifiable risk factors. Mobile health or mHealth is defined as the use of mobile computing and communication technologies (i.e., mobile phones, wearable sensors) for the delivery of health services and health-related information. In this review, we examine some recent studies that utilized mHealth tools to improve management of these risk factors, with examples from developing countries where available. The mHealth intervention used depends on the availability of resources. While developing countries are often restricted to text messages, more resourceful settings are shifting towards mobile phone applications and wearable technology. Diabetes mellitus has been extensively studied in different settings, and results have been encouraging. Tools utilized to increase physical activity are expensive, and studies have been limited to resource-abundant areas and have shown mixed results. Smoking cessation has had promising initial results with the use of technology, but mHealth’s ability to recruit participants beyond those actively seeking to quit has not been established. mHealth interventions appear to be a potential tool in improving control of cardiovascular risk factors that rely on individuals making healthy lifestyle choices. Data related to clinical impact, if any, of commercially available tools is lacking. More studies are needed to assess interventions that target multiple cardiovascular risk factors and their impact on hard cardiovascular outcomes.

Background: The 2013 ACC/AHA cholesterol guideline recommends high-intensity statin therapy in patients 75 years or younger and moderate-intensity statin therapy in patients > 75 years with atherosclerotic cardiovascular disease including those with peripheral artery disease (PAD). Statin prescribing patterns and their facility-level variation in patients with PAD are unknown. Methods: We examined the frequency and facility-level variation in the use of any and correct intensity of statins in patients with known PAD receiving primary care in 130 facilities across the Veterans Affairs (VA) health care system with or without concomitant ischemic heart disease (IHD) or ischemic cerebrovascular disease (ICVD). We calculated the median rate ratios (MRR) adjusted for patient demographic factors to assess the magnitude of facility-level variation in statin prescribing patterns for comparable patients. Results: Among 194,151 patients with PAD, 88,905 (45.8%) had PAD without IHD (with or without ICVD) and 70,404 (36.3%) had PAD without IHD or ICVD. Rates of statin use in the entire PAD cohort, patients with PAD without IHD and PAD alone were 79.0%, 69.1% and 66.3%, respectively. Median facility-level rates of statin use were 78.9% (IQR 75.9-81.5), 69.2% (65.4-72.6) and 66.4% (62.6-70.1), respectively. Correct intensity statins were prescribed among 40.9% for the entire PAD cohort, 28.9% of those with PAD without IHD, and 26.4% of those with PAD alone. Median facility-level rate of correct statin intensity use in all PAD patients was 40.1% (36.4-44.2), 27.8% (24.1-32.4) for patients with PAD without IHD and 25.3% (10.8-29.7) in patients with PAD alone. Calculated MRRs reflected a 20-22% variation among two facilities in treating identical PAD patients with statin therapy and a 24-28% variation in treating identical patients with correct statin intensity (Table). Conclusions: The use of statin and especially correct statin intensity is suboptimal in PAD patients, especially in PAD patients without concomitant IHD or ICVD. There is a significant facility-level variation in the receipt of guideline directed statin therapy in PAD patients. Interventions are needed to improve guideline directed moderate to high-intensity statin use and to reduce variation in care in this high-risk group.

Hypertension and hyperlipidemia represent two major risk factors for atherosclerotic cardiovascular disease. Mobile health or mHealth is defined as the use of mobile phone and wireless technologies to support the achievement of health objectives. Management of hypertension, and to some extent hyperlipidemia, has often employed mHealth interventions given lower cost and greater patient engagement compared to traditional methods. These interventions include the use of text messaging, wireless devices, and mobile phone applications. This review considers recent studies evaluating the effectiveness of mHealth interventions in the management of hypertension and hyperlipidemia. Numerous studies have evaluated the role of mHealth interventions in the management of hypertension, while very few have evaluated their role in hyperlipidemia. Text messaging has been used most frequently. However, the trend is shifting towards the use of mobile phone applications and wireless devices. Interventions in developing countries have been modified for greater applicability to local settings. mHealth interventions were found to be frequently effective. However, studies comparing the relative efficacy of various mHealth strategies are scarce. Long-term cardiovascular outcomes data and analyses relating to cost effectiveness are also lacking. mHealth interventions may be effective in improving hypertension management. More studies are needed to evaluate the role of mHealth strategies in hyperlipidemia management, particularly in identifying high-risk individuals and improving medication adherence. Studies assessing the long-term impact of these interventions, comparing different interventions and analyzing their relative cost effectiveness, are also needed. Following recently published guidelines on reporting results of mHealth interventions will provide a more meaningful context for interpreting these promising early studies.

Transient ischemic dilation (TID) in the setting of abnormal stress–rest cardiac SPECT myocardial perfusion imaging (MPI) has been linked with increased cardiovascular risk. However, the significance of TID in the setting of an otherwise normal SPECT MPI study has not been clearly established. In this study, cardiac CT was used to evaluate the prevalence of atherosclerotic lesions and the severity of coronary artery stenosis in patients with TID of the left ventricle with or without associated myocardial perfusion defects on SPECT MPI. Methods: The study population consisted of 1,553 consecutive patients who had undergone both cardiac CT and SPECT MPI within 1 mo between January 1, 2006, and September 1, 2011. Patients included in the study group had a pathologic TID value defined as ≥1.18 for men and ≥1.22 for women. Coronary CT angiography was used to evaluate each coronary segment for the presence and composition of atherosclerotic plaque and the degree of coronary stenosis. TID-positive patients were compared with a 2:1 risk-factor-matched-pair control cohort without TID. Results: TID was identified in 30 patients who were compared with TID-negative risk-factor-matched controls (n = 60). When compared with the TID-negative control cohort, TID-positive patients had no significant differences in the presence and extent of atherosclerosis, the degree of coronary artery stenosis, or the calcium score at cardiac CT. Similarly, there were no significant differences in these CT measures in TID-positive patients with a normal perfusion study (n = 20) when compared with TID-negative patients with a normal perfusion study (n = 48). In addition, there was no significant difference in the incidence of major adverse cardiac events when comparing both the TID-positive patients and the TID-negative control cohort and when comparing patients who were TID-positive with normal perfusion with patients who were TID-negative with normal perfusion. Conclusion: The presence of TID with an otherwise normal SPECT MPI study does not translate into a greater extent of coronary artery disease as assessed by cardiac CT or increased risk for future major adverse cardiac events.