10-Year Resource Utilization and Costs for Cardiovascular Care

Association of longitudinal trajectories of fasting plasma glucose with all-cause and cardiovascular mortality among a Chinese older population: a retrospective cohort study

The association between fasting plasma glucose (FPG), an important indicator of overall glycemic status, and the risk of cardiovascular mortality has been well investigated. The longitudinal study can repeatedly collect measured results for the variables to be studied and then consider the potential effects of intraindividual changes in measurement. This study aimed to identify long-term FPG trajectories and investigate the association between trajectory groups and cardiovascular and all-cause mortality. A latent class growth mixture modeling (LCGMM) was used to identify FPG trajectories. Cox proportional hazard models were used to estimate associations between FPG trajectories and the risk of all-cause and cardiovascular mortality. A U-shaped relationship between FPG and all-cause and cardiovascular mortality was observed in the restricted cubic spline regression models. Two FPG longitudinal trajectories of low-level (mean FPG = 5.12mmol/L) and high-level (mean FPG = 6.74mmol/L) were identified by LCGMM. After being adjusted for potential confounders, compared with the low-level category, the hazard ratios (HRs) for all-cause and cardiovascular mortality were 1.23(1.16-1.30) and 1.25(1.16-1.35), respectively, for the high-level group. Long-term FPG trajectories are significantly associated with and potentially impact the risk of all-cause and cardiovascular mortality.

Associations of trajectories in body roundness index with incident cardiovascular disease: a prospective cohort study in rural China

Aims

The body roundness index (BRI) has good predictive ability for both body fat and visceral adipose tissue. Longitudinal BRI trajectories can reveal the potential dynamic patterns of change over time. This prospective study assessed potential associations between BRI trajectories and incident cardiovascular disease (CVD) in rural regions of Northeast China.

Methods

In total, 13,209 participants (mean age: 49.0 ± 10.3 years, 6,856 [51.9%] male) were enrolled with three repeated times of BRI measurements at baseline (2004-2006), 2008, and 2010, and followed up until 2017 in this prospective study. Using latent mixture model, the BRI trajectories were determined based on the data from baseline, 2008 and 2010. Composite CVD events (myocardial infarction, stroke, and CVD death combined) was the primary endpoint. Cox proportional-hazards models were used to analyze the longitudinal associations between BRI trajectories and incident CVD.

Results

Three distinct BRI trajectories were identified: high-stable (n = 538), moderate-stable (n = 1,542), and low-stable (n = 11,129). In total, 1,382 CVD events were recorded during follow-up. After adjustment for confounders, the moderate-stable and high-stable BRI groups had a higher CVD risk than did the low-stable BRI group, and the HR (95%CI) were 1.346 (1.154, 1.571) and 1.751 (1.398, 2.194), respectively. Similar associations were observed between the trajectories of BRI and the risk of stroke and CVD death. The high-stable group was also significantly and independently associated with CVD, myocardial infarction, stroke, and CVD death in participants aged <50 years.

Conclusion

BRI trajectory was positively associated with incident CVD, providing a novel possibility for the primary prevention of CVD in rural regions of China.

Habitual physical activity minimizes healthcare costs resulting from comorbidities among adults with cardiovascular diseases

BACKGROUND

Habitual physical activity (HPA) can be used as a non-pharmacological strategy to prevent and control chronic diseases, as well as playing a role in minimizing healthcare costs.

OBJECTIVE

To verify the impact of HPA on healthcare costs at different levels of care, over 24 months, in an adult population with cardiovascular diseases (CVD), including individuals with or without comorbidities.

METHODS

Two-hundred and seventy-eight adults with CVD, aged between 30 and 65 years, participated in the study. Information on healthcare costs was obtained from medical records and included primary, secondary, and tertiary levels. Comorbidities such as diabetes, dyslipidemia, arterial hypertension, and obesity were registered. HPA was measured using the Baecke questionnaire. Comparisons between groups were performed using Student's t (

RESULTS

The presence of comorbidities increased healthcare costs (p<0.05). HPA provided savings ranging from US$ 22.5/24 months to US$ 63.9/24 months with primary healthcare services, regardless of the presence of comorbidities.

CONCLUSION

Considering adults with CVD, HPA significantly minimizes healthcare costs in the primary care in Brazil, even in the presence of comorbidities, such as diabetes, dyslipidemia, arterial hypertension, and obesity.

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Key Words

• Brazilian national health system
• Exercise
• Obesity
• Primary health care

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MESH Headings

• Adult
• Humans
• Middle Aged
• Aged
• Cardiovascular Diseases/epidemiology
• Health Care Costs
• Obesity
• Hypertension
• Diabetes Mellitus
• Exercise
• Dyslipidemias

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Affiliation(s)

Monique Yndawe Castanho Araujo Post-graduation Program in Movement Sciences, Universidade Estadual Paulista (UNESP), Presidente Prudente, São Paulo, Brazil; Group of Studies in Health, Physical Activity, and Economy (GESAFE), Universidade Estadual Paulista (UNESP), Presidente Prudente, São Paulo, Brazil.
Eduardo Kokubun Post-graduation Program in Movement Sciences, Universidade Estadual Paulista (UNESP), Rio Claro, São Paulo, Brazil
Maria Carolina Castanho Saes Norberto Post-graduation Program in Movement Sciences, Universidade Estadual Paulista (UNESP), Presidente Prudente, São Paulo, Brazil; Group of Studies in Health, Physical Activity, and Economy (GESAFE), Universidade Estadual Paulista (UNESP), Presidente Prudente, São Paulo, Brazil
André Lucas Servo Bento Group of Studies in Health, Physical Activity, and Economy (GESAFE), Universidade Estadual Paulista (UNESP), Presidente Prudente, São Paulo, Brazil
Bruna Camilo Turi-Lynch Department of Physical Education and Exercise Science, Lander University, Greenwood, South Carolina, USA
Jamile Sanches Codogno Post-graduation Program in Movement Sciences, Universidade Estadual Paulista (UNESP), Presidente Prudente, São Paulo, Brazil; Group of Studies in Health, Physical Activity, and Economy (GESAFE), Universidade Estadual Paulista (UNESP), Presidente Prudente, São Paulo, Brazil

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Lifetime healthcare expenses across demographic and cardiovascular risk groups: The application of a novel modeling strategy in a large multiethnic cohort study

Objective

To understand the burden of healthcare expenses over the lifetime of individuals and evaluate differences among those with cardiovascular risk factors and among disadvantaged groups based on race/ethnicity and sex.

Methods

We linked data from the longitudinal multiethnic Dallas Heart Study, which recruited participants between 2000 and 2002, with inpatient and outpatient claims from all hospitals in the Dallas-Fort Worth metroplex through December 2018, capturing encounter expenses. Race/ethnicity and sex, as well as five risk factors, hypertension, diabetes, hyperlipidemia, smoking, and overweight/obesity, were defined at cohort enrollment. For each individual, expenses were indexed to age and cumulated between 40 and 80 years of age. Lifetime expenses across exposures were evaluated as interactions in generalized additive models.

Results

A total of 2184 individuals (mean age, 45±10 years; 61% women, 53% Black) were followed between 2000 and 2018. The mean modeled lifetime cumulative healthcare expenses were $442,629 (IQR, $423,850 to $461,408). In models that included 5 risk factors, Black individuals had $21,306 higher lifetime healthcare spending compared with non-Black individuals (P < .001), and men had modestly higher expenses than women ($5987, P < .001). Across demographic groups, the presence of risk factors was associated with progressively higher lifetime expenses, with significant independent association of diabetes ($28,075, P < .001), overweight/obesity ($8816, P < .001), smoking ($3980, P = .009), and hypertension ($528, P = .02) with excess spending.

Conclusion

Our study suggests Black individuals have higher lifetime healthcare expenses, exaggerated by the substantially higher prevalence of risk factors, with differences emerging in older age.

Comorbidities do not mitigate the effect of habitual physical activity on the reduction of healthcare costs among adults with cardiovascular diseases: A mediation analysis

BACKGROUND

Habitual Physical activity (HPA) is a non-pharmacological strategy to prevent and control chronic diseases, and it plays an important role in minimizing healthcare costs.

OBJECTIVES

This study aimed to investigate the relationship between HPA and healthcare costs from the perspective of the Brazilian National Healthcare System, and to establish the mediating role of comorbidities in this relationship among patients with cardiovascular diseases (CVD).

DESIGN AND SETTING

This longitudinal study was conducted in a medium-sized Brazilian city and included 278 participants assisted by the Brazilian National Healthcare System.

METHODS

Information on healthcare costs were obtained from medical records and included primary, secondary, and tertiary levels. Comorbidities (diabetes, dyslipidemia, and arterial hypertension) were self-reported, and obesity was confirmed with the percentage of body fat. HPA was measured using a questionnaire (Baecke questionnaire). Face-to-face interviews provided information on sex, age, and education level. Statistical analysis included linear regression and Structural Equation Modeling, significance was set at 5 % and the Stata software (version 16.0) was used to perform the analysis.

RESULTS

The sample included 278 adults with a mean age of 54.49 (8.32) years. For each score of HPA, there was a reduction in healthcare costs of US$ 83.99/_{24 months} (95 % CI: - 159.15; - 8.84), and the sum of comorbidities did not mediate this relationship.

CONCLUSION

It is concluded that healthcare costs seem to be affected by HPA among patients with CVD, while this phenomenon seems not to be mediated by the sum of comorbidities.

Association of body roundness index and its trajectories with all-cause and cardiovascular mortality among a Chinese middle-aged and older population: A retrospective cohort study

Objectives

The body roundness index (BRI) is a novel anthropometric index that is a better indicator for predicting fat distribution than the body mass index (BMI). The longitudinal study can repeatedly collect measured results for the variables to be studied and then consider the potential effects of intraindividual changes in measurement. However, few population-based, longitudinal studies of BRI have been conducted, especially among the Chinese population. The study aimed to investigate the association of BRI and its longitudinal trajectories with all-cause and cardiovascular mortality.

Methods

A total of 71,166 participants with four times BRI measurements between January 2010 and December 2019 were included in this longitudinal study, with a median follow-up was 7.93 years, and 11,538 deaths were recorded, of which 5,892 deaths were due to cardiovascular disease (CVD). A latent class growth mixture modeling (LCGMM) was used to identify BRI trajectories. Cox proportional hazard models were used to estimate associations between BRI trajectories and the risk of all-cause and cardiovascular mortality.

Results

In the restricted cubic spline regression models, a U-shaped relationship between BRI and all-cause and cardiovascular mortality was observed. Three BRI longitudinal trajectories of low-stable (mean BRI = 2.59), moderate-stable (mean BRI = 3.30), and high-stable (mean BRI = 3.65) were identified by LCGMM. After being adjusted for potential confounders, the HRs for all-cause mortality were 1.18 (1.13-1.24) for the moderate-stable group and 1.74 (1.66-1.82) for the high-stable group compared to the low-stable group. The HRs for cardiovascular mortality were 1.12 (1.05-1.18) for the moderate-stable group and 1.64 (1.53-1.75) for the high-stable group compared to the low-stable group.

Conclusion

A nonlinear association of BRI with all-cause and cardiovascular mortality was observed, and participants in the higher BRI longitudinal trajectory group were significantly associated with an increased risk of all-cause and cardiovascular mortality.

Pharmacokinetic Study and Metabolite Identification of 1-(3'-bromophenyl)-heliamine in Rats

Tetrahydroisoquinolines have been widely investigated for the treatment of arrhythmias. 1-(3'-bromophenyl)-heliamine (BH), an anti-arrhythmias agent, is a synthetic tetrahydroisoquinoline. This study focuses on the pharmacokinetic characterization of BH, as well as the identification of its metabolites, both in vitro and in vivo. A UHPLC-MS/MS method was developed and validated to quantify BH in rat plasma with a linear range of 1-1000 ng/mL. The validated method was applied to a pharmacokinetic study in rats. The maximum concentration C_max (568.65 ± 122.14 ng/mL) reached 1.00 ± 0.45 h after oral administration. The main metabolic pathways appeared to be phase-I of demethylation, dehydrogenation, and epoxidation, and phase II of glucuronide and sulfate metabolites. Finally, a total of 18 metabolites were characterized, including 10 phase I metabolites and 8 phase II metabolites. Through the above studies, we have gained a better understanding of the absorption and metabolism of BH in vitro and in vivo, which will provide us with guidance for future in-depth studies on this compound.

Improvements and Maintenance of Clinical and Functional Measures Among Rural Women: Strong Hearts, Healthy Communities-2. 0 Cluster Randomized Trial

BACKGROUND

Cardiovascular disease is the leading cause of death in the United States; however, women and rural residents face notable health disparities compared with male and urban counterparts. Community-engaged programs hold promise to help address disparities through health behavior change and maintenance, the latter of which is critical to achieving clinical improvements and public health impact.

METHODS

A cluster-randomized controlled trial of Strong Hearts, Healthy Communities-2.0 conducted in medically underserved rural communities examined health outcomes and maintenance among women aged ≥40 years, who had a body mass index >30 or body mass index 25 to 30 and also sedentary. The multilevel intervention provided 24 weeks of twice-weekly classes with strength training, aerobic exercise, and skill-based nutrition education (individual and social levels), and civic engagement components related to healthy food and physical activity environments (community, environment, and policy levels). The primary outcome was change in weight; additional clinical and functional fitness measures were secondary outcomes. Mixed linear models were used to compare between-group changes at intervention end (24 weeks); subgroup analyses among women aged ≥60 years were also conducted. Following a 24-week no-contact period, data were collected among intervention participants only to evaluate maintenance.

RESULTS

Five communities were randomized to the intervention and 6 to the control (87 and 95 women, respectively). Significant improvements were observed for intervention versus controls in body weight (mean difference: -3.15 kg [95% CI, -4.98 to -1.32]; P=0.008) and several secondary clinical (eg, waist circumference: -3.02 cm [-5.31 to -0.73], P=0.010; systolic blood pressure: -6.64 mmHg [-12.67 to -0.62], P=0.031; percent body fat: -2.32% [-3.40 to -1.24]; P<0.001) and functional fitness outcomes; results were similar for women aged ≥60 years. The within-group analysis strongly suggests maintenance or further improvement in outcomes at 48 weeks.

CONCLUSIONS

This cardiovascular disease prevention intervention demonstrated significant, clinically meaningful improvements and maintenance among rural, at-risk older women.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03059472.

Assessment of Prices for Cardiovascular Tests and Procedures at Top-Ranked US Hospitals

This cross-sectional study describes variation in prices for common cardiovascular tests and procedures, both between and within top-ranked US hospitals.

Experiences of unexplained chest pain and physical activity: A Meta-Ethnography

AIMS AND OBJECTIVES

The aim was to examine the experiences of physical activity in the patients with unexplained chest pain.

BACKGROUND

Previous qualitative studies have compiled data on the physical activity experiences of people with unexplained chest pain. Nevertheless, no meta-synthesis exists on this topic to advance the theoretical development of future-related studies.

DESIGN

A meta-ethnographic synthesis of qualitative studies was conducted. Original qualitative studies on the physical activity experiences of people with unexplained chest pain were identified and systematically synthesised using a meta-ethnographic approach.

METHODS

Seven databases were searched for relevant full-text articles in English, Danish, Norwegian and Swedish. There were no limitations concerning year of publication. Articles were first screened against inclusion criteria for eligibility and then assessed for quality and analysed using Noblit and Hare's seven-step meta-ethnography process. The ENTREQ checklist for systematic reviews was used.

RESULTS

Nine qualitative studies were included in the analysis. The physical activity experiences of people with unexplained chest pain illuminates the metaphor: "Physical activity means balancing uncertainty" with four themes: looking for possible explanations, feeling vulnerable, feeling uncertain of consequences and being physically active may mean becoming more capable.

CONCLUSION

For people with unexplained chest pain, being physically active meant moving toward being more capable. The participants felt vulnerable and physical activity helped in balancing uncertainty. A comprehensive model illustrates the antecedents and succedent for the physical activity experiences of individuals with unexplained chest pains.

RELEVANCE TO CLINICAL PRACTICE

An approach to care which considers the patient's experience might be applicable; however, it needs to be accompanied with a biomedical perspective. Nurses and other health professionals need to provide a bridge between the patient's experiences and health professionals' advice and recommendations.

Effect of No-Charge Coronary Artery Calcium Scoring on Cardiovascular Prevention

Prevention of cardiovascular disease is currently guided by probabilistic risk scores that may misclassify individual risk and commit many middle-aged patients to prolonged pharmacotherapy. The coronary artery calcium (CAC) score, although endorsed for intermediate-risk patients, is not widely adopted because of barriers in reimbursement. The impact of removing cost barrier on cardiovascular outcomes in real-world settings is not known. Within the University Hospitals Health System (Cleveland, Ohio), CAC was offered to patients with at least 1 cardiovascular risk factor at low charge between 2014 and 2017 ($99) and no charge from January 1, 2018 onward. CAC use and access, patient characteristics, reclassification of risk compared with the pooled cohort equations (PCEs) for atherosclerotic vascular disease, statin use, changes in parameters of cardiometabolic health, downstream cardiovascular testing, downstream coronary revascularization, and cardiovascular outcomes were evaluated. A total of 52,151 patients underwent CAC testing over the study period. Median 10-year PCE for atherosclerotic vascular disease, in the entire cohort was 8.3% (4.0% to 15.9%). Among patients with PCE >20%, 21% had CAC <100, whereas 37% of those with PCE <7.5% had CAC ≥100. Among patients who were not on statin before CAC testing, 1-year statin prescription was 24% and was significantly associated with higher CAC scores. Total cholesterol, low-density lipoprotein cholesterol, and triglycerides all decreased significantly 1-year after CAC, and the degree of decrease was strongly linked with CAC scores. One year after CAC, 14% underwent noninvasive ischemic evaluation, 1.4% underwent invasive coronary angiography, and 0.9% underwent revascularization. The majority (74%) of revascularization procedures occurred in patients with CAC >400. In conclusion, reducing or removing the cost burden of CAC leads to significant test uptake by patients, which is followed by reclassification of statin eligibility, increases in the use of preventive medications, and improvement in risk factors, with very low rates of invasive downstream testing.

Associations of longitudinal trajectories in body roundness index with mortality and cardiovascular outcomes: a cohort study

BACKGROUND

The body roundness index (BRI) is a new anthropometric index that combines height and waist circumference to predict the percentages of total and regional fat. The longitudinal trajectories of BRI can reflect the long-term pattern of BRI changes; however, their effects on the incidence of cardiovascular disease (CVD) and mortality are poorly characterized.

OBJECTIVES

Our aim was to identify BRI trajectories and to estimate their associations with mortality and incident CVD events.

METHODS

This study included a total of 59,278 participants (mean age, 54.8 years) free of malignant tumors and CVD and with repeated measurements of BRI from 2006 to 2012. The BRI trajectories from 2006 to 2012 were identified using the latent mixture model. A Cox proportional hazards model was used to analyze the associations between BRI trajectories and the risk of CVD events and mortality.

RESULTS

We grouped the BRI trajectories into 4 distinct groups during 2006-2012: low-stable (mean BRI = 2.7), moderate-stable (mean BRI = 3.7), moderate-high-stable (mean BRI = 4.7), and high-stable (mean BRI = 5.8). We identified 1928 CVD events and 2928 deaths during the follow-up. After adjustment for potential confounders, compared with the low-stable group, the HRs of CVD were 1.37 (95% CI: 1.19-1.58) for the moderate-stable group, 1.64 (95% CI: 1.40-1.91) for the moderate-high-stable group, and 2.03 (95% CI: 1.64-2.52) for the high-stable group. We observed similar associations for myocardial infarction and ischemic stroke. The association between BRI trajectories and CVD was more prominent in subjects aged <55 years.

CONCLUSIONS

BRI trajectories were significantly associated with the risk of CVD, and the association was more evident in younger adults.

A functional variant of the long noncoding RNA AL110200 is associated with the risk of ischaemic stroke recurrence

BACKGROUND AND PURPOSE

This study aimed to test the hypothesis that long noncoding RNA (lncRNA) AL110200 exerts a proinflammatory effect on atherosclerosis and that the variant rs901681 contributes to ischaemic stroke incidence and recurrence.

METHODS

The expression of AL110200 was analyzed in THP-1 cells treated with oxidized low-density lipoprotein and in human peripheral blood in a coronary heart disease and control population to determine the role of AL110200 in atherosclerosis. The effect of AL110200 on cell adhesion and invasion was tested. The plasma level of leukotriene B4 and rs901681 genotype distribution were assessed in 220 participants. In 1004 ischaemic stroke patients and 1434 controls, the association between rs901681 and stroke incidence was analyzed by logistic regression, and the association of rs901681 and stroke prognosis was analyzed using Kaplan-Meier analysis and the Cox proportional hazards model.

RESULTS

Increased expression of AL110200 was observed in THP-1 cells under oxidized low-density lipoprotein treatment. Knockdown of AL110200 reduced the adhesive and invasive ability of THP-1 cells. AL110200 expression in peripheral blood was significantly higher in the coronary heart disease group than in the controls. The GG genotype of rs901681 is associated with reduced plasma leukotriene B4. In the ischaemic stroke population, rs901681 was not associated with ischaemic stroke incidence (p = 0.686). Patients carrying rs901681 GG had a lower risk for stroke recurrence at age ≥60 years (p = 0.001), cardiovascular stroke death (p = 0.022) and all-cause mortality (p = 0.034) in the all-age group.

CONCLUSIONS

AL110200 might exert a proinflammatory effect on atherosclerosis, and the variant rs901681 might be a strong predictor of stroke prognosis in ischaemic stroke patients.

Effect of Implementation of HEART Chest Pain Protocol on Emergency Department Disposition, Testing and Cost

BACKGROUND

Symptoms concerning for acute coronary syndromes (ACS) such as chest pain and dyspnea are some of the most common reasons for presenting to an emergency department (ED). The HEART score (history, electrocardiogram, age, risk factors and troponin) was developed and has been externally validated in an emergency setting to determine which patients with chest pain are at increased risk for poor outcomes. Our hospital adopted a HEART score-based protocol in late 2015 to facilitate the management and disposition of these patients. In this study we aimed to analyze the effects of the adoption of this protocol. Prior studies have included only patients with chest pain. We included both patients with chest pain and patients with only atypical symptoms.

METHODS

This was a retrospective chart review of two cohorts. We identified ED charts from six-month periods prior to and after adoption of our HEART score-based protocol. Patients in whom an electrocardiogram and troponin were ordered were eligible for inclusion. We analyzed data for patients with typical symptoms (chest pain) and atypical symptoms both together and separately.

RESULTS

We identified 1546 charts in the pre-adoption cohort and 1623 in the post-adoption cohort that met criteria. We analyzed the first 900 charts in each group. Discharges from the ED increased (odds ratio [OR[1.56, P<.001), and admissions for cardiac workup decreased (OR 0.46, P <.001). ED length of stay was 17 minutes shorter (P = .01). Stress testing decreased (OR 0.47, P<.001). We estimate a cost savings for our hospital system of over $4.5 million annually. There was no significant difference in inpatient length of stay or catheterization rate. When analyzing typical and atypical patients separately, these results held true.

CONCLUSION

After adoption of a HEART score-based protocol, discharges from the ED increased with a corresponding decrease in admissions for cardiac evaluations as well as cost. These effects were similar in patients presenting without chest pain but with presentations concerning for ACS.

SALAD-BAAR: A numerical risk score for hospital admission or emergency department presentation in ambulatory patients with cardiovascular disease

BACKGROUND

While many interventions to reduce hospital admissions and emergency department (ED) visits for patients with cardiovascular disease have been developed, identifying ambulatory cardiac patients at high risk for admission can be challenging.

HYPOTHESIS

A computational model based on readily accessible clinical data can identify patients at risk for admission.

METHODS

Electronic health record (EHR) data from a tertiary referral center were used to generate decision tree and logistic regression models. International Classification of Disease (ICD) codes, labs, admissions, medications, vital signs, and socioenvironmental variables were used to model risk for ED presentation or hospital admission within 90 days following a cardiology clinic visit. Model training and testing were performed with a 70:30 data split. The final model was then prospectively validated.

RESULTS

A total of 9326 patients and 46 465 clinic visits were analyzed. A decision tree model using 75 patient characteristics achieved an area under the curve (AUC) of 0.75 and a logistic regression model achieved an AUC of 0.73. A simplified 9-feature model based on logistic regression odds ratios achieved an AUC of 0.72. A further simplified numerical score assigning 1 or 2 points to each variable achieved an AUC of 0.66, specificity of 0.75, and sensitivity of 0.58. Prospectively, this final model maintained its predictive performance (AUC 0.63-0.60).

CONCLUSION

Nine patient characteristics from routine EHR data can be used to inform a highly specific model for hospital admission or ED presentation in cardiac patients. This model can be simplified to a risk score that is easily calculated and retains predictive performance.

Cardiovascular Biomarkers and Imaging in Older Adults: JACC Council Perspectives

Whereas the burgeoning population of older adults is intrinsically vulnerable to cardiovascular disease, the utility of many management precepts that were validated in younger adults is often unclear. Whereas biomarker- and imaging-based tests are a major part of cardiovascular disease care, basic assumptions about their use and efficacy cannot be simply extrapolated to many older adults. Biology, physiology, and body composition change with aging, with important influences on cardiovascular disease testing procedures and their interpretation. Furthermore, clinical priorities of older adults are more heterogeneous, potentially undercutting the utility of testing data that are collected. The American College of Cardiology and the National Institutes on Aging, in collaboration with the American Geriatrics Society, convened, at the American College of Cardiology Heart House, a 2-day multidisciplinary workshop, "Diagnostic Testing in Older Adults with Cardiovascular Disease," to address these issues. This review summarizes key concepts, clinical limitations, and important opportunities for research.

Trends in Utilization and Cost of Low-Density Lipoprotein Cholesterol-Lowering Therapies Among Medicare Beneficiaries: An Analysis From the Medicare Part D Database

Importance

Low-density lipoprotein cholesterol (LDL-C)-lowering therapies are a cornerstone of prevention in atherosclerotic cardiovascular disease. With the introduction of generic formulations and the release of new therapies, including proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, contemporary Medicare utilization of these therapies remains unknown.

Objective

To determine trends in utilization and spending on brand-name and generic LDL-C-lowering therapies and to estimate potential savings if all Medicare beneficiaries were switched to available therapeutically equivalent generic formulations.

Design, Setting, and Participants

This cross-sectional study analyzed prescription drug utilization and cost trend data from the Medicare Part D Prescription Drug Event data set from 2014 to 2018 for LDL-C-lowering therapies. A total of 11 LDL-C-lowering drugs with 25 formulations, including 16 brand-name and 9 generic formulations, were included. Data were collected and analyzed from October 2019 to June 2020.

Main Outcomes and Measures

Number of Medicare Part D beneficiaries, annual spending, and spending per beneficiary for all formulations.

Results

The total number of Medicare Part D beneficiaries ranged from 37 720 840 in 2014 to 44 249 461 in 2018. The number of Medicare beneficiaries taking LDL-C-lowering therapies increased by 23% (from 20.5 million in 2014 to 25.2 million in 2018), while the associated Medicare expenditure decreased by 46% (from $6.3 billion in 2014 to $3.3 billion in 2018). Lower expenditure was driven by greater uptake of generic statin and ezetimibe and a concurrent rapid decline in the use of their brand-name formulations. Medicare spent $9.6 billion on brand-name statins and ezetimibe and could have saved $2.1 billion and $0.4 billion, respectively, if brand-name formulations were switched to equivalent generic versions when available. The number of beneficiaries using PCSK9 inhibitors since their introduction in 2015 has been modest, although use has increased by 144% (from 25 569 in 2016 to 62 476 in 2018) and total spending has increased by 199% (from $164 million in 2016 to $491 million in 2018).

Conclusions and Relevance

Between 2014 and 2018, LDL-C-lowering therapies were used by 4.8 million more Medicare beneficiaries annually, with an associated $3.0 billion decline in Medicare spending. This cost reduction was driven by the rapid transition from brand-name formulations to lower-cost generic formulations of statins and ezetimibe. Use of PCSK9 inhibitions, although low, increased over time and could have broad implications on future Medicare spending.

Downregulation of G3BP2 reduces atherosclerotic lesions in ApoE-/- mice

BACKGROUND AND AIMS

Atherosclerosis is mainly caused by stress in arterial microenvironments, which results in the formation of stress granules as a consequence of the stress response. As the core protein of stress granules, GTPase-activating protein (SH3 domain)-binding protein 2 (G3BP2) is known to play pivotal roles in tumour initiation, viral infection and Alzheimer's disease, but the role of G3BP2 in atherosclerosis development is poorly understood. Previous studies have shown that vaccination with epitopes from self-antigens could reduce atherosclerotic lesions. Here, we investigated the effect of immunizing ApoE^-/- mice with G3BP2 peptides, and whether this immunization exerted an anti-atherogenic effect.

METHODS AND RESULTS

In our study, ApoE^-/- mice were fed a high-fat diet for 12 weeks from 8 to 20 weeks of age. Then, using a repetitive multiple site strategy, the mice were immunized with a Keyhole limpet haemocyanin (KLH) conjugated G3BP2 peptide for 2 weeks from weeks 16 to 18. High levels of G3BP2 antibodies were detectable before sacrifice. Histological analyses showed that the number of atherosclerotic lesions in ApoE^-/- mice was significantly reduced following G3BP2 immunotherapy. The levels of pro-inflammatory cytokines and macrophages were also greatly decreased, while the collagen content of the plaques showed significant increase. Furthermore, knocking down G3BP2 in ApoE^-/- mice reduced the number of lesions compared to ApoE^-/- mice fed a high-fat diet for eight weeks. In vitro studies demonstrated that G3BP2 regulated ox-LDL-induced inflammation in HUVECs via controlling the localization of IκBα.

CONCLUSIONS

Immunization with the G3BP2 peptide antigen or knocking down of G3BP2 significantly decreased early atherosclerotic plaques in the ApoE^-/- mouse model of atherosclerosis. G3BP2 is a promising potential target for atherosclerosis therapy.

Challenges and Potential Improvements to Patient Access to Pharmaceuticals: Examples From Cardiology

Patient access to a drug after US regulatory approval is controlled by complex interactions between governmental and third-party payers, pharmacy benefit managers, distributers, manufacturers, health systems, and pharmacies that together mediate the receipt of goods by patients after prescription by clinicians. Recent medication approvals highlight why and how the distribution of clinically beneficial novel therapies is controlled. Although imposed limitations on availability may be rational considering the fiduciary responsibilities of payers and escalating spending on health care and pharmaceuticals, transparency and communication are lacking, and some utilization management may disproportionately affect vulnerable populations. Analysis of the current health insurance landscape suggests mechanisms by which patient access to appropriate medications can be improved and patient and clinician frustration reduced while acknowledging the financial realities of the pharmaceutical marketplace. We propose creation of a shared, standardized, and transparent process for coverage decisions that minimizes administrative barriers and is defensible on the basis of clinical and cost-effectiveness evidence. These reforms would benefit patients and improve the efficiency of the pharmaceutical system.

Economic and Clinical Burden of Acute Myeloid Leukemia Episodes of Care in the United States: A Retrospective Analysis of a Commercial Payer Database

BACKGROUND

In the United States, the incidence of acute myeloid leukemia (AML) has steadily increased over the last decade; in 2019, it was estimated that AML would affect 21,450 new patients and lead to 10,920 deaths. Detailed real-world cost estimates and comparisons of key AML treatment episodes, such as in high-intensity chemotherapy (HIC), low-intensity chemotherapy (LIC), hematopoietic stem cell transplantation (HSCT), and relapsed/refractory (R/R), are scarce in the commercially insured U.S.

POPULATION

OBJECTIVE

To examine health resource utilization (HRU), clinical burden, and direct health care costs across various AML treatment episodes in a large sample of commercially insured U.S.

PATIENTS

METHODS

A retrospective cohort analysis was conducted. Patients with newly diagnosed AML were followed to identify the key active treatment episodes across the course of their disease. Data were obtained from 2 sources: IQVIA's Real-World Data (RWD) Adjudicated Claims Database - U.S. (formerly known as PharMetrics Plus), which comprises adjudicated claims for more than 150 million unique enrollees across the United States, and IQVIA Charge Detail Master Hospital Database, which has detailed data regarding services received in an inpatient setting. Calculation of all-cause HRU was based on physician office visits, nonphysician office visits, emergency department visits, inpatient visits, and outpatient pharmacy utilization. Calculation of all-cause health care costs was based on total allowed costs and reported by the following cost components: physician office visits, nonphysician office visits, emergency department visits, inpatient visits, and outpatient pharmacy utilization. Symptom and toxicity events were estimated via proxies such as diagnosis codes, procedures, and treatments administered.

RESULTS

The final study sample consisted of 1,542 HIC-induction (HIC-I), 591 HIC-consolidation (HIC-C), 628 LIC, 1,000 patients with HSCT, and 707 patients with R/R AML. Total mean episode costs were highest in R/R episodes ($439,104), followed by HSCT ($329,621), HIC-I ($198,657), HIC-C ($73,428), and LIC ($53,081) episodes. Across all treatment episodes, hospitalization was the largest contributor to cost with mean hospitalization costs ranging from $308,978 in the R/R setting to $49,580 for patients receiving LIC; of these, costs related to intensive care unit admission were a noteworthy contributor. In patients with R/R AML and HSCT, expenditures related to pharmacy utilization averaged $24,640 and $12,203, respectively, and expenditures related to physician office visits averaged $10,926 and $6,090, respectively; these expenditures were much lower across other episodes. Across all categories of symptom and toxicity events, cardiovascular events was the only category of event that was a significant predictor of higher cost across all episodes. Symptom and toxicity events commonly associated with AML were associated with significantly increased costs, especially in R/R episodes.

CONCLUSIONS

This resource utilization and direct health care cost analysis highlights the substantial economic burden associated with key AML treatment episodes in the United States, specifically during HIC-I, HSCT, and R/R episodes.

DISCLOSURES

This study was funded by Astellas Pharma. Astellas employees were involved in the study design, interpretation of data, writing of the manuscript, and the decision to submit the manuscript for publication. Pandya and Wilson are employees of Astellas Pharma U.S. Walsh was an employee of Astellas Pharma U.S. while the study was conducted. Chen, McGuiness, and Wade are employees of IQVIA, which received funding from Astellas Pharma U.S. Madeiros was employed at Stanford University while this study was conducted and received a consulting fee from Astellas for work on this study. Data discussed in this study were previously presented at the 59th Annual American Society for Hematology Meeting & Exposition, 2017; December 9-12, 2017; Atlanta, GA.

Can risk be predicted? An umbrella systematic review of current risk prediction models for cardiovascular diseases, diabetes and hypertension

OBJECTIVE

To provide an overview of the currently available risk prediction models (RPMs) for cardiovascular diseases (CVDs), diabetes and hypertension, and to compare their effectiveness in proper recognition of patients at risk of developing these diseases.

DESIGN

Umbrella systematic review.

DATA SOURCES

PubMed, Scopus, Cochrane Library.

ELIGIBILITY CRITERIA

Systematic reviews or meta-analysis examining and comparing performances of RPMs for CVDs, hypertension or diabetes in healthy adult (18-65 years old) population, published in English language.

DATA EXTRACTION AND SYNTHESIS

Data were extracted according to the following parameters: number of studies included, intervention (RPMs applied/assessed), comparison, performance, validation and outcomes. A narrative synthesis was performed. Data were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

STUDY SELECTION

3612 studies were identified. After title/abstract screening and removal of duplicate articles, 37 studies met the eligibility criteria. After reading the full text, 13 were deemed relevant for inclusion. Three further papers from the reference lists of these articles were then added.

STUDY APPRAISAL

The methodological quality of the included studies was assessed using the AMSTAR tool.

RISK OF BIAS IN INDIVIDUAL STUDIES

Risk of Bias evaluation was carried out using the ROBIS tool.

RESULTS

Sixteen studies met the inclusion criteria: six focused on diabetes, two on hypertension and eight on CVDs. Globally, prediction models for diabetes and hypertension showed no significant difference in effectiveness. Conversely, some promising differences among prediction tools were highlighted for CVDs. The Ankle-Brachial Index, in association with the Framingham tool, and QRISK scores provided some evidence of a certain superiority compared with Framingham alone.

LIMITATIONS

Due to the significant heterogeneity of the studies, it was not possible to perform a meta-analysis. The electronic search was limited to studies in English and to three major international databases (MEDLINE/PubMed, Scopus and Cochrane Library), with additional works derived from the reference list of other studies; grey literature with unpublished documents was not included in the search. Furthermore, no assessment of potential adverse effects of RPMs was carried out.

CONCLUSIONS

Consistent evidence is available only for CVD prediction: the Framingham score, alone or in combination with the Ankle-Brachial Index, and the QRISK score can be confirmed as the gold standard. Further efforts should not be concentrated on creating new scores, but rather on performing external validation of the existing ones, in particular on high-risk groups. Benefits could be further improved by supplementing existing models with information on lifestyle, personal habits, family and employment history, social network relationships, income and education.

PROSPERO REGISTRATION NUMBER

CRD42018088012.

Incorporating content related to value and cost-considerations in clinical decision-making: enhancements to medical education

Although incorporating cost-considerations during healthcare decision-making is increasingly important to American patients and physicians, content related to these constructs is not routinely included in medical education. As a result, physicians are ill-equipped to consider costs. This study sought input from practicing physicians on perceived deficiencies in current teaching and recommendations for necessary content to include in medical teaching. We conducted a qualitative descriptive study using semi-structured interviews utilizing a purposeful maximum variation sample of cardiologists and neonatologists practicing in diverse settings. We analyzed interviews using conventional content analysis. 18 cardiologists and 17 neonatologists participated in this study. Respondents perceived that current teaching does not impart sufficient knowledge of value and cost considerations to achieve patient-centered, high-value decision-making. They identified the following priority areas for education related to healthcare costs: the business of medicine and information about out-of-pocket patient costs, training in health research interpretation skills to critically appraise evidence, and communication skills to engage patients as partners in shared decision-making. Participants recommended a variety of teaching methods, including didactic sessions on core topics, role modeling and case studies. American physicians perceive learning needs related to the incorporation of costs into clinical decision-making that can inform curriculum development initiatives in this field. Physicians perceive knowledge of these topics and skills to be crucial to achieving patient-centered high-value care. Concomitant health system reforms supporting the needs of the patient at its center are essential to enable physicians to focus on a patient-centered approach to healthcare delivery.

Resveratrol attenuates endothelial oxidative injury by inducing autophagy via the activation of transcription factor EB

Background

Endothelial oxidative injury is a key event in the pathogenesis of atherosclerosis (AS). Resveratrol (RSV) attenuates the oxidative injury in human umbilical vein endothelial cells (HUVECs). Autophagy is critical for the RSV-induced protective effects. However, the exact underlying mechanisms haven’t been completely elucidated. Thus, we aimed to explore the role of autophagy of the anti-oxidation of RSV and the underlying mechanism in palmitic acid (PA)-stimulated HUVECs.

Methods

HUVECs were pretreated with 10 μM of RSV for 2 h and treated with 200 μM of PA for an additional 24 h. Cell viability, intracellular reactive oxygen species (ROS) and malondialdehyde (MDA) levels were estimated with a microplate reader and confocal microscope. Autophagosomes were analyzed by transmission electron microscopy, while lysosomes by confocal microscopy. The expression of transcription factor EB (TFEB) and related genes were quantified by qRT-PCR assay. Furthermore, TFEB levels, autophagy, and lysosomes were examined by western blot assay.

Results

RSV pretreatment suppressed the PA-induced decline in cell viability and elevation in ROS and MDA levels in HUVECs. RSV pretreatment also increased LC3 production and P62 degradation while promoted the autophagosomes formation. However, 3-methyladenine (3-MA) treatment attenuated RSV-induced autophagy. RSV pretreatment upregulated the TFEB and TFEB-modulated downstream genes expression in a concentration-dependent manner. Additionally, in cells transfected with TFEB small interfering RNA, RSV-induced TFEB expression and subsequent autophagy were abolished. Meanwhile, the TFEB-modulated genes expression, the lysosomes formation and the RSV-induced anti-oxidation were suppressed.

Conclusions

In HUVECs, RSV attenuates endothelial oxidative injury by inducing autophagy in a TFEB-dependent manner.

Coronary artery calcium testing: A call for universal coverage

Heart attacks kill more Americans than all cancers combined. Fatal heart attack victims have no symptoms until minutes before they die, hence early detection of high-risk asymptomatic individuals is needed. Even though heart attacks kill and cost more than cancers, as a nation we spend over 20 times more on screening for asymptomatic cancer than for asymptomatic atherosclerotic cardiovascular disease (ASCVD), the underlying cause of heart attacks. Currently, payers only cover screening for risk factors of ASCVD such as blood pressure and blood cholesterol. This approach tends to miss high-risk and over-treat low-risk individuals. Although treadmill stress testing with ECG is not indicated for ASCVD detection in asymptomatic individuals, it is done often, and frequently leads to misleading conclusions or unnecessary downstream diagnostic procedures. For example, former President Clinton had passed his treadmill stress tests for several years during his presidential annual checkup but had a heart attack shortly after his presidency. This common practice is a waste of our limited resources. Instead, a more accurate risk assessment using coronary artery calcium (CAC) testing is available; and has just been adopted by ACC/AHA guidelines, however payers do not cover it. CAC is measured non-invasively with a 5-minute CT-scan of the heart, and costs less than $200, whereas cancer screening with colonoscopy and mammography costs over $3000. There is an opportunity to save lives and dollars if CAC testing is covered for appropriately selected individuals. Texas has already passed HB1290 to mandate CAC coverage. Other states must step up and take actions.

Silica-coated magnetic nanoparticles labeled endothelial progenitor cells alleviate ischemic myocardial injury and improve long-term cardiac function with magnetic field guidance in rats with myocardial infarction

Low retention of endothelial progenitor cells (EPCs) in the infarct area has been suggested to be responsible for the poor clinical efficacy of EPC therapy for myocardial infarction (MI). This study aimed to evaluate whether magnetized EPCs guided through an external magnetic field could augment the aggregation of EPCs in an ischemia area, thereby enhancing therapeutic efficacy. EPCs from male rats were isolated and labeled with silica‐coated magnetic iron oxide nanoparticles to form magnetized EPCs. Then, the proliferation, migration, vascularization, and cytophenotypic markers of magnetized EPCs were analyzed. Afterward, the magnetized EPCs (1 × 10⁶) were transplanted into a female rat model of MI via the tail vein at 7 days after MI with or without the guidance of an external magnet above the infarct area. Cardiac function, myocardial fibrosis, and the apoptosis of cardiomyocytes were observed at 4 weeks after treatment. In addition, EPC retention and the angiogenesis of ischemic myocardium were evaluated. Labeling with magnetic nanoparticles exhibited minimal influence to the biological functions of EPCs. The transplantation of magnetized EPCs guided by an external magnet significantly improved the cardiac function, decreased infarction size, and reduced myocardial apoptosis in MI rats. Moreover, enhanced aggregations of magnetized EPCs in the infarcted border zone were observed in rats with external magnet‐guided transplantation, accompanied by the significantly increased density of microvessels and upregulated the expression of proangiogenic factors, when compared with non‐external‐magnet‐guided rats. The magnetic field‐guided transplantation of magnetized EPCs was associated with the enhanced aggregation of EPCs in the infarcted border zone, thereby improving the therapeutic efficacy of MI.

Resveratrol attenuates oxidative injury in human umbilical vein endothelial cells through regulating mitochondrial fusion via TyrRS-PARP1 pathway

Background/aims

Oxidative stress-induced damage in endothelial cells is a crucial initiator of atherosclerosis (AS), which is highly related to excessive reactive oxygen species (ROS) and mitochondrial dynamics. Resveratrol (RSV) exerts beneficial effects against endothelial oxidative injury, while the underlying mechanisms have not been fully elucidated. Thus, we aimed to explore the role of mitochondria dynamics during the anti-oxidative activities of RSV in palmitic acid (PA)-stimulated human umbilical vein endothelial cells (HUVECs) and to verify whether tyrosyl transfer- RNA synthetase (TyrRS) and poly (ADP-ribose) polymerase 1 (PARP1) are targeted during this process.

Methods

HUVECs were exposed to 200 μM of PA for 16 h before treated with 10 μM of RSV for 8 h. Cell viability was detected using Cell counting kit-8 (CCK-8) assay. The intracellular ROS level and mitochondria membrane potential (MMP) were measured using microplate reader and flow cytometry. The malondialdehyde and superoxide dismutase were measured using the microplate reader. The mitochondrial morphology and fusion process was observed under transmission electron microscopy and confocal microscopy. TyrRS and PARP1 were knocked down with the specific small interference RNAs (siRNA), and the protein expressions of TyrRS, PARP1, and mitochondrial fusion proteins (MFN1, MFN2, and OPA1) were measured by western blot.

Results

RSV treatment suppressed the PA-induced injuries in HUVECs, including the damage to cell viability, oxidative stress, and loss of MMP. Additionally, RSV improved the protein levels of MFN1, MFN2, and OPA1 as well as inhibited the PA-induced fragmentation of mitochondria. However, the effects of RSV on oxidative stress and mitochondrial fusion were abolished by the pretreatment of siRNAs of TyrRS and PARP1, indicating that these effects of RSV were dependent on the TyrRS-PARP1 pathway.

Conclusions

RSV attenuated endothelial oxidative injury by regulating mitochondrial fusion via TyrRS-PARP1 signaling pathway.

Electronic supplementary material

The online version of this article (10.1186/s12986-019-0338-7) contains supplementary material, which is available to authorized users.

Children Present a Window of Opportunity for Promoting Health: JACC Review Topic of the Week

Cardiovascular disease is the leading cause of death and disability in the world, largely because of risk factors modifiable by changes in behavior. There is evolving evidence that our behavior as adults has its roots in the environment that we live in from early childhood. Early sustained multicomponent educational programs focused on health promotion in children may represent a window of opportunity to potentially prevent disease in adulthood. The integration of school-based, family-based, and community-based strategies, along with the support of public policies, are likely necessary for the success of these programs. In this review, the authors describe the future of promoting health. Specifically: 1) reasons why children should be a focus for health promotion (alarming trends of risk factors, association between unhealthy factors and subclinical disease, and cost-effectiveness); 2) strategies for health promotion in children (school-based, family-based, and community-based approaches) along with legislative efforts; and 3) research gaps are discussed.

Dietary Intake of Anti-Oxidant Vitamins A, C, and E Is Inversely Associated with Adverse Cardiovascular Outcomes in Chinese-A 22-Years Population-Based Prospective Study

Background: Conflicting and population-dependent findings have been reported from epidemiological studies on the associations of dietary intake of anti-oxidant vitamins with cardiovascular events. We investigated the prospective relationship between dietary intake of anti-oxidant vitamins and incident adverse cardiovascular outcomes amongst Hong Kong Chinese. Methods: In this prospective population-based study, baseline dietary intake of anti-oxidant vitamins (A, C, and E) were assessed using a food frequency questionnaire in 875 Chinese participants from the Hong Kong Cardiovascular Risk Factor Prevalence Study (CRISPS) in 1995–1996. The adjusted hazard ratio (HR) of incident adverse cardiovascular outcomes, defined as the first recorded diagnosis of cardiovascular deaths, non-fatal myocardial infarction or non-fatal stroke, and coronary or other arterial revascularizations, was calculated per unit intake of each vitamin using multivariable Cox regression. Results: Over a median follow-up of 22 years, 85 participants (9.7%) developed adverse cardiovascular outcomes. Dietary intakes of vitamin A, C, and E were independently and inversely associated with incident adverse cardiovascular outcomes (HR 0.68, 95%CI 0.53–0.88, p = 0.003 for vitamin A; HR 0.66, 95%CI 0.52–0.85, p = 0.001 for vitamin C; and HR 0.57, 95%CI 0.38–0.86, p = 0.017 for vitamin E) after adjustments for conventional cardiovascular risk factors at baseline. Conclusions: Dietary intakes of anti-oxidant vitamins A, C, and E reduced the risk of adverse cardiovascular outcomes in Hong Kong Chinese.

Dysbiosis signatures of gut microbiota in coronary artery disease

Gut microbiota dysbiosis has been considered to be an important risk factor that contributes to coronary artery disease (CAD), but limited evidence exists about the involvement of gut microbiota in the disease. Our study aimed to characterize the dysbiosis signatures of gut microbiota in coronary artery disease. The gut microbiota represented in stool samples were collected from 70 patients with coronary artery disease and 98 healthy controls. 16S rRNA sequencing was applied, and bioinformatics methods were used to decipher taxon signatures and function alteration, as well as the microbial network and diagnostic model of gut microbiota in coronary artery disease. Gut microbiota showed decreased diversity and richness in patients with coronary artery disease. The composition of the microbial community changed; Escherichia-Shigella [false discovery rate (FDR = 7.5*10−5] and Enterococcus (FDR = 2.08*10−7) were significant enriched, while Faecalibacterium (FDR = 6.19*10−10), Subdoligranulum (FDR = 1.63*10−6), Roseburia (FDR = 1.95*10−9), and Eubacterium rectale (FDR = 2.35*10−4) were significant depleted in the CAD group. Consistent with the taxon changes, functions such as amino acid metabolism, phosphotransferase system, propanoate metabolism, lipopolysaccharide biosynthesis, and protein and tryptophan metabolism were found to be enhanced in CAD patients. The microbial network revealed that Faecalibacterium and Escherichia-Shigella were the microbiotas that dominated in the healthy control and CAD groups, respectively. The microbial diagnostic model based on random forest also showed probability in identifying those who suffered from CAD. Our study successfully identifies the dysbiosis signature, dysfunctions, and comprehensive networks of gut microbiota in CAD patients. Thus, modulation targeting the gut microbiota may be a novel strategy for CAD treatment.