Socioeconomic Status and Cardiovascular Outcomes: Challenges and Interventions

Autopsy results and factors associated with sudden cardiac death in young individuals with congenital heart disease - a nationwide study

OBJECTIVES

Sudden cardiac death (SCD) is a leading cause of mortality among individuals with congenital heart disease (CHD), and risk stratification remains challenging. This study aimed to describe the underlying structural cardiac abnormalities in a national cohort of SCD victims with CHD, their socioeconomic status, and interactions with the healthcare system before death.

METHODS

The Swedish study of Sudden Cardiac Death in the Young, 2000-2010, included SCD victims under 36 years, along with population-based controls and their parents. Of 903 SCD victims, 39 with autopsy-defined CHD were included in this study, together with 195 controls. Information on socioeconomic variables and healthcare contacts was gathered from Swedish national registers.

RESULTS

The median age for SCD was 24 years, and 64% were male. The CHD was undiagnosed before death in 31% of the cases, of whom 8 had coronary anomalies. Moderate to complex CHD was observed in 41%. Structural abnormalities of the ventricles were prevalent, with left ventricular hypertrophy present in 56% and fibrosis in 64%. The cases had a higher frequency of hospital admissions within 6 months before SCD compared to controls (OR 14.1,95% CI 3.80-52.44), p < 0.001. No socioeconomic differences were observed.

CONCLUSIONS

This study identified a broad spectrum of underlying anatomical defects, with ventricular structural abnormalities being a common autopsy finding. The majority of cases had moderate to severe lesions. An increased frequency of healthcare contacts prior to death was noted, which may be a variable needing more attention as a predictor for a higher risk of SCD.

Cardiovascular disease mortality in Brazilian municipalities: estimates from the lobal urden of isease study, 2000-2018

Background

Age-standardized mortality rates (ASMR) for cardiovascular diseases (CVD) have decreased in Brazil in the last decades due to better control of risk factors and access to healthcare. However, how this reduction is distributed across the country's municipalities is unknown. We aimed to evaluate changes in CVD mortality rates across Brazilian municipalities from 2000 to 2018 using estimates from the Global Burden of Disease (GBD) study.

Methods

In this ecological study, ASMR for CVD were estimated using GBD methodology for 5564 Brazilian municipalities from 5 regions in the triennials: 2000-2002, 2009-2011, 2016-2018. A visuospatial analysis was applied to create clusters in ASMR with Moran Local analysis. Municipalities were stratified by population size in <30,000, 30,000-300,000, and >300,000 inhabitants per region. The % changes in ASMR from 2000-2002 to 2016-2018 were calculated.

Findings

In 2000-2002, ASMR for CVD were higher in more developed regions and in larger municipalities of all regions, except for the South. In 2016-2018, CVD ASMR increased in the least developed Northern regions. The % reduction in CVD ASMR was lower in small vs large municipalities within all 5 regions, varying from -3% in small Northern municipalities to -43% in large Southern municipalities.

Interpretation

The reduction in CVD mortality in Brazil was lower in municipalities from the most vulnerable regions and smaller populations. Public policies tailored to these smaller municipalities, particularly on the least developed regions, must be considered a priority.

Funding

Brazilian Ministry of Health [grant 148/2018] and Pan American Health Organization [Letter of Agreement SCON2021-00288].

Positive childhood experiences and adult cardiovascular health

OBJECTIVE

To test whether positive childhood experiences (PCEs) assessed prospectively in adolescence predict ideal cardiovascular health in adulthood, even after controlling for experiences of childhood maltreatment. We also tested whether PCEs would moderate the association between childhood maltreatment and adult cardiovascular health and whether sex moderated the association between PCEs and cardiovascular health.

METHOD

Data originated from the National Longitudinal Study of Adolescent to Adult Health (Add Health), a nationally representative longitudinal study in the United States (n = 2,916). Using data from the Wave 1 adolescent assessment (Mage = 15.70 years, 1994-1995), a 12-item index of cumulative self-reported PCEs (e.g., stable caregiver, adult mentor, one good friend, enjoyed school, good neighbors) was created. Childhood maltreatment experiences were self-reported at Wave 3 (Mage = 22.06 years, 2001-2002) and Wave 4 (Mage = 28.53 years, 2008). An ideal cardiovascular health score was calculated in Wave 5 (Mage = 37.47 years, 2016-2018) using the American Heart Association's Life's Essential 8 cardiovascular health index.

RESULTS

Greater PCEs predicted more ideal cardiovascular health (β = .13, p < .001), and greater childhood maltreatment predicted less ideal cardiovascular health in adulthood (β = -.12, p < .001). PCEs did not moderate the association between childhood maltreatment and adult cardiovascular health. Sex moderated the association between PCEs and adult cardiovascular health (β = .09, p = .042), such that the association was stronger for female (β = .20, p < .001) than male (β = .08, p = .073).

CONCLUSION

The finding that PCEs prospectively predict more ideal cardiovascular health in adulthood beyond the effect of childhood maltreatment suggests that promoting PCEs should be tested as part of interventions to prevent adult cardiovascular disease. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Sexual Health After a Stroke: A Topical Review and Recommendations for Health Care Professionals

The devastating physical, emotional, and social effects of stroke can disrupt all aspects of life for the stroke survivor. Ensuring that survivor and caregiver needs are met after a stroke is essential in ongoing care to ensure optimal quality of life. Despite health care professionals making significant strides in poststroke symptom management, education, and rehabilitative support, the common poststroke symptom of sexual dysfunction is rarely addressed. Multiple barriers across health care settings and systems have contributed to this gap. The purpose of this article is to provide evidence that supports the importance of addressing sexual health by health care providers with the stroke survivor and their partner as they transition through the recovery process. We have the following recommendations to optimize care and quality of life for stroke survivors: (1) comprehensive sex education must include information on healthy sex and sexuality for people with neurological disabilities; (2) rehabilitation programs offered in postacute settings should include a structured culturally sensitive interprofessional sexual rehabilitation component that addresses sexuality of the stroke survivor in collaboration with their intimate partners; (3) sexual rehabilitation programs should be tailored for each person based on a thorough assessment of the person's health literacy and learning needs; and (4) the American Heart Association should develop an extensive toolkit for health care providers and survivors that is easily and readily available to the public. Health care providers, survivors, and their partners have a stake in optimal stroke recovery. Sexuality and sexual function are important quality of life indicators thus conversations addressing issues must be included as part of the recovery process. This discussion is best initiated by a health care provider to address system barriers and misconceptions across care transitions. Likewise, survivors and their partners must be encouraged to take ownership to address sexuality issues and initiate the conversation with their health care partners to achieve full recovery.

Income, Healthy Food Availability, and Consumption Mediate Rural-Urban Health Disparities

BACKGROUND

Examine the role of income, perceived healthy foods availability, and consumption as mediators of rural-urban health disparities.

METHOD

Pre-registered simple mediation models with post hoc multi-mediator models were tested using national- and state-level survey data. Oregon data was collected in an online Qualtrics survey between October 8 and November 9, 2021 using CloudResearch; Health Information National Trends Survey (HINTS) 5, a nationally representative dataset, was collected over 4 cycles from 2017 to 2020. Oregon residents (n = 771; rural = 313, urban = 458) self-reported online: income, perceived fruits and vegetable (FV) availability, FV consumption, and BMI measures (height, weight). HINTS respondents (rural n = 1235; urban n = 13,912) self-reported the same variables of interest without FV availability, and with an additional self-rated health variable detailed below.  RESULTS: The effect of rurality on BMI (b = 0.012, SE = 0.005, p = 0.01) and self-rated health (b = 0.003, SE = 0.001, p = 0.008) when combining datasets was mediated by a series of income, perceived FV availability, and FV consumption.

CONCLUSION

To address rural-urban health disparities, individual (cognition, behavior), social (household income), and community (healthy food availability) factors should be targeted together.

Association between social determinants of health with the all-cause and cause-specific (cancer and cardio-cerebrovascular) mortality among the population with metabolic syndrome: NHANES 2005-2018

BACKGROUND

Social determinants of health (SDOH) and metabolic syndrome (MetS) are related, but their combined effect on mortality risk remains unclear.

METHODS

We analyzed data from NHANES (National Health and Nutrition Examination Survey) cycles between 2005 and 2018. The composite SDOH score was calculated by summing the weighted scores for each SDOH, categorizing participants into four groups: Q1 (0-1), Q2 (2-3), Q3 (4) and Q4 (≥ 5). Kaplan-Meier survival curves and multivariate Cox proportional hazards models were used to examine the relationship between SDOH and mortality outcome. Restricted cubic spline (RCS) analyses were conducted to explore nonlinear relationships. Subgroup analyses assessed the consistency and robustness of the findings across various demographic and clinical factors.

RESULTS

Of the 7,366 patients with MetS, 1,193 died, including 407 from cardiovascular and cerebrovascular diseases and 269 from cancer. Cox regression analyses, using fully adjusted Model 2, revealed that higher SDOH levels had increased hazards for all-cause mortality (HR = 2.41, 95% CI: 1.87,3.12), cancer-related death (HR = 2.45, 95% CI: 1.54,3.89), and Cardio - cerebrovascular disease (HR = 2.62, 95% CI: 1.79,3.84). Kaplan-Meier analyses further supported these findings, demonstrating that participants with higher SDOH scores had lower survival rates. Additionally, RCS modeling confirmed a linear relationship between SDOH and mortality, with no indication of a nonlinear relationship (P for nonlinear > 0.05).

CONCLUSION

Our findings indicate that adverse social determinants of health are strongly linked to an increased risk of all-cause mortality in individuals with MetS. However, due to the observational and cross-sectional nature of this study, it is important to interpret these results as associations rather than implying any causal relationships.

Breaking the code: Using the Precision Health Model to guide research and clinical care

BACKGROUND

Precision health is a person-centered approach to health and well-being that is operationalized through evaluating omics-level profiles and their associations with the exposome. A precision health approach addresses the challenge that "one size does not fit all" in the management of an individual's health.

PURPOSE

The purpose of this white paper is to introduce a Precision Health Model and its application in research and clinical care.

METHODS

An expert panel reviewed and synthesized the extant literature related to precision health, the current state of omics' science, and common exposome factors that influence the health/illness continuum. A case study provides the framework for the application of the Precision Health Model.

DISCUSSION

Precision health and key domains are defined and serve as the platform for the development of the Precision Health Model.

CONCLUSION

Application of the Precision Health Model will provide inclusive, equitable, person-centered research and clinical care.

Real-world analyses of major adverse cardiovascular events and mortality risk after androgen deprivation therapy initiation in black vs. white prostate cancer patients

BACKGROUND

Prostate cancer(PCa) patients treated with androgen deprivation therapy(ADT) may experience major adverse cardiovascular events(MACE) [1]. Racial disparities in PCa incidence and outcomes have been noted. In contrast to older studies, three recent studies found significantly longer overall survival in Black vs. White patients: 2019 meta-analysis of nine phase III trials in men with metastatic castration-resistant PCa(CRPC) (n = 8820) [2]; 2020 registry study in men with metastatic CRPC (n = 1902) [3]; and 2023 study in men with non-metastatic CRPC (n = 12,992) [4]. Our "real-world" data study compared MACE and all-cause mortality risk for Black vs. White PCa patients. Compared to prior studies [1-4], our study encompassed a broader scope and was not exclusive to CRPC patients.

METHODS

Historical, longitudinal patient-level were collected from the Decision Resources Group (DRG, now Clarivate) Real World Evidence repository. The analysis included PCa patients receiving ≥1 ADT 1991-2020. Multivariable regression model accounted for baseline metastasis, BMI (<18.5 vs. ≥18.5 kg/m2), oncology vs. urology setting, antagonist vs. agonist, personal MACE history, tobacco history, baseline prostate-specific antigen (>4 vs. ≤4 ng/mL), race (White vs. Black), statin use, increasing age per year, ethnicity (non-Hispanic vs. Hispanic), increasing ADT exposure per year, diabetes, hypertension, and family MACE history.

RESULTS

MACE risk was higher for White patients than Black (4.0% vs. 2.4% at one year after ADT initiation; 21.0% vs. 13.3% at four years). Mortality risk after ADT initiation was 1.6% and 2.6% at 1 year and 11.7% and 18.1% at 4 years for Black and White patients, respectively.

CONCLUSIONS

Our analysis reveals a unique finding that MACE and all-cause mortality incidence were higher in White vs. Black patients. Black race is associated with lower MACE rates and improved survival for men undergoing ADT treatment. Whether selection bias, underlying biology or other factors are responsible for these differences remains unknown.

Evaluation of an Interdisciplinary Hypertension Management Program at a Large Primary Care Practice

Hypertension control remains challenging for many primary care patients. The goal of this study was to implement an evidence-based team approach to improve hypertension control, self-reported health distress, and self-efficacy in adult patients with hypertension at a large academic family medicine practice. The 5-year intervention included team-based medication therapy management, patient-centered behavioral counseling, and home blood pressure monitoring. Pre- and post-intervention blood pressure and patient surveys were analyzed using paired t-tests. The authors observed significant decreases in systolic blood pressure (148.4 vs. 135.6, P = 0.001) and self-reported health distress over the enrollment period in participants who completed the study. The multidisciplinary intervention was associated with reduced systolic blood pressure and health distress in patients who enrolled and completed the program. A multidisciplinary blood pressure monitoring program can be implemented by providers referring patients with uncontrolled hypertension after pharmacologic interventions.

Approaches to harmonize mortality data sets in three diverse radiation worker cohorts

While there is a well-established link between ionizing radiation and cancer, there are uncertainties with effects following low doses delivered at low dose rates. To address these gaps, the ongoing Million Person Study of Radiation Workers and Veterans (MPS) is investigating the likelihood of a variety of cancer and non-cancer effects following chronic exposure to low dose-rate ionizing radiation. One challenge is and will be combining and harmonizing diverse cohorts with widely different measures of socio-economic status, birth cohorts, dose distributions and sex ratios. Herein, we have evaluated non-cancer mortality in three cohorts for which dose reconstructions have been completed: Rocketdyne (Atomics International, California, 1948-2008), Mound (Dayton, Ohio, 1944-2009) and nuclear weapons test participants (Atomic Veterans, 1945-2012). These three cohorts represent a small fraction of the overall MPS but provide valuable insight into methods of combining and harmonizing data from multiple diverse cohorts that can later be considered for all MPS cohorts. Heart disease mortality, including both underlying and contributing causes of death, was chosen for illustrating the statistical approaches. In all three cohorts, radiation dose estimates were distributed very differently by different measures of socio-economic status. Further, the effect of birth cohort was significantly different for heart disease mortality in all three cohorts, with all studies showing that later birth cohorts have lower rates of heart disease mortality than the earlier. The goal of this paper is not to quantify radiation effects based on these combined cohorts and it would be inappropriate to do so. Rather these cohorts are used to illustrate approaches for combining multiple data sets that incorporate the full set of individual confounder and cofactor information available from each cohort, though widely different. We identified five different methods to combine the results of these three datasets: the simple pooled analysis (PA), PA including study interactions, traditional stratified analysis, and both fixed and random effects meta-analysis. We describe the similarities and differences between the combined results using these approaches.

Assessing ethnicity as a factor in myocardial infarction emergency response and recovery: a study from the Negev Desert

BACKGROUND

We compared short- and long-term management and outcomes between Bedouin Arabs and Jewish patients in the Negev region (Israel) to assess disparities in myocardial infarction care and subsequent impacts on patient health.

METHODS

A retrospective cohort study was conducted at Soroka University Medical Center, Israel, spanning from 2016 to 2022. It included all cases of ST elevation myocardial infarction (STEMI) requiring urgent catheterisation. Data were extracted on demographics, comorbidities and key time metrics from symptom onset to intervention. Outcomes included in-hospital mortality, 1-year mortality and 1-year mortality for those who survived and were discharged.

RESULTS

Among the 1530 participants (1092 Jews, 438 Bedouins), no significant differences were found in immediate treatment metrics. However, multivariable logistic regression revealed a difference in a long-term outcome; Bedouins had a higher risk of 1-year mortality (adjusted OR=1.49, 95% CI: 0.99 to 2.22).

CONCLUSIONS

While the initial treatment outcomes for STEMI appear comparable between ethnic groups, ethnic disparities become apparent in long-term health outcomes. Tailored interventions such as improved follow-up systems, community-specific health education and enhanced access to rehabilitation services are essential for ensuring equitable health outcomes for all populations.

The Association of Elevated Depression Levels and Life's Essential 8 on Cardiovascular Health With Predicted Machine Learning Models and Interpretations: Evidence From NHANES 2007-2018

Background and Objective: The association between depression severity and cardiovascular health (CVH) represented by Life's Essential 8 (LE8) was analyzed, with a novel focus on ranked levels and different ages. Machine learning (ML) algorithms were also selected aimed at providing predictions to suggest practical recommendations for public awareness and clinical treatment. Methods: We included 21,279 eligible participants from the National Health and Nutrition Examination Survey (NHANES) 2007-2018. Weighted ordinal logistic regression (LR) was utilized with further sensitivity and dose-response analysis, and ML algorithms were analyzed with SHapley Additive exPlanations (SHAP) applied to make interpretable results and visualization. Results: Our studies demonstrated an inverse relationship between LE8 and elevated depressive levels, with robustness confirmed through subgroup and interaction analysis. Age-specific findings revealed middle-aged and older adults (aged 40-60 and over 60) which showed higher depresion severity, highlighting the need for greater awareness and targeted interventions. Eight ML algorithms were selected to provide predictive results, and further SHAP would become ideal supplement to increase model interpretability. Conclusions: Our studies demonstrated a negative association between LE8 and elevated depressive levels and provided a suite of ML predictive models, which would generate recommendations toward clinical implications and subjective interventions.

Associations between education and ideal cardiovascular health metrics across 36 low- and middle-income countries

BACKGROUND

The relationship between education and cardiovascular health (CVH) metrics in low- and middle-income countries (LMICs) remains unclear. This study explores the associations between education and ideal cardiovascular health score (CVHS), as well as seven CVH metrics.

METHODS

This cross-sectional study extracted data from the STEPwise approach to surveillance surveys in 36 LMICs between 2010 and 2020. We assessed CVHS using the sum score in seven metrics defined by American Heart Association: (1) ≥ 150 min/week of moderate, or 75 min/week of vigorous activity, or an equivalent combination; (2) BMI < 25 kg/m2 for non-Asians (< 23 kg/m2 for Asians); (3) fruit and vegetable intake ≥ 4.5 servings per day; (4) nonsmoking; (5) blood pressure < 120/80 mmHg (untreated); (6) total cholesterol < 200 mg/dL (untreated); and (7) fasting blood glucose < 100 mg/dL (untreated). The ideal CVHS score ranged from 5 to 7. We disaggregated prevalence of ideal CVHS and seven metrics by education, and constructed Poisson regression models to adjust for other socioeconomic factors.

RESULTS

Among 81,327 adult participants, the overall ideal CVHS prevalence for the studied countries was highest among individuals with primary education (52.9%, 95% CI: 51.0-54.9), surpassing those of other education levels - 48.0% (95% CI: 44.6-51.3, P = 0.003) for those with no education and 39.1% (95% CI: 36.5-41.8, P < 0.001) for those with tertiary education. Five (ideal physical activity, BMI, blood pressure, total cholesterol, and blood glucose) in seven CVH metrics peaked among participants with primary or secondary education. For instance, the prevalence of ideal blood pressure among individuals with primary education was 34.4% (95% CI: 32.7-36.1), higher than the prevalence in other education levels, ranging from 28.6% to 32.3%. These patterns were concentrated in low-income countries and lower-middle-income countries, while in upper-middle-income countries, the prevalence of ideal CVHS increased with higher education levels, ranging from 15.4% for individuals with no education to 33.1% for those with tertiary education.

CONCLUSIONS

In LMICs, the association between education and ideal CVHS, along with several CVH metrics, exhibited un inverted U-shape, which may be closely related to the different stages of epidemiologic transition.

Association between the atherogenic index of plasma and the systemic immuno-inflammatory index using NHANES data from 2005 to 2018

The atherogenic index of plasma (AIP) is used to evaluate the risk of atherosclerosis, while the systemic immune-inflammation index (SII) measures inflammation. The AIP and SII are indicators used to predict diseases in various areas. This study aims to explore the relationship between AIP and SII. A cross-sectional study design was used to recruit 70,190 participants from the National Health and Nutrition Examination Survey (NHANES) conducted between 2005 and 2018, excluding AIP missing data, SII missing data, participants under 20 years of age, and participants with missing covariates to eventually include 8163 participants. We used weighted multiple linear regression analysis, trend test, smooth curve fitting and threshold effect analysis to examine the relationship between AIP and SII. Among the 8163 participants included in the study, the mean (± SD) age was 48.412 ± 16.842 years. The mean SII (± SD) for all participants was 519.910 ± 316.974. In a model adjusted for all covariates (Model 3), AIP showed a significant positive correlation with SII [β (95% CI) 32.497 (5.425, 59.569), P = 0.021]. The smooth curve fitting results of AIP and SII are an "inverted U-shape" non-linear relationship, and the inflection point is at AIP = 0.82. This positive association between AIP and SII was found only in females and participants under 50. Specifically, for females, the positive correlation between AIP and SII was linear [β (95% CI) 80.791 (44.625, 116.958); P < 0.001]. In participants under 50, the positive correlation between AIP and SII was [β (95% CI) 34.198 (3.087, 65.310); P = 0.034], and there was also an "inverted U-shape" non-linear relationship with an inflection point of AIP = 0.549. For participants aged 20-50 years and males, the smooth curve showed a "down-flat-down" non-linear relationship. There is a significant positive correlation between AIP and SII. A positive association between AIP and SII was observed exclusively in females and among participants under 50. Furthermore, AIP and SII demonstrated a nonlinear relationship that resembles an "inverted U-shape". These findings offer new insights into the prevention, treatment, and management of cardiovascular disease. However, further comprehensive cohort studies are necessary to validate the relationship between AIP and SII.

Combined action of dietary-based approaches and therapeutic agents on cholesterol metabolism and main related diseases

BACKGROUND

Dyslipidaemia is among the major causes of severe diseases and, despite being well-established, the hypocholesterolaemic therapies still face significant concerns about potential side effects (such as myopathy, myalgia, liver injury digestive problems, or mental fuzziness in some people taking statins), interaction with other drugs or specific foods. Accordingly, this review describes the latest developments in the most effective therapies to control and regulate dyslipidaemia.

SCOPE AND APPROACH

Herein, the metabolic dynamics of cholesterol and their integration with the current therapies: statins, bile acid sequestrants, fibrates, niacin, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, reconstituted high-density lipoprotein (rHDL), or anti-inflammatory and immune-modulating therapies), were compared focusing their effectiveness, patients' adhesion and typical side-effects. Likewise, the interaction of these therapies with recommended dietary habits, focusing functional foods and nutraceuticals uptake were also considered.

KEY FINDINGS AND CONCLUSIONS

Since none of the current therapeutic alternatives represent an ideal solution (mainly due to side-effects or patients' tolerance), the potential adjuvant action of selected diets (and other healthy habits) was proposed as a way to improve the cholesterol-lowering effectiveness, while reducing the adverse effects caused by dose-increase or continuous uptake of alternating therapeutic agents. In general, the relevance of well-adapted diets must be acknowledged and their potential effects must be exhorted among patients, who need to be aware of the associated multifactorial advantages.

Biomarkers and Social Determinants in Atherosclerotic Arterial Diseases: A Scoping Review

BACKGROUND

Arterial diseases like coronary artery disease (CAD), carotid stenosis (CS), peripheral artery disease (PAD), and abdominal aortic aneurysm (AAA) have high morbidity and mortality, making them key research areas. Their multifactorial nature complicates patient treatment and prevention. Biomarkers offer insights into the biochemical and molecular processes, while social factors also significantly impact patients' health and quality of life. This scoping review aims to search the literature for studies that have linked the biological mechanisms of arterial diseases through biomarkers with social issues and to analyze them, supporting the interdependence of biological and social sciences.

METHODS

After a rigorous selection process, adhering to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines for Scoping Reviews, 30 articles were identified through Scopus, Web of Science, and PubMed. Inclusion and exclusion criteria were based on the population, intervention, comparator, outcome, time, and setting framework. Inclusion criteria were studies involving human subjects that explored the relationships among arterial diseases, biomarkers, and psychosocial factors, with no restrictions on publication date. Nonhuman studies, purely biological or medical analyses without psychosocial dimensions, and non-English publications were excluded. Eligible study types included experimental, observational, and review articles published in peer-reviewed journals. Data extraction focused on study characteristics, such as authors, publication year, country, methods, population, and findings. Results were synthesized narratively, as this format was deemed the most suitable for summarizing diverse findings. The quality or methodological rigor of the included studies was not formally assessed, consistent with the scoping review methodology.

RESULTS

In CAD, biomarkers such as high-sensitivity C-reactive protein are strongly associated with psychological stress, whereas lipoprotein (a) and the apolipoprotein B/apolipoprotein A1 ratio reflect lipid profiles that are influenced by socioeconomic factors and ethnicity. In CS, increased carotid intima-media thickness is linked to psychiatric conditions like attention deficit/hyperactivity disorder, and heat shock protein-70 levels are associated with socioeconomic status and gender. In PAD, inflammatory markers, including interleukin-6, intracellular adhesion molecule-1, and high-sensitivity C-reactive protein, mediate the connection between depression and disease severity, with gender and ethnicity influencing the expression of biomarkers and clinical outcomes. In AAA, factors like smoking and exposure to air pollution have increased matrix metalloproteinase levels and other inflammatory markers. Additionally, estradiol provides partial protection in women, underscoring the role of hormones and environmental influences in disease progression. Social determinants such as socioeconomic status, healthcare access, and ethnicity significantly affect biomarker levels and arterial disease progression.

CONCLUSIONS

These findings are crucial for the assumption that social determinants of health modulate the levels of inflammatory biomarkers involved in the progression of arterial diseases such as CAD, CS, PAD, and AAA. This highlights the need to integrate highly predictive mathematical systems into clinical practice, combining biological sciences with social sciences to achieve advanced standards in precision medicine. However, further studies are needed to validate these approaches fully.

Investigating socioeconomic disparities in prescribing new diabetes medications in individuals with type 2 diabetes and very high cardiovascular risk in the Netherlands

AIMS

This study aims to analyze prescription patterns of new diabetes medication and assess socioeconomic disparities in their initiation among individuals with T2DM with very high cardiovascular risk.

METHODS

Individuals diagnosed with T2DM and very high cardiovascular risk were identified (N = 10,768) based on general practitioner's electronic health record data. SGLT-2is and GLP-1RAs prescription patterns were examined. Furthermore, the association between SES and the prescription of SGLT-2is and GLP-1RAs in 2022 was investigated.

RESULTS

Despite the increase in prescription rates of SGLT-2is and GLP-1RAs between 2019 and 2022, approximately 85 % and 93 % of eligible individuals did not receive SGLT-2is and GLP-1RAs in 2022, respectively. We found a positive association between SGLT-2is prescription and SES in only the 4th quintile compared to 1st quintile (referent) in the fully adjusted model (OR 1.29 95 % CI:1.08-1.54).

CONCLUSIONS

The prescription rates among eligible individuals highlight significant room for improvement in aligning prescribing practices with guidelines. We found no profound socioeconomic gradient in initiation of SGLT-2is and GLP-1RAs. The latter may be due to guidelines' clear indication of the eligible population and GP education. Future development and potential disparities in initiation and maintenance should be monitored to ensure equitable prescribing.

2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" incorporates new evidence since the "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction" and the corresponding "2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes" and the "2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction." The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" and the "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization" retire and replace, respectively, the "2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease."

METHODS

A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Machine learning-based prediction of elevated N terminal pro brain natriuretic peptide among US general population

AIMS

Natriuretic peptide-based pre-heart failure screening has been proposed in recent guidelines. However, an effective strategy to identify screening targets from the general population, more than half of which are at risk for heart failure or pre-heart failure, has not been well established. This study evaluated the performance of machine learning prediction models for predicting elevated N terminal pro brain natriuretic peptide (NT-proBNP) levels in the US general population.

METHODS AND RESULTS

Individuals aged 20-79 years without cardiovascular disease from the nationally representative National Health and Nutrition Examination Survey 1999-2004 were included. Six prediction models (two conventional regression models and four machine learning models) were trained with the 1999-2002 cohort to predict elevated NT-proBNP levels (>125 pg/mL) using demographic, lifestyle, and commonly measured biochemical data. The model performance was tested using the 2003-2004 cohort. Of the 10 237 individuals, 1510 (14.8%) had NT-proBNP levels >125 pg/mL. The highest area under the receiver operating characteristic curve (AUC) was observed in SuperLearner (AUC [95% CI] = 0.862 [0.847-0.878], P < 0.001 compared with the logistic regression model). The logistic regression model with splines showed a comparable performance (AUC [95% CI] = 0.857 [0.841-0.874], P = 0.08). Age, albumin level, haemoglobin level, sex, estimated glomerular filtration rate, and systolic blood pressure were the most important predictors. We found a similar prediction performance even after excluding socio-economic information (marital status, family income, and education status) from the prediction models. When we used different thresholds for elevated NT-proBNP, the AUC (95% CI) in the SuperLearner models 0.846 (0.830-0.861) for NT-proBNP > 100 pg/mL and 0.866 (0.849-0.884) for NT-proBNP > 150 pg/mL.

CONCLUSIONS

Using nationally representative data from the United States, both logistic regression and machine learning models well predicted elevated NT-proBNP. The predictive performance remained consistent even when the models incorporated only commonly available variables in daily clinical practice. Prediction models using regularly measured information would serve as a potentially useful tools for clinicians to effectively identify targets of natriuretic-peptide screening.

Income, education, and the clustering of risk in cardiovascular disease in the US, 1999-2018: an observational study

Background

Health metrics in the United States (US) have lagged behind other high-income countries in recent decades, and show persistent gaps between socio-demographic groups. Top 20% income earners and college graduates have also increasingly diverged from the reminder of the population in various dimensions over the past few decades. This study described population patterns in cardiovascular diseases (CVD) by income and education over a twenty-year period.

Methods

This analysis used nationally representative data from 10 cycles (1999-2018) of the National Health and Nutrition Examination Survey (NHANES). Participants were stratified by income and education into four groups: top 20% income earners, college graduates; top 20% income earners, non-college graduates; bottom 80% income earners, college graduates; and bottom 80% income earners, non-college graduates. For income, we created a binary variable (ratio > 5 cutoff) using NHANES income-to-poverty ratio variable to create a standardized measure of income. We calculated the age-standardized prevalence and odds ratios of four conditions: congestive heart failure (CHF), angina, heart attack, and stroke, for each income-education group.

Findings

49,704 participants reported data for both income and education. The age-standardized prevalence of CVD outcomes varied across the four groups. This was most significant when comparing the prevalence among the top 20% income, college graduate group to the bottom 80% income, non-college graduate group: CHF (0.5% vs. 3.0%), angina (1.4% vs. 2.8%), heart attack (1.7% vs. 3.9%), and stroke (1.1% vs. 3.4%). Compared to the top 20% income, college graduate group, the odds of all CVD conditions were significantly higher in the bottom 80% income groups (college graduates: odds ratios (ORs) 1.48-3.67; non-college graduates: ORs 2.36-6.52), as well as for CHF and heart attack in the top 20% income, non-college graduates (OR 3.11 [95% CI: 1.92, 5.06] and OR 1.92 [95% CI: 1.35, 2.73], respectively).

Interpretation

Health gaps extend beyond extremes, with risk clustering favoring top 20% income earners with college degrees while most Americans are left behind. Future research should include longitudinal studies that focus on the mechanisms through which both income and education intersect to shape CVD outcomes in the US.

Funding

The Rockefeller Foundation.

Racial Disparities in Outcomes of Delivery and Cardiac Complications Among Pregnant Women with Congenital Heart Disease

Advances in cardiology have led to improved survival among patients with congenital heart disease (CHD). Racial disparities in cardiovascular and maternal outcomes are well known and are likely to be more profound among pregnant women with CHD. Using the 2001 to 2018 National Inpatient Sample, we identified all hospitalizations for delivery among women ≥ 18 years of age with CHD. Unadjusted and adjusted between-race differences in adverse maternal cardiovascular, obstetric, and fetal events were assessed using logistic regression models. During the study period, we identified 52,711 hospitalizations for delivery among women with concomitant CHD. Of these, 66%, 11%, and 16% were White, Black, and Hispanic, respectively. Obstetric complications and fetal adverse events were higher among Blacks compared to Whites and Hispanics (44% vs. 33% vs. 37%, p < .001; 36% vs. 28% vs. 30%, p < .001), respectively. No between-race differences were observed in overall cardiovascular adverse events (27% vs. 24% vs. 23%, p < .21). However, heart failure was significantly higher among Black women (3.6% vs. 1.7% vs. 2.2%, p = 0.001). While a lower income quartile was associated with higher rates of adverse outcomes, adjustment for income did not attenuate the adverse impact of race. Black females with CHD diagnoses were more likely to experience adverse obstetric, fetal events, and heart failure compared to White and Hispanic women irrespective of their income status. Further research is needed to identify causes and devise interventions to mitigate racial disparities in the care of pregnant women with CHD.

Rurality and Area Deprivation and Outcomes After Out-of-Hospital Cardiac Arrest

Importance

Large regional variations in outcomes after out-of-hospital cardiac arrest (OHCA) exist.

Objective

To assess whether neighborhood rurality or economic deprivation where an OHCA occurred is associated with variation in emergency medical services (EMS) outcomes after OHCA.

Design, Setting, and Participants

This cohort study used data collated by ESO Inc on US adult patients (aged ≥18 years) with nontraumatic OHCA receiving chest compressions or defibrillation from EMS between January 1, 2022, and December 31, 2023.

Exposures

Rurality was assessed using Rural-Urban Commuting Area codes. Deprivation was assessed using the Area Deprivation Index. Both were derived from US Census data and grouped by EMS agency.

Main Outcomes and Measures

Outcomes were restoration of spontaneous circulation (ROSC) at emergency department (ED) arrival, survival to hospital discharge, and favorable discharge destination. Discharge outcomes were only available for patients transported to hospitals using health data exchange. Generalized estimating equations were used to account for correlated data.

Results

A total of 162 289 patients with OHCA had resuscitation attempted (median [IQR] age, 66 [53-76] years; 62.3% male). Overall, 28.1% of these patients lived in rural or suburban locations, 12.3% lived in areas with high deprivation, 18.7% had a first rhythm of ventricular tachycardia or ventricular fibrillation or shockable by automated external defibrillator rhythm, and 27.6% received bystander cardiopulmonary resuscitation. The mean (SD) EMS response time was 8.7 (5.6) minutes. Upon arrival at the ED, 23.7% of patients had ROSC. Compared with OHCAs in urban areas with low deprivation, those in rural areas with high deprivation (adjusted odds ratio [AOR], 0.81; 95% CI, 0.72-0.91), moderate deprivation (AOR, 0.75; 95% CI, 0.70-0.81), or low deprivation (AOR, 0.74; 95% CI, 0.62-0.88) had lower odds of ROSC at ED arrival. Among patients transported to hospitals using health data exchange, OHCAs in urban areas with high or moderate deprivation had lower odds of survival (AOR, 0.78 [95% CI, 0.68-0.90] and 0.82 [95% CI, 0.75-0.89], respectively) and favorable discharge destination (AOR, 0.65 [95% CI, 0.53-0.79] and 0.77 [95% CI, 0.69-0.87], respectively).

Conclusions and Relevance

In this cohort study, OHCAs in rural areas of all levels of economic deprivation were associated with less ROSC at ED arrival vs urban areas with low deprivation, and OHCAs in urban areas with high or moderate deprivation are associated with less survival and less favorable discharge destination, suggesting worse neurologic outcomes. Care improvements alone may not reduce geographic differences in outcomes after OHCA.

Particulate matter, socioeconomic status, and cognitive function among older adults in China

BACKGROUND

Both air pollution and low socioeconomic status (SES) are associated with worse cognitive function. The extent to which low SES may compound the adverse effect of air pollution on cognitive function remains unclear.

METHODS

7,087 older adults aged 65 and above were included from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) and followed up in 4 waves during 2008-2018. Cognitive function was measured repeatedly at each wave using the modified Chinese Mini-Mental State Examination (MMSE). Concentrations of particulate matter (PM1, PM2.5, and PM10) were evaluated using satellite-based spatiotemporal models. SES was measured based on five components and categorized into three levels (low, middle, and high). Generalized estimating equation models were used to estimate the association of PM and SES with cognitive function. Stratified analyses and effect modification by SES levels were further conducted.

RESULTS

Each 10 µg/m3 increase in PM1, PM2.5, and PM10 was associated with a 0.43 (95 % CI: -0.58, -0.27), 0.29 (95% CI: -0.37, -0.20), and 0.17 (95 % CI: -0.22, -0.13) unit decrease in MMSE scores, respectively. Lower SES was associated with worse cognitive function. Significant effect modifications were observed by SES, with the corresponding association of PM exposure being more pronounced among participants with a lower SES (p-interaction = 0.006, 0.001, and 0.006 for PM1, PM2.5, and PM10, respectively).

CONCLUSIONS

SES is an important effect modifier, and lower SES may compound the detrimental effect of PM on cognitive health. This finding may have implications for identifying vulnerable populations and targeted interventions against air pollution.

Uncovering actionable cardiovascular risk subgroups in type 2 Diabetes: A latent class analysis

AIMS

The study aimed to identify type 2 diabetes subgroups with varying, actionable cardiovascular disease (CVD) risk factor patterns and explored subgroup differences in characteristics and three-year CVD incidence.

METHODS

A Latent Class Analyses was performed to determine classes with similar lifestyle and psychosocial CVD risk patterns, predictive value of demographic, socioeconomic and medical factors, and class differences in CVD outcomes.

RESULTS

The 3-class model was superior. The 'low risk' class was largest (71.2 %). The 'mobility related risk' class (19.3 %) showed high probability of limitations in mobility (0.90) and not meeting the exercise norm (0.89). The 'psychosocial risk' class (9.5 %) had similar risks, with additional probabilities to be lonely (0.49) and have anxiety and depression (0.56). Strong predictors (OR ≥ 2.00) for membership of risk classes were: female gender, non-western immigrant status, lower education, financial difficulties, being unfit for work and/or prior heart failure. Three years CVD incidence was lower in members of the 'low risk' class had cardiology care and/or stroke diagnosis compared to the risk classes.

CONCLUSIONS

Diverse lifestyle and psychosocial CVD risk factor patterns impact CVD outcomes in individuals with type 2 diabetes, emphasizing the necessity of a whole-person CVD prevention tailored to the person's needs.

Associations Between Social Determinants of Health, Allostatic Load, and Anthracycline Cardiotoxicity in a Diverse Patient Population

BACKGROUND

Allostatic load (AL) is a measurement of physiological burden of chronic stress, operationalized using a composite score derived from biomarkers from multiple physiologic systems. The relationship between AL and anthracycline cardiotoxicity is unclear.

METHODS AND RESULTS

We included consecutive adult patients who underwent anthracycline-based chemotherapy from 2016 to 2019 for any type of cancer. Patients with preexisting heart failure and lack of AL score measures were excluded from the analysis. A composite AL score was calculated using 9 biomarkers tested before initiating chemotherapy. The end point was the development of cardiotoxicity (defined as clinical heart failure or drop in left ventricular ejection fraction≥10% to <50%). A total of 718 patients were included in the analysis (29% Non-Hispanic White, 31% Non-Hispanic Black, 40% Hispanic). The mean AL score was 2.4±1.4 and it was significantly higher in Non-Hispanic Black and Hispanic patients compared with Non-Hispanic White patients (2.5±1.3 in Non-Hispanic Black versus 2.4±1.3 in Hispanic versus 2.1±1.5 in Non-Hispanic White, P=0.031). In patients who developed cardiotoxicity, AL score was significantly higher than patients without cardiotoxicity (2.7±1.4 versus 2.3±1.3, P=0.006). AL score was independently associated with incident anthracycline cardiotoxicity after adjusting for race and ethnicity, age, sex, cardiovascular risk factors, anthracycline dose, baseline left ventricular ejection fraction, cancer type, and cancer metastasis (hazard ratio 1.20 per 1 AL score increase [95% CI, 1.02-1.43], P=0.033). AL score remained significantly associated with anthracycline cardiotoxicity after additional adjustment of social determinants of health.

CONCLUSIONS

AL score can be a potential important prognostic marker in the prediction of cardiotoxicity in patients with cancer undergoing cardiotoxic treatment independent of social determinants of health.

Understanding macroeconomic indicators affected by COVID-19 containment policies in the United States: a scoping review

Containment policies were essential in controlling the spread of the COVID-19 pandemic in the United States, but they also introduced significant economic challenges. This scoping review aimed to examine the macroeconomic indicators used to assess COVID-19 closure and containment policies in the United States. We reviewed 42 eligible studies from 4516 records identified across PubMed, Web of Science, and EconLit. These studies explored various economic impacts, focusing on employment, labor market indicators, consumer spendings, etc., primarily using publicly available sources. During the pandemic, high-frequency data (eg, mobility and card transactions) became newly accessible and played a key role in evaluating the real-time effects of mitigation policies. Our review summarizes macroeconomic indicators investigated and provides researchers and policymakers with a list of data sources for assessment of economic impacts in the future. This review emphasizes the need for comprehensive evaluations to balance public health measures with economic considerations in future pandemic responses.

Socio-economic position and sudden cardiac death: a Danish nationwide study

AIMS

The aim of this study was to examine differences in incidence rates of all-cause mortality (ACM) and sudden cardiac death (SCD) in persons of differing socio-economic position (SEP).

METHODS AND RESULTS

All deaths in Denmark from 1 January to 31 December 2010 (1 year) were included. Autopsy reports, death certificates, discharge summaries, and nationwide health registries were reviewed to identify cases of SCD. Socio-economic position was measured as either household income or highest achieved educational level and analysed separately. Hazard rates were calculated using univariate and multivariable Cox regression models adjusting for age, sex, and selected comorbidities. A total of 53 452 deaths were included, of which 6820 were classified as SCDs. Incidence rates of ACM and SCD increased with age and were higher in the lower SEP groups. The greatest difference in SCD incidence was found between the low and high education level groups, with an incidence rate ratio of 5.1 (95% confidence interval 3.8-6.8). The hazard ratios for ACM and SCD were significantly higher for low SEP groups, independent of comorbidities. Compared with the highest income group, the low-income group had adjusted hazard ratios of ACM and SCD that were 2.17 (2.01-2.34) and 1.72 (1.67-1.76), respectively.

CONCLUSION

We observed an inverse association between both income and education level and the risk of ACM and SCD in the general population, which persisted independently of baseline comorbidities. Our results indicate a need for further research into the mechanisms behind socio-economic disparities in healthcare and targeted preventative strategies.

Ethnic variations in cardiovascular disease (CVD) risk factors and associations with prevalent CVD and CVD mortality in the United States

OBJECTIVE

To explore the association between ethnicity and cardiovascular disease (CVD) risk factors, including physical inactivity, obesity, hypertension, type 2 diabetes (T2D), lack of health insurance and low family income in a nationally representative sample of U.S. adults.

RESEARCH DESIGN AND METHODS

Adults from the National Health and Nutrition Examination Survey (NHANES 2011-2020, n = 17,355) were classified as having CVD risk factors based on both self-reported and metabolic data. Ethnic differences in how these CVD risk factors relate to prevalent CVD and CVD mortality was examined in Whites, Blacks, Asians and Hispanics.

RESULTS

Compared to Whites, significant disparities were noted in several CVD risk factors in ethnic minorities, such as lower PA, lower income, and more prevalent metabolic risk factors. Blacks and Hispanics commonly had higher prevalent CVD risk as compared to Whites even after adjusting for income and metabolic risk factors. Physical inactivity was most strongly associated with prevalent CVD and CVD mortality among Whites and Blacks. There were no ethnic differences in the inverse association between income and prevalent CVD risk, but Blacks with low income were associated with the greatest elevated CVD mortality. Hypertension and T2D were similarly related with prevalent CVD across ethnic groups, but Blacks and Hispanics with hypertension or T2D were at greater CVD mortality risk as compared to Whites.

CONCLUSION

Our study identified that socioeconomic and metabolic risk factors may relate differently to CVD outcomes among ethnic minority groups in the United States. Addressing these ethnic disparities in health warrants further investigation.

Lactation duration and ischemic heart disease among parous postmenopausal females from a prospective cohort study

BACKGROUND

This study aimed to evaluate the association of lactation duration with incident ischemic heart disease (IHD) and to determine the potential health gains from scaling up breastfeeding practice.

METHODS

130,147 parous postmenopausal females without IHD were included at baseline (2004-2008) from the China Kadoorie Biobank study. Lactation duration was self-reported and measured as lifetime, per child, and first child, respectively. Incident IHD was identified during follow-up (2004-2015). The dose-response associations between lactation duration and IHD were examined using Cox models with restricted cubic splines. Stratification analyses were conducted by socioeconomic status (SES) and residence. The number of preventable IHD cases was estimated using the population attributable fraction and potential impact fraction in various scenarios.

RESULTS

The study shows that parous postmenopausal females who ever lactated have significantly lower risks of IHD, with adjusted hazard ratios (aHRs) varying from 0.71 (95%CI: 0.63-0.80) to 0.85 (95%CI: 0.75-0.96) for a lifetime, from 0.70 (0.63-0.78) to 0.82 (0.72-0.93) for per-child, and from 0.80 (0.74-0.87) to 0.92 (0.85-0.99) for the first-child, appearing as U-shaped associations. Similar associations are found in females with low SES and urban residence. The scaling up of breastfeeding to near-universal levels could have prevented up to 115,000 new IHD cases among Chinese females aged over 40 years in 2019.

CONCLUSIONS

Lactation demonstrates potential benefits in reducing IHD risk, appearing as U-shaped associations among Chinese parous postmenopausal females, especially for those with low SES in urban areas. Scaling up breastfeeding practices serves as a promising strategy for reducing the IHD burden in China.

Accelerated Metabolomic Aging and Its Association with Social Determinants of Health in Multiple Sclerosis

Objectives

Biological age may better capture differences in disease course among people with multiple sclerosis (PwMS) of identical chronological age. We investigated biological age acceleration through metabolomic age (mAge) in PwMS and its association with social determinants of health (SDoH) measured by the area deprivation index (ADI).

Methods

mAge was calculated for three cohorts: 323 PwMS and 66 healthy controls (HCs); 102 HCs and 72 DMT-naïve PwMS; and 64 HCs and 67 pediatric-onset MS/clinically isolated syndrome patients, using an aging clock derived from 11,977 healthy adults. mAge acceleration, the difference between mAge and chronological age, was compared between groups using generalized linear and mixed-effects models, and its association with ADI was assessed via linear regression.

Results

Cross-sectionally, PwMS had higher age acceleration than HCs: 9.77 years in adult PwMS (95% CI:6.57-12.97, p=5.3e-09), 4.90 years in adult DMT-naïve PwMS (95% CI:0.85-9.01, p=0.02), and 6.98 years (95% CI:1.58-12.39, p=0.01) in pediatric-onset PwMS. Longitudinally, PwMS aged 1.19 mAge years per chronological year (95% CI:0.18, 2.20; p=0.02), faster than HCs. In PwMS, a 10-percentile increase in ADI was associated with a 0.63-year (95% CI:0.10-1.18; p=0.02) increase in age acceleration.

Discussion

We demonstrated accelerated mAge in adult and pediatric-onset PwMS and its association with social disadvantage.

Hospital Volume and Social Determinants of Health Do Not Impact Outcomes in Fenestrated Visceral Segment Endovascular Aortic Repair for Patients Treated at VQI Centers

ObjectiveThe purpose of this study is to investigate the impact of social determinants of health on access to high volume centers and clinical outcomes in fenestrated abdominal aortic endografting. Further, the effect of center volume in fenestrated endografting on outcomes will be sought as this is ill defined. The data herein have the potential to affect referral patterns and locations of complex fenestrated aortic aneurysm care. If lower volume centers achieve equivalent outcomes to higher volume centers, then limiting access to a small number of centers may not be justified.MethodsVascular Quality Initiative (VQI) was utilized as the data source. Four adverse outcomes categories were investigated : (1) Lack of follow up data in the VQI database at 1 year postoperatively; (2) Thirty day operative mortality; (3) Composite perioperative adverse event outcome; and (4) Twelve month mortality. Social determinants of health exposure variables included rural status, non-metropolitan living area, highest and lowest decile and quintile area deprivation index, insurance status, and non-home living status. Designated categories were created for patients operated on in centers within the top 25% of case volume, centers in the bottom 25% of case volume, and in centers with less than 10 total fenestrated endograft cases. Univariable analyses were performed with Chi-squared testing for categorical variables and t test for comparison of means. Multivariable binary logistic regression was performed to identify risks for the composite adverse perioperative event.ResultsThere was no statistically significant association with the composite adverse perioperative event category, 30-day mortality or 12-month mortality for any of the social determinants of health or center volume categories. Patients who live in rural areas (P = .029) and patients with Military/VA insurance (P < .001) were significantly more likely to be lost to follow up at their index VQI center at 1 year. When accounting for all standard co-morbidities, none of the following variables had any significant association with the composite adverse perioperative event on multivariable analysis: absolute center volume as an ordinal variable (P = .985); procedure at a bottom 25th percentile volume center (P = .214); procedure at a center with less than 10 total fenestrated cases in the database (P = .521); rural home status (P = .622); remote from metropolitan home status (P = .619); highest 10% ADI (P = .903); highest 20% ADI (P = .219); Lowest 10% of ADI (P = .397). The variables that had a statistically significant multivariable association with the composite adverse event were 3 or 4 visceral vessels stented vs 2 vessels (P < .001), baseline renal insufficiency (P < .001), female sex (P < .001), ESRD on dialysis (P = .002), and history of coronary revasculizaiton (P = .047). There was noted to be a statistically significant (P < .01) increase in 30 day mortality, composite adverse perioperative event, and 12 month mortality in moving from 2 to 3 to 4 fenestrated stented vessels. However, amongst patients who were treated with 3 and 4 vessel fenestrated stenting, patients treated at bottom 25th percentile centers and centers with less than 10 total cases did not experience a higher rate of composite adverse perioperative event, 30 day mortality, or 12 month mortality relative to top 25% volume centers indicating safety of these procedures in lower volume centers.ConclusionsSocial determinants of health and center volume do not impact outcomes in fenestrated visceral segment aortic endograft procedures performed at centers participating in the Vascular Quality Initiative. There is progressive morbidity and mortality in moving from 2 to 3 to 4 visceral stents and fenestrations, however lower volume centers within VQI achieve equivalent outcomes to high volume centers in performing 3 and 4 vessel visceral fenestrated stent cases. Female sex, ESRD, prior coronary revascularization, and baseline renal insufficiency portend an increased risk for perioperative morbidity for fenestrated visceral segment aortic endografting.

Survival and neurological outcomes among OHCA patients in middle- and high-income countries in the Asia-Pacific

BACKGROUND

Currently, there is a knowledge gap on how OHCA impacts lower-resourced areas, and how they fare compared to their higher-resourced counterparts. This study aims to explore the relationship between a country's income category and neurological outcomes after OHCA in the Asia-Pacific region.

METHODS

A multivariable logistic regression model was applied to the prospective Pan-Asian Resuscitation Outcomes Study (PAROS) dataset. The main exposure was country income status (defined by the World Bank), and the main outcome was neurological outcomes (measured by cerebral performance category score). Sensitivity analyses were run to evaluate the robustness of our findings.

RESULTS

Out of a total of 207,450 PAROS cases between 2009-2018, 168,967 OHCA cases were included in the study. 165,404 cases were from high-income countries and 3,563 cases were from middle-income countries. All pediatric, pronounced dead at scene, unknown on-scene survival status, no resuscitation attempted, and traumatic cases were excluded from the analysis. A larger proportion of OHCA patients in high-income countries survived with favorable neurological outcomes (3.65%) compared to middle-income countries (0.75%). High-income countries were associated with better neurological outcomes (AOR 9.05; 95% CI 6.27 to 13.72). Results remained consistent throughout sensitivity analyses.

CONCLUSION

In the PAROS cohort, high-income countries outperform middle income countries in post-OHCA neurological outcomes. Further research is needed to obtain better quality data in middle-income countries and expand reach into low-income countries.

An audit of physical waste and fluoroscopy energy consumption in vascular surgery and suggestions for the future

OBJECTIVE

Hospitals are responsible for 4% to 5% of global greenhouse gas production and are significant contributors to climate change. We sought to understand the contributions of vascular surgery to the carbon footprint of hospitals by examining emissions from fluoroscopy and physical waste across common vascular surgeries.

METHODS

Vascular operations at a single tertiary hospital were prospectively audited for physical waste. Additional cases from the same hospital were audited retrospectively for energy expenditure during fluoroscopy digital subtraction angiography (DSA). The fluoroscopy time (minutes), number of DSA runs, amplitude, and voltage were recorded, and subsequently, power (kW) and energy (kWh) were calculated. The operations were separated into cohorts based on operation: endovascular aneurysm repair, thoracic endovascular aortic repair, transcarotid artery revascularization (TCAR), carotid endarterectomy, femoral endarterectomy with iliac intervention, lower extremity bypass, endovascular lower extremity revascularization. Using a certified Greenhouse Gas Equivalencies Calculator from the United States Environmental Protection Agency, total carbon dioxide emissions (CO2e) were estimated.

RESULTS

Eighteen vascular operations were audited for physical waste. Lower extremity bypasses produced the largest amount of CO2e from physical waste (85.75 kg CO2e; 95% confidence interval [CI], 71.4-100.2 kg), whereas the least was produced by carotid endarterectomy (57.22 kg CO2e; 95% CI, 48.7-65.7 kg). No significant correlation was seen between operative length and amount of waste. Ninety-seven operations were retrospectively audited for fluoroscopy energy use during DSA runs. Endovascular aortic repair produced the largest CO2e from DSA runs (41.11 kg; 95% CI, 28.82-53.40 kg), whereas the least was produced by TCAR (7.33 kg; 95% CI, 5.15-9.49 kg). When DSA CO2e were analyzed against fluoroscopy time, thoracic endovascular aortic repair produced CO2e at the highest rate of 3.63 kg/min DSA, whereas TCAR produced CO2e at the lowest rate of 1.37 kg/min DSA. Although no linear correlation was found between operation length and CO2e from waste (r2 = 0.099), a linear correlation was found between fluoroscopy time and CO2e (r2 = 0.76).

CONCLUSIONS

Vascular operations, on average, generate 108.47 kg of CO2e from waste and fluoroscopy, the equivalent of driving an average gasoline-powered vehicle for 278 miles. This study found a correlation between increased fluoroscopy time and CO2e. It also found that the rate of emissions differs between different operations, suggesting a role in optimizing fluoroscopy and intraoperative techniques to lower emissions. Efforts to track current energy output from imaging devices, investing in efficient devices, and adjusting intraoperative settings may all play a role in decreasing vascular surgery's environmental footprint.

The Perception of Illness in People with Advanced Chronic Kidney Disease

Background/objectives: Chronic kidney disease (CKD) has become an important public health issue; however, there are few investigations regarding the perception of CKD in its advanced stages. Personalized medicine approaches, which take into account knowledge of the disease, symptoms and treatment responses, can improve the perception of the disease and help control the progression of CKD. This study aimed to describe illness perception in people with advanced CKD in primary healthcare settings. Methods: A cross-sectional and multicenter descriptive study was conducted amongst a sample of 189 people over 18 years of age with advanced CKD and a glomerular filtration rate between 15 and 29 mL/min/1.73 m2 in three community health centers, including rural and urban areas, during 2023. Data on sociodemographic and clinical variables were collected through an ad hoc questionnaire and those on the perception of disease through the Brief Illness Perception Questionnaire. Nurses at the centers collected data from the study. Results: The mean age was 79.7, and all participants suffered from another chronic condition in addition to CKD. The mean total score for perception of the disease was 44.02 points, and the dimensions of the duration of treatment control and understanding had the highest evaluations. Men had a greater perception in the dimensions of concern (p = 0.023) and understanding (p = 0.006). The dimension of consequences showed a correlation with identity (Spearman's Rho 0.688; p = 0.001), and concern about the disease was associated with emotional response (Spearman's Rho 0.689; p < 0.001). A higher number of hospital admissions was associated with a higher score on the questionnaire (B = 4.93; p < 0.001; CI: 3.01-6.84) in a multiple linear regression. Conclusions: Participants in this study with advanced CKD had low illness perception; women expressed less concern in understanding their health status. Higher symptom burden was linked to greater illness perception, greater emotional impact, and increased hospital admissions.

Food Insecurity and Its Cardiovascular Implications in Underresourced Communities

BACKGROUND

Food insecurity is linked to poorer cardiovascular health (CVH) outcomes, particularly in underresourced communities, where social determinants of health play a critical role. Despite the recognized connections, there remains a lack of empirical evidence delineating the implications of food insecurity on CVH. CVH, a broader concept than cardiovascular disease, encompasses the overall well-being of the cardiovascular system and is supported by favorable lifestyle choices and physiological metrics. Particularly in underresourced communities, the study of CVH could provide valuable insights for early intervention and targeted public health initiatives. This study aimed to fill this knowledge gap.

METHODS AND RESULTS

We conducted a cross-sectional analysis of baseline data from the E-DUCASS (Educational Strategy on a Vulnerable Population to Improve Cardiovascular Health and Food Insecurity) program (NCT05379842), a 24-month randomized study targeting participants at risk for food insecurity. CVH was assessed using the Life's Essential 8 score. The sample included 451 participants aged 12 to 80 years, stratified by age (30.6% children [aged 12-19 years], 35.9% young adults [aged 20-39 years], and 33.5% adults [aged 40-80 years]) and sex (42.1% men and 57.9% women). The mean CVH score was 65.1 (95% CI, 63.9-66.4), with diet, physical activity, nicotine exposure, and body mass index being the lowest-scoring metrics. Food insecurity significantly influenced CVH; those participants with severe food insecurity had lower CVH scores than those without (effect size, -2.83 [95% CI, -5.10 to -0.56]; P<0.05).

CONCLUSIONS

Our findings highlight the negative association between food insecurity and CVH in underresourced Mediterranean communities. These results underscore the need for strategies aimed at reducing cardiovascular risk, potentially through health literacy programs like E-DUCASS, that focus on improving lifestyle and alleviating food insecurity.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique Identifier: NCT05379842.

Cardiovascular disease-specific and all-cause mortality across socioeconomic status and lifestyles among patients with established cardiovascular disease in communities of China: data from a national population-based cohort

BACKGROUND

Evidence of socioeconomic status (SES)-related health inequality is scarce in patients with cardiovascular diseases (CVDs) who need both lifestyle change and medical care, particularly in developing countries.

METHODS

The study employed a nationwide population-based cohort design, covering all 31 provinces of Chinese mainland from September 2014 to March 2021. Participants aged 35-75 years with self-reported CVD diagnoses were included. Information on SES and lifestyle details were collected via a questionnaire, and the unequal mortality across SES groups and the mediating effects of lifestyles were explored.

RESULTS

Among the 104 718 participants included, 27 943 (26.7%) were allocated to high SES, 35 802 (34.2%) were allocated to medium SES and 40 973 (39.1%) were allocated to low SES. During a mean follow-up of 48.9±18.9 months, 5010 deaths were recorded. Participants with low SES had a 65% (HR=1.65, 95% CI: 1.50 to 1.80) greater risk of all-cause death and a 95% (HR=1.95, 95% CI: 1.72 to 2.20) greater risk of CVD death in Chinese communities. A low SES with the worst lifestyle was associated with a significant increase in the risk of all-cause mortality by 172% (HR=2.72, 95% CI: 2.37 to 3.12) and CVD mortality by 218% (HR=3.18, 95% CI: 2.64 to 3.83) compared with a high SES with healthy lifestyle. The joint mediating effects of lifestyles on CVD mortality accounted for 19.6% (95%CI: 14.8% to 24.2%) of the excess mortality risk for individuals with low SES, and these effects varied by genders (p for interaction=0.013) and urbanity (p for interaction=0.004). Leisure-time physical activity was the strongest mediator, followed by dietary factors. For all-cause mortality, outcomes were similar to this.

CONCLUSIONS

Both SES-related health inequalities and lifestyle disparities should be comprehensively considered when caring for this population, and upstream structural interventions that integrate SES and lifestyle factors and are tailored to the target population are urgently needed.

TRIAL REGISTRATION NUMBER

NCT02536456.

Developing a Novel Index for Individual-Level Social Determinants and Cardiovascular Diseases in the Coronary Artery Risk Development in Young Adults (CARDIA) Study

BACKGROUND

Social determinants of health (SDH) have been found to contribute to cardiovascular risk and the development of cardiovascular disease (CVD). However, few studies have examined early-life exposure to SDH and the combined effect of multiple SDH measures on CVD. There is an urgent need to develop an SDH index for use in practice and clinical settings.

METHODS

A total of 3189 participants from the CARDIA Study who had chest CT scans at the year-25 (Y25) visit were included in this study. Personal and parental SDH measures, including education, occupation, income, financial strain, and childhood family environment, were obtained through interviews. The participants' coronary artery calcification (CAC) was measured using chest CT scans, and left-ventricular mass (LVM) was measured using M-mode echocardiography. The values of the individual social determinants of health (iSDH) index were determined based on individual-level measures and CAC using a supervised learning method-the Boosted Regression Tree (BRT) model. This index's association with the LVM index (LVMI) was evaluated as an external validation using linear regression models adjusting for race, sex, BMI, smoking status, alcohol intake, and physical activity.

RESULTS

Each one-standard-deviation (SD) increase in the iSDH index was associated with an increase in LVMI ranging from 0.376 (95% CI -0.016, 0.767) at year 0 to 0.468 (95% CI 0.115, 0.821) at year 20. The association between the iSDH index and the LVMI was more pronounced as the participants aged. Also, the iSDH indices were more strongly associated with LVMI among Black participants (β = 0.969, 95% CI = 0.081, 1.858) than White participants (β = 0.202, 95% CI = -0.228, 0.633) at year 5.

CONCLUSIONS

Higher iSDH indices in early adulthood were associated with increased LVMI values in midlife. The association between the iSDH index and CVD was stronger among Black adults than with White adults.

The Impact of Social Deprivation on Outcomes in Forefoot Surgery

BACKGROUND

The impact of social deprivation (SD) on health outcomes is a topic of increasing interest in orthopaedics. There are limited studies and no clear consensus, though, on the impact of SD on outcomes in foot and ankle surgery. Area deprivation index (ADI) is a well-studied and validated surrogate metric for SD. We hypothesized that patients with greater SD would have worse patient-reported pain and physical function at baseline and at 6 weeks and 6 months following elective forefoot surgery.

METHODS

We retrospectively analyzed data from 477 forefoot surgeries between January 2015 and December 2022 to determine if SD was associated with patient-reported outcomes (PROs) related to pain and physical function. Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) assessments administered preoperatively and at 6 weeks and 6 months postoperatively. SD was quantified using the ADI. Patients were divided into high- and low-deprivation groups using the national median ADI of 50.

RESULTS

At baseline before surgery, PROMIS-PF and PROMIS-PI scores were similar between high and low social deprivation groups. At 6 weeks and 6 months after surgery, there were no significant differences between high- and low-deprivation groups for either PROMIS-PF or PROMIS-PI. Both groups (high and low social deprivation) demonstrated similar improvements in pain and function at 6 months after surgery. The only variable associated with outcomes was employment status, with disabled and unemployed patients exhibiting greater pain and less function before surgery. Disabled patients also had greater pain after surgery.

CONCLUSION

Based on our data, social deprivation did not appear to be associated with patient-reported pain or physical function prior to forefoot surgery or at 6 weeks or 6 months following surgery.

Health Disparities in Diagnosis and Treatment of Heterozygous Familial Hypercholesterolemia

OBJECTIVE

To examine the association of social determinants of health and age at heterozygous familial hypercholesterolemia (HeFH) diagnosis and treatment.

STUDY DESIGN

We performed a retrospective, single-center study of children with HeFH. Multivariable linear regression models were used to examine the association between Child Opportunity Index (COI) and age at HeFH diagnosis and statin initiation. Additional covariates included sex, race, ethnicity, health insurance type, primary language, body mass index percentile, and low-density lipoprotein cholesterol (LDL-C). To explore potential referral bias, we compared the COI of the study cohort with that of the institution's catchment area.

RESULTS

We evaluated 577 patients. The median age at presentation was 12 (9, 14) years and the median LDL-C was 199 (169, 235) mg/dL; 58% were prescribed a statin at a median age of 13 (10, 15) years. There was no association between COI and the age at HeFH diagnosis or statin initiation. On multivariable analysis, Black race was associated with older age at HeFH diagnosis but not statin initiation compared with White race (adjusted estimate 1.1 ± 0.50 yrs, P = .023). Higher LDL-C, male sex, and lower body mass index percentile were associated with younger age at HeFH diagnosis and statin initiation. The COI of the study cohort was significantly higher than that of the catchment area (P < .001).

CONCLUSIONS

Black race was associated with older age at HeFH diagnosis; however, there were no differences in age at statin initiation. The COI of the cohort was significantly higher than that of the catchment area indicating that low COI populations are likely under-referred for HeFH evaluation.

Ethnic disparities in STEMI outcomes among older adults: a comparative study of bedouins and jews

BACKGROUND

ST-Elevation Myocardial Infarction (STEMI) is a critical condition, especially in the older population, who are at increased risk due to comorbidities and delayed diagnosis. This study aimed to investigate the impact of ethnicity on the clinical characteristics, treatment timelines, and outcomes of older patients with STEMI in southern Israel, comparing Jewish and Bedouin populations.

METHODS

We conducted a retrospective cohort study at Soroka University Medical Center from 2016 to 2022, including older patients (≥ 65 years) diagnosed with STEMI. Patients were grouped by ethnicity: Jews and Bedouins. Data on demographics, comorbidities, treatment timelines, and clinical outcomes were collected. Statistical analysis included a comparison analysis and a multivariable logistic regression, adjusting for potential confounders.

RESULTS

575 older patients diagnosed with STEMI were included in the study, of them 469 Jews (81.6%) and 106 Bedouins (18.4%). The mean age of the cohort was 74.35 ± 7.33 years, with no significant difference between Jews (74.56 years 7.53) and Bedouins (73.40 ± 5.99 years, p = 0.139). Bedouins had higher rates of diabetes (53.8% vs. 40.7%, p = 0.019) and smoking (40.6% vs. 27.9%, p = 0.015) and were less likely to arrive by ambulance (39.6% vs. 62.5%, p < 0.00). Bedouins also experienced longer median times from pain onset to first medical contact (126.5 min vs. 90.0 min, p = 0.006) and total ischemic time (240.0 min vs. 205.0 min, p = 0.003). Despite these differences, there were no significant differences in in-hospital mortality (13.2% Bedouins vs. 10.9% Jews, p = 0.606), 30-day mortality (14.2% Bedouins vs. 11.5% Jews, p = 0.556), or one-year mortality (21.7% Bedouins vs. 20.9% Jews, p = 0.959). Multivariable analysis confirmed no significant association between ethnicity and mortality outcomes.

CONCLUSIONS

Despite the higher prevalence of comorbidities among Bedouin patients, less likely to arrive by ambulance, and experienced longer delays in receiving care, their mortality outcomes were comparable to Jewish patients. These findings highlight the effectiveness of the acute care system in southern Israel. However, further research is needed to explore potential differences in other outcomes, such as quality of life and functional recovery, to better address healthcare disparities in this population.

Built Environment and Cardiovascular Diseases - Insights from a Global Review

PURPOSE OF REVIEW

This narrative review aims to synthesize global literature on the relationship between cardiovascular diseases (CVD) and components of built environment (green spaces, walkability, food environment, accessibility and availability of recreational and healthcare facilities, and effects of air and noise pollution).

RECENT FINDINGS

Increased green space and neighborhood walkability are associated with lower CVD mortality and morbidity; however, benefits have shown differential effects by socioeconomic status (SES). Air pollution is a leading environmental risk factor contributing to CVDs, and it disproportionately impacts low SES populations and women. Findings on relationships between food environment and CVDs are inconsistent and limited. This global review reports on the multifactorial and complex relationship between built environment and higher CVD risk and poor CVD outcomes. Future research can address an unmet need to understand this relationship with further depth and breadth, and to investigate resulting health disparities.

Sex Differences in the Relationship of Socioeconomic Position With Cardiovascular Disease, Cardiovascular Risk Factors, and Estimated Cardiovascular Disease Risk: Results of the German National Cohort

BACKGROUND

Using data from the largest German cohort study, we aimed to investigate sex differences in the relationship of socioeconomic position (SEP) with cardiovascular disease (CVD), CVD risk factors, and estimated CVD risk.

METHODS AND RESULTS

A total of 204 780 (50.5% women) participants from the baseline examination of the population-based NAKO (German National Cohort) were included. Logistic, multinomial, and linear regression models were used to estimate sex-specific odds ratios (ORs) and β coefficients with 95% CIs of CVD, CVD risk factors, and very high-risk score (Systemic Coronary Risk Estimation-2) for CVD associated with SEP. Women-to-men ratios of ORs (RORs) with 95% CIs were estimated. In women compared with men, low versus high SEP (educational attainment and relative income) was more strongly associated with myocardial infarction, hypertension, obesity, overweight, elevated blood pressure, antihypertensive medication, and current alcohol consumption, but less strongly with current and former smoking. In women with the lowest versus highest educational level, the OR for a very high 10-year CVD risk was 3.61 (95% CI, 2.88-4.53) compared with 1.72 (95% CI, 1.51-1.96) in men. The women-to-men ROR was 2.33 (95% CI, 1.78-3.05). For the comparison of low versus high relative income, the odds of having a very high 10-year CVD risk was 2.55 (95% CI, 2.04-3.18) in women and 2.25 (95% CI, 2.08-2.42) in men (women-to-men ROR, 1.31 [95% CI, 1.05-1.63]).

CONCLUSIONS

In women and men, there was an inverse relationship between indicators of SEP and the likelihood of having several CVD risk factors and a very high 10-year CVD risk. This association was stronger in women, suggesting that CVD risk is more strongly influenced by SEP in women compared with men.

An interactive visualization dashboard for predicting the effect of sacubitril/valsartan initiation in patients with heart failure

BACKGROUND

Sacubitril/valsartan (S/V) reduces mortality and hospitalization rates in patients with heart failure with reduced ejection fraction (HFrEF), but low adherence remains a challenge. Early initiation of S/V is recommended, yet no practical tool currently exists to effectively communicate its benefits to outpatients or assess patient stability before S/V initiation during hospitalization.

METHODS

We collected data retrospectively from 527 HFrEF patients who started S/V between March 2017 and January 2020 at the National Taiwan University Hospital, with follow-up through September 2022. A modern stepwise variable selection approach was applied to fit the optimal Cox's proportional-hazards model to address nonlinear covariate effects and potential multicollinearity. Penalized smoothing splines were used to visualize nonlinear effects and identify cutoff values for continuous covariates. The model was then integrated into an interactive Streamlit dashboard for real-time simulation and risk prediction based on patient-specific covariates.

RESULTS

We identified 20 key variables - 12 associated with increased risk and 8 conferring protective effects. Some variables presented actionable cutoff values. The predictive model helped estimate individualized hazard ratios and covariate-adjusted survival curves, which serve as both a patient engagement platform in outpatient settings and a practical tool for physicians to assess inpatient stability before initiating S/V.

CONCLUSION

Our interactive visualization dashboard can potentially improve medication adherence and clinical outcomes by involving patients in their treatment journey and facilitating more informed decision-making. A pragmatic clinical trial is currently underway to further evaluate the dashboard's clinical utility and effectiveness in both outpatient and inpatient environments.

Cardiovascular safety of fixed-dose extended-release naltrexone/bupropion in clinical practice

Background

The fixed-dose extended-release combination of naltrexone/bupropion (NB-ER) is indicated to treat overweight and obesity in adults as an adjunct to a reduced-calorie diet and increased physical activity. This study compared the rate of major adverse cardiovascular events (MACE) and its components (nonfatal acute myocardial infarction [AMI], nonfatal stroke, and cardiovascular death) between patients initiating NB-ER and those initiating lorcaserin (removed from US market in 2020; included as active comparator to minimize possible confounding by indication) in routine clinical practice.

Methods

This was a retrospective cohort study with a new-user, active-comparator design. Patients initiating NB-ER or lorcaserin were identified using Arcadia Data Research electronic health records, including insurance claims (June 2012-February 2020). Incidence rate ratios were estimated, and adjusted hazard ratios (aHRs) with 95 % confidence intervals (CIs) were estimated using a propensity score (PS)-weighted Cox proportional hazard model in an intention-to-treat analysis.

Results

Patients initiating NB-ER (n = 12 475) or lorcaserin (n = 12 171) were followed for a mean observation period of 4.7 years. After PS weighting, baseline comorbidities, concomitant medications, lifestyle factors, and clinical measures were balanced between cohorts. MACE incidence was 0.77/1000 person-years for NB-ER and 1.03/1000 person-years for lorcaserin. Compared to lorcaserin, patients initiating NB-ER had statistically similar rates of MACE (aHR, 0.76; 95 % CI, 0.48-1.22), nonfatal AMI (aHR, 0.74; 95 % CI, 0.45-1.23), and nonfatal stroke (aHR, 1.05; 95 % CI, 0.34-3.22). No deaths were observed within 30 days of an AMI or stroke.

Conclusion

Patients initiating NB-ER compared with lorcaserin were not at an increased risk of MACE or its components. Conclusions from this study must be interpreted in the context of certain assumptions related to PS methodology and use of lorcaserin as an active comparator. Causal interpretations for the cardiovascular safety of NB-ER should be evaluated further in a prospective, randomized, blinded, controlled clinical trial.

Procedural Complications and Inpatient Outcomes of Leadless Pacemaker Implantations in Rural Versus Urban Hospitals in the United States

BACKGROUND

Disparities in invasive cardiovascular care and outcomes in rural and urban hospitals across the United States have been reported. However, studies investigating disparities regarding leadless pacemaker outcomes and complications based on hospital location are lacking.

OBJECTIVE

To evaluate differences in outcomes and complications related to leadless pacemaker implantations among rural and urban hospitals.

METHODS

The National Inpatient Sample was used to identify patients who underwent leadless pacemaker implantations in the United States from 2016 to 2020. Study endpoints assessed included procedural complications and inpatient outcomes of leadless pacemaker implantations among rural and urban hospitals.

RESULTS

From 2016 to 2020, there were a total of 28 340 and 665 leadless pacemaker implantations in urban and rural hospitals, respectively. Baseline characteristics were similar among both groups, with notable exceptions of higher rates of coagulopathies (13.2% vs. 6.8%, p < 0.001) and peripheral vascular disorders (10.4% vs. 4.5%, p < 0.001) among urban patients. After multivariable adjustment for confounding variables, leadless pacemaker placements occurring in rural hospitals had lower odds of major complications (aOR 0.59, 95% CI 0.41-0.86), but increased odds of inpatient mortality (aOR 1.70, 95% CI 1.21-2.40). Overall, rural leadless pacemaker recipients experienced lower rates of discharge to home, as well as lower costs and length of stay.

CONCLUSIONS

A majority of leadless pacemaker implantations occurred in urban hospitals in the United States. Important differences in outcomes were described based on urban and rural hospital location. Further investigation and policy changes are encouraged to promote improved cardiovascular care and outcomes in rural residents.

Composite cardiovascular risk factor control in US adults with diabetes and relation to social determinants of health: The All of Us research program

Background

Data are limited on composite cardiovascular risk factor control in patients with type 2 diabetes mellitus (T2DM). This study aims to identify disparities in cardiovascular risk factor control based on most recent recommendations and relationships to social determinants of health in a large-scale real-world cohort of US adults.

Methods

We analyzed data from 88,416 participants with T2DM in the NIH Precision Medicine Initiative All of Us Research Program 2018-2022. We investigated the management of five key cardiovascular risk factors-glycated hemoglobin (HbA1c), LDL cholesterol (LDL-C), body mass index (BMI), blood pressure (BP), and smoking status. Statistical methods included Chi-square tests for categorical comparisons, t-tests for mean differences, and multiple logistic regression to assess the impact of demographic and socioeconomic factors on risk factor control.

Results

The study revealed low risk factor control with only 27.7 % of participants achieving recommended levels for three or more risk factors (RFs) and 4.9 % for four or more RFs. Overall, while 81.0% were at target for HbA1c, only 37.9% were at target for BP and 10.4% for LDL-C. Notably, only 1.9 % and 6.9 % were at target for HbA1c, LDL-C, and BP together, based on current and prior recommendations, respectively. Significant disparities were observed across race/ethnicity, sex, and socioeconomic lines with 43.1 % of Asian participants at control for ≥3 RFs compared to 21.1 % of non-Hispanic black participants. In logistic regression analysis, factors such as higher income, higher educational attainment, and health insurance were associated with better RF control, while higher polysocial risk scores linked to poorer control.

Conclusions

Despite some progress in managing individual CVD risk factors in T2DM, overall composite risk factor control remains poor, especially among underrepresented and socioeconomically disadvantaged groups. The findings highlight the necessity for integrated healthcare strategies that address both medical and social needs to improve control of CVD risk factors and outcomes in T2DM.

Achievement of guideline-based lipid goals among very-high-risk patients with atherosclerotic cardiovascular disease and type 2 diabetes: results in 213,380 individuals from the cvMOBIUS2 registry

Objective

Lowering lipid to reach guideline-indicated goals significantly reduces cardiovascular outcomes in very-high-risk (VHR) patients with atherosclerotic cardiovascular disease (ASCVD) and type 2 diabetes (DM2). How well VHR patients currently achieve these goals in community practice is unknown.

Methods

VHR patients with ASCVD and DM2 were identified across 14 US healthcare systems using electronic health records between 1/1/2021-12/31/2022. Achievement of guideline-based lipid goals was determined according to the 2018 AHA/ACC/Multisociety guideline, defined as either having a low-density lipoprotein-cholesterol <70 mg/dL or receiving maximal lipid-lowering therapy (i.e., on a PCSK9i monoclonal antibody). Multivariable logistic regression was used to evaluate factors associated with the achievement of these goals.

Results

Among 213,380 eligible patients (median age 71.0 years, 42 % women), 51.8 % achieved guideline-based lipid goals. Female sex (odds ratio [OR], 0.64; 95 % confidence interval [CI], 0.61-0.66), Black race (OR, 0.67; 95 % CI, 0.63-0.72 vs white race), and those on Medicaid (OR, 0.92; 95 % CI, 0.86-0.97 vs Medicare) were associated with a lower likelihood of achieving guideline-based lipid goals. Overall, 76.0 % of patients were on statin, 40.5 % were on a high-intensity statin and only 5.8 % were on a statin in combination with ezetimibe or a PCSK9i monoclonal antibody.

Conclusion

Almost half of all VHR patients with ASCVD and DM2 do not achieve current guideline lipid goals. Women, Black individuals, and those on Medicaid were significantly less likely to achieve these goals relative to their counterparts. Further targeted quality improvement interventions are needed to improve the equitable achievement of guideline-based lipid goals.

Social Determinants of Health in the Development of Cardiovascular-kidney-metabolic Syndrome

Cardiovascular-kidney-metabolic (CKM) syndrome is characterized by the interactions among the metabolic risk factors, chronic kidney diseases (CKD) and cardiovascular diseases (CVD). Social determinants of health (SDOH) include society, economy, environment, community and psychological factors, which correspond with cardiovascular and kidney events of the CKM population. SDOH are integral components throughout the entire spectrum of CKM, acting as key contributors from initial preventative measures to ongoing management, as well as in the formulation of health policies and the conduct of research, serving as vital instruments in the pursuit of health equity and the improvement of health standards. This article summarizes the important role of SDOH in CKM syndrome and explores the prospects of comprehensive management based on SDOH. It is hoped that these insights will offer valuable contributions to improving CKM-related issues and enhancing health standards.