Publications by authors named "Fatima Rodriguez"

137 Publications

Statin Use in Older Adults for Primary Cardiovascular Disease Prevention Across a Spectrum of Cardiovascular Risk.

J Gen Intern Med 2021 Sep 10. Epub 2021 Sep 10.

Division of Cardiovascular Medicine and Cardiovascular Institute, Department of Medicine, Stanford University School of Medicine, 870 Quarry Road, Falk CVRC, Stanford, CA, 94305-5406, USA.

Background: There remains uncertainty regarding optimal primary atherosclerotic cardiovascular disease (ASCVD) prevention practices for older adults.

Objective: To assess statin treatment patterns and incident ASCVD among older patients for primary prevention across the spectrum of ASCVD risk.

Design: Retrospective cohort study of participants without ASCVD aged 65-79 years. Patients were stratified by age (65-69, 70-75, > 75 years) and 10-year ASCVD risk category (low/borderline, intermediate, high) based on the Pooled Cohort Equations. Multivariable logistic regressions were used to identify predictors of moderate- or high-intensity statin prescriptions. Cox proportional models were used to estimate hazard ratios (HRs) for incident ASCVD.

Participants: Patients aged 65-79 years without ASCVD from a Northern California health system.

Main Measures: Statin prescriptions and incident ASCVD events.

Key Results: There were 54,066 patients, with 10,288 (19%) aged > 75 years and 57% women. Compared with younger groups, adults > 75 years were less likely to be prescribed moderate- or high-intensity statin prescriptions across ASCVD risk groups (all p < 0.001); this persisted after multivariable adjustment including for ASCVD risk (odds ratio [OR] 0.80, 95% confidence interval [CI] 0.74-0.86). Adults > 75 years were more likely to experience incident ASCVD (HR 1.42, 95% CI 1.23-1.63). Women (OR 0.85, 95% CI 0.81-0.89) and underweight older adults (OR 0.45, 95% CI 0.33-0.61) were also less likely to receive moderate- or high-intensity statins.

Conclusions: Among older adults aged 65-79 years without prior ASCVD, those > 75 years of age were less likely to receive moderate- or high-intensity statins regardless of ASCVD risk compared with their younger counterparts, while experiencing more incident ASCVD. Efforts are warranted to study the reasons for age-based differences in statin use in older adults, particularly those at highest ASCVD risk.
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http://dx.doi.org/10.1007/s11606-021-07107-7DOI Listing
September 2021

Initial Outcomes of CardioClick, a Telehealth Program for Preventive Cardiac Care: Observational Study.

JMIR Cardio 2021 Sep 9;5(2):e28246. Epub 2021 Sep 9.

Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States.

Background: Telehealth use has increased in specialty clinics, but there is limited evidence on the outcomes of telehealth in primary cardiovascular disease (CVD) prevention.

Objective: The objective of this study was to evaluate the initial outcomes of CardioClick, a telehealth primary CVD prevention program.

Methods: In 2017, the Stanford South Asian Translational Heart Initiative (a preventive cardiology clinic focused on high-risk South Asian patients) introduced CardioClick, which is a clinical pathway replacing in-person follow-up visits with video visits. We assessed patient engagement and changes in CVD risk factors in CardioClick patients and in a historical in-person cohort from the same clinic.

Results: In this study, 118 CardioClick patients and 441 patients who received in-person care were included. CardioClick patients were more likely to complete the clinic's CVD prevention program (76/118, 64.4% vs 173/441, 39.2%, respectively; P<.001) and they did so in lesser time (mean, 250 days vs 307 days, respectively; P<.001) than the patients in the historical in-person cohort. Patients who completed the CardioClick program achieved reductions in CVD risk factors, including blood pressure, lipid concentrations, and BMI, which matched or exceeded those observed in the historical in-person cohort.

Conclusions: Telehealth can be used to deliver care effectively in a preventive cardiology clinic setting and may result in increased patient engagement. Further studies on telehealth outcomes are needed to determine the optimal role of virtual care models across diverse preventive medicine clinics.
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http://dx.doi.org/10.2196/28246DOI Listing
September 2021

Gender disparities in difficulty accessing healthcare and cost-related medication non-adherence: The CDC behavioral risk factor surveillance system (BRFSS) survey.

Prev Med 2021 Sep 3;153:106779. Epub 2021 Sep 3.

Department of Medicine, Baylor College of Medicine, Houston, TX, United States of America; Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX, United States of America; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States of America; Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, United States of America. Electronic address:

Ensuring healthcare access is critical to maintain health and prevent illness. Studies demonstrate gender disparities in healthcare access. Less is known about how these vary with age, race/ethnicity, and atherosclerotic cardiovascular disease. We utilized cross-sectional data from 2016 to 2019 CDC Behavioral Risk Factor Surveillance System (BRFSS), a U.S. telephone-based survey of adults (≥18 years). Measures of difficulty accessing healthcare included absence of healthcare coverage, delay in healthcare access, absence of primary care physician, >1-year since last checkup, inability to see doctor due to cost, and cost-related medication non-adherence. We studied the association between gender and these variables using multivariable-adjusted logistic regression models, stratifying by age, race/ethnicity, and atherosclerotic cardiovascular disease status. Our population consisted of 1,737,397 individuals; 54% were older (≥45 years), 51% women, 63% non-Hispanic White, 12% non-Hispanic Black,17% Hispanic, 9% reported atherosclerotic cardiovascular disease. In multivariable-adjusted models, women were more likely to report delay in healthcare access: odds ratio (OR) and (95% confidence interval): 1.26 (1.11, 1.43) [p < 0.001], inability to see doctor due to cost: 1.29 (1.22, 1.36) [p < 0.001], cost-related medication non-adherence: 1.24 (1.01, 1.50) [p = 0.04]. Women were less likely to report lack of healthcare coverage: 0.71 (0.66, 0.75) [p < 0.001] and not having a primary care physician: 0.50 (0.48, 0.52) [p < 0.001]. Disparities were pronounced in younger (<45 years) and Black women. Identifying these barriers, particularly among younger women and Black women, is crucial to ensure equitable healthcare access to all individuals.
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http://dx.doi.org/10.1016/j.ypmed.2021.106779DOI Listing
September 2021

Could Clinician Sensitivity to Cultural and Historical Considerations Help Reduce COVID-19 Deaths among Blacks?

South Med J 2021 09;114(9):591-592

From Hackensack Meridian School of Medicine, Nutley, New Jersey, Stanford University, Stanford, California, University of Arizona College of Nursing, Tucson, Mashantucket Pequot Tribal Nation, Connecticut, and the National Minority Cardiovascular Alliance/Make Well Known Foundation, Princeton, New Jersey.

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http://dx.doi.org/10.14423/SMJ.0000000000001288DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8395970PMC
September 2021

Associations of Insulin Resistance With Systolic and Diastolic Blood Pressure: A Study From the HCHS/SOL.

Hypertension 2021 Sep 11;78(3):716-725. Epub 2021 Aug 11.

Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY (N.A.B.).

[Figure: see text].
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http://dx.doi.org/10.1161/HYPERTENSIONAHA.120.16905DOI Listing
September 2021

Health disparities in cardiometabolic risk among Black and Hispanic youth in the United States.

Am J Prev Cardiol 2021 Jun 23;6:100175. Epub 2021 Mar 23.

Stanford Department of Medicine, Cardiovascular Medicine, Cardiovascular Institute, Prevention Research Center, Stanford University, Room CV273, MC 5406, 300 Pasteur Drive, Stanford, CA 94305, USA.

Cardiometabolic risk factors in children and adolescents track into adulthood and are associated with increased risk of atherosclerotic cardiovascular disease. The purpose of this review is to examine the pervasive race and ethnic disparities in cardiometabolic risk factors among Black and Hispanic youth in the United States. We focus on three traditional cardiometabolic risk factors (obesity, type 2 diabetes mellitus, and dyslipidemia) as well as on the emerging cardiometabolic risk factor of non-alcoholic fatty liver disease. Additionally, we highlight interventions aimed at improving cardiometabolic health among these minority pediatric populations. Finally, we advocate for continued research on effective prevention strategies to reduce cardiometabolic risk and avert further disparities in cardiovascular morbidity and mortality.
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http://dx.doi.org/10.1016/j.ajpc.2021.100175DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8315636PMC
June 2021

Risk factor control across the spectrum of cardiovascular risk: Findings from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL).

Am J Prev Cardiol 2021 Mar 13;5:100147. Epub 2021 Jan 13.

Department of Hospital Medicine, San Francisco VA Medical Center, San Francisco, CA, USA.

Background: Presence of cardiovascular disease (CVD) risk factors (RFs) should prompt patients and their providers to work aggressively towards controlling those that are modifiable. The extent to which a greater CVD RF burden is related to CVD RF control in a contemporary and diverse Hispanic/Latino population is not well-understood.

Methods: Using multicenter community-based data from the Hispanic Community Health Study/Study of Latinos, we assessed the self-reported prevalence of hypertension, hypercholesterolemia, diabetes, and prevalent CVD (ischemic heart disease or stroke). We used contemporaneous guidelines to define RF control. Multivariable logistic regression for complex survey sampling was used to examine whether having more CVD RFs was associated with CVD RF control (adjusting for age, sex, Hispanic background group, education, and health insurance).

Results: Our sample included 8521 participants with at least one CVD RF or prevalent CVD. The mean age in HCHS/SOL target population was 49 (SE 0.3) years and 56% were women. Frequency of one, two, or three self-reported CVD RFs was 57%, 26%, 8%, respectively, and overall 9% of participants had prevalent CVD. After adjusting for sociodemographic factors, compared to those reporting one CVD RF, individuals with three CVD RFs were the least likely to have blood pressure, cholesterol, and glucose optimally controlled (odds ratio [OR]: 0.56; 95% confidence interval [CI]: 0.40-0.80). However, those with prevalent CVD were more likely to have all three risk factors controlled, (OR: 1.43; 95% CI: 1.01-2.01).

Conclusion: Hispanic/Latino adults with three major CVD RFs represent a group with poor overall CVD RF control. Secondary CVD prevention fares better. The potential contributors to inadequate CVD RF control in this highly vulnerable group warrants further investigation.
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http://dx.doi.org/10.1016/j.ajpc.2021.100147DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8315414PMC
March 2021

Disparity in the Setting of Incident Heart Failure Diagnosis.

Circ Heart Fail 2021 Aug 27;14(8):e008538. Epub 2021 Jul 27.

Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of Medicine (A.T.S., F.R., D.J.M., E.L., P.A.H.), Stanford University, CA.

Background: Early heart failure (HF) recognition can reduce morbidity, yet HF is often initially diagnosed only after a patient clinically worsens. We sought to identify characteristics that predict diagnosis in the acute care setting versus the outpatient setting.

Methods: We estimated the proportion of incident HF diagnosed in the acute care setting (inpatient hospital or emergency department) versus outpatient setting based on diagnostic codes from a claims database covering commercial insurance and Medicare Advantage between 2003 and 2019. After excluding new-onset HF potentially caused by a concurrent acute cause (eg, acute myocardial infarction), we identified demographic, clinical, and socioeconomic predictors of diagnosis setting. Patients were linked to their primary care clinicians to evaluate diagnosis setting variation across clinicians.

Results: Of 959 438 patients with new HF, 38% were diagnosed in acute care. Of these, 46% had potential HF symptoms in the prior 6 months. Over time, the relative odds of acute care diagnosis increased by 3.2% annually after adjustment for patient characteristics (95% CI, 3.1%-3.3%). Acute care diagnosis setting was more likely for women compared with men (adjusted odds ratio, 1.11 [95% CI, 1.10-1.12]) and for Black patients compared with White patients (adjusted odds ratio, 1.18 [95% CI, 1.16-1.19]). The proportion of acute care diagnosis varied substantially (interquartile range: 24%-39%) among clinicians after adjusting for patient-level risk factors.

Conclusions: A large proportion of first HF diagnoses occur in the acute care setting, particularly among women and Black patients, yet many had potential HF symptoms in the months before acute care visits. These results raise concerns that many HF diagnoses are missed in the outpatient setting. Earlier diagnosis could allow for timelier high-value interventions, addressing disparities and reducing the progression of HF.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.121.008538DOI Listing
August 2021

Racial and Ethnic Disparities in Cardio-Oncology: A Call to Action.

JACC CardioOncol 2021 Jun 15;3(2):201-204. Epub 2021 Jun 15.

Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA.

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http://dx.doi.org/10.1016/j.jaccao.2021.05.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8301207PMC
June 2021

Repeated cross-sectional analysis of hydroxychloroquine deimplementation in the AHA COVID-19 CVD Registry.

Sci Rep 2021 07 23;11(1):15097. Epub 2021 Jul 23.

Center for Innovation and Value at Parkland, University of Texas Southwestern Medical Center, Dallas, TX, USA.

There is little data describing trends in the use of hydroxychloroquine for COVID-19 following publication of randomized trials that failed to demonstrate a benefit of this therapy. We identified 13,957 patients admitted for active COVID-19 at 85 U.S. hospitals participating in a national registry between March 1 and August 31, 2020. The overall proportion of patients receiving hydroxychloroquine peaked at 55.2% in March and April and decreased to 4.8% in May and June and 0.8% in July and August. At the hospital-level, median use was 59.4% in March and April (IQR 48.5-71.5%, range 0-100%) and decreased to 0.3% (IQR 0-5.4%, range 0-100%) by May and June and 0% (IQR 0-1.3%, range 0-36.4%) by July and August. The rate and hospital-level uniformity in deimplementation of this ineffective therapy for COVID-19 reflects a rapid response to evolving clinical information and further study may offer strategies to inform deimplementation of ineffective clinical care.
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http://dx.doi.org/10.1038/s41598-021-94203-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8302649PMC
July 2021

Gender Disparities in Cardiology-Related COVID-19 Publications.

Cardiol Ther 2021 Jul 15. Epub 2021 Jul 15.

Division of Cardiovascular Medicine and the Cardiovascular Institute, Stanford University, Stanford, CA, USA.

Introduction: Female authors are underrepresented in cardiology journals, although prior work suggested improvement in reducing disparities over time. Early in the recent COVID-19 pandemic, female authorship continued to lag that of their male counterparts despite a surge in publications. The cumulative impact of the COVID-19 pandemic on authorship gender disparities remains unclear. We aimed to characterize gender disparities in COVID-19-related cardiology publications across the duration of the ongoing pandemic.

Methods: We retrospectively analyzed COVID-19-related research articles published in the top 20 impact factor cardiology journals between March and June 2021. Gender representation data were extracted for any author, first authors, and senior authors.

Results: We found that 841 articles were related to COVID-19, with a total of 5586 authors and an average of 42 articles per journal. Less than a third (29.9%) of the total authors from publications were women. Women represented a smaller proportion of first authors (21.3%) and senior authors (16.4%).

Conclusions: Female authorship has continued to lag male authorship for the duration of the ongoing COVID-19 pandemic. The pandemic may have impeded progress in reducing gender disparities in academic cardiology publications. The low proportions of first and senior female authors may reflect the impact of the pandemic on women in cardiology in leadership domains.
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http://dx.doi.org/10.1007/s40119-021-00234-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8280580PMC
July 2021

Real-World Diagnosis and Treatment of Diabetic Kidney Disease.

Adv Ther 2021 08 13;38(8):4425-4441. Epub 2021 Jul 13.

Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford University School of Medicine, 300 Pasteur Drive, H2157, Stanford, CA, 94305-5233, USA.

Introduction: People with type 2 diabetes mellitus (T2DM) and diabetic kidney disease (DKD) have increased morbidity and mortality risk. Angiotensin-converting enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARB) are recommended to slow kidney function decline in DKD. This representative, real-world data analysis of patients with T2DM was performed to detect onset of DKD and determine methods and timing of DKD diagnosis and time to initiation of ACEi/ARB therapy.

Methods: Patients diagnosed with T2DM before January 1, 2016 who developed DKD between January 1, 2017 and June 30, 2019 were identified from a longitudinal ambulatory electronic health record (EHR) dataset (Veradigm Inc). Each record was analyzed using the CLinical INTelligence engine (CLINT™, HealthPals, Inc.) to identify delays and gaps in diagnosing DKD. DKD was diagnosed through two reduced estimated glomerular filtration rate (eGFR; < 60 mL/min/1.73 m) measurements at least 90 days apart, a single elevated urine albumin-to-creatinine ratio (UACR; > 30 mg/g) measurement, or ICD-9/10 diagnosis codes for DKD and/or albuminuria. Time to diagnose (TTD), time to treat (TTT), and diagnosis to treatment time were assessed.

Results: Of 6,499,409 patients with T2DM before January 2016, 245,978 developed DKD between January 1, 2017 and June 30, 2019. In this DKD cohort, ca. 50% were first identified through EHR diagnosis and ca. 50% by UACR or eGFR lab-based diagnosis. In patients who had UACR/eGFR assessed, more than 90% exhibited DKD-level results on the first diagnostic test. Average TTD after eGFR labs was 2 years; average TTT with ACEi/ARB was 6-9 months after DKD lab evidence. The majority of patients who developed DKD received ACEi/ARB therapy 6-7 months after diagnosis.

Conclusion: In a contemporary, large national cohort of patients with T2DM, progression to DKD was common but likely underrepresented. The low rate of DKD-screening labs, along with sizable delays in diagnosis of DKD and initiation of ACEi/ARB therapy, indicates that many patients who progress to DKD are not being properly treated.
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http://dx.doi.org/10.1007/s12325-021-01777-9DOI Listing
August 2021

Prevalence and Determinants of Difficulty in Accessing Medical Care in U.S. Adults.

Am J Prev Med 2021 Jul 4. Epub 2021 Jul 4.

Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Health Policy, Quality & Informatics Program, Center for Innovations in Quality, Effectiveness and Safety, U.S. Department of Veterans Affairs, Houston, Texas; Research & Development, Michael E. DeBakey VA Medical Center, U.S. Department of Veterans Affairs, Houston, Texas; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, U.S. Department of Veterans Affairs, Houston, Texas; Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas. Electronic address:

Introduction: Ensuring adequate access to health care is essential for timely delivery of preventive services. It is important to evaluate the prevalence and determinants of difficulty in accessing medical care in the overall U.S. population and among those with high-risk chronic conditions.

Methods: The study utilized cross-sectional data from the 2016-2019 Behavioral Risk Factor Surveillance System, a nationally representative telephone-based survey of adults aged ≥18 years. The prevalence and sociodemographic characteristics associated with difficulty in receiving medical care were assessed, including regional variations across U.S. states.

Results: The prevalence of difficulty in accessing medical care was 14% overall, 15% among those with hypertension, 15% among those with diabetes mellitus, and 17% among those with atherosclerotic cardiovascular disease. Age 18-34 years, having less than high school education, having annual household income <$75,000, unemployment, and living in a state without Medicaid expansion were all associated with a higher risk of not accessing medical care. The prevalence of difficulty in accessing medical care was 27% among individuals with ≥3 of these sociodemographic characteristics. There was regional variation across the U.S. states in the distribution of difficulty in accessing medical care with a median of 13.6% (IQR=11.3%-15.9%) for the overall population: 16.3% (IQR=14.1%-19.0%) among those living in states without Medicaid expansion versus 12.7% (IQR=10.9%-15.6%) among those living in states with Medicaid expansion (p=0.01).

Conclusions: In total, 1 in 7 adults report difficulty in accessing medical care. This prevalence is nearly 1 in 4 adults with ≥3 sociodemographic characteristics related to difficulty in accessing medical care. There are regional variations in the distribution of the difficulty in accessing medical care, especially among individuals living in states that have not undergone Medicaid expansion.
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http://dx.doi.org/10.1016/j.amepre.2021.03.026DOI Listing
July 2021

Increases in SARS-CoV-2 Test Positivity Rates Among Hispanic People in a Northern California Health System.

Public Health Rep 2021 Sep-Oct;136(5):543-547. Epub 2021 Jun 23.

Department of Medicine, Stanford University, Stanford, CA, USA.

Racial/ethnic minority groups are disproportionately affected by the COVID-19 pandemic. We examined ethnic differences in SARS-CoV-2 testing patterns and positivity rates in a large health care system in Northern California. The study population included patients tested for SARS-CoV-2 from March 4, 2020, through January 12, 2021, at Stanford Health Care. We used adjusted hierarchical logistic regression models to identify factors associated with receiving a positive test result. During the study period, 282 916 SARS-CoV-2 tests were administered to 179 032 unique patients, 32 766 (18.3%) of whom were Hispanic. Hispanic patients were 3 times more likely to receive a positive test result than patients in other racial/ethnic groups (odds ratio = 3.16; 95% CI, 3.00-3.32). The rate of receiving a positive test result for SARS-CoV-2 among Hispanic patients increased from 5.4% in mid-March to 15.7% in mid-July, decreased to 3.9% in mid-October, and increased to 21.2% toward the end of December. Hispanic patients were more likely than non-Hispanic patients to receive a positive test result for SARS-CoV-2, with increasing trends during regional surges. The disproportionate and growing overrepresentation of Hispanic people receiving a positive test result for SARS-CoV-2 demonstrates the need to focus public health prevention efforts on these communities.
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http://dx.doi.org/10.1177/00333549211026778DOI Listing
August 2021

Analysis of Female Enrollment and Participant Sex by Burden of Disease in US Clinical Trials Between 2000 and 2020.

JAMA Netw Open 2021 Jun 1;4(6):e2113749. Epub 2021 Jun 1.

Center for Population Health Sciences, Stanford University School of Medicine, Palo Alto, California.

Importance: Although female representation has increased in clinical trials, little is known about how clinical trial representation compares with burden of disease or is associated with clinical trial features, including disease category.

Objective: To describe the rate of sex reporting (ie, the presence of clinical trial data according to sex), compare the female burden of disease with the female proportion of clinical trial enrollees, and investigate the associations of disease category and clinical trial features with the female proportion of clinical trial enrollees.

Design, Setting, And Participants: This cross-sectional study included descriptive analyses and logistic and generalized linear regression analyses with a logit link. Data were downloaded from the Aggregate Analysis of ClinicalTrials.gov database for all studies registered between March 1, 2000, and March 9, 2020. Enrollment was compared with data from the 2016 Global Burden of Disease database. Of 328 452 clinical trials, 70 095 were excluded because they had noninterventional designs, 167 936 because they had recruitment sites outside the US, 69 084 because they had no reported results, 1003 because they received primary funding from the US military, and 314 because they had unclear sex categories. A total of 20 020 interventional studies enrolling approximately 5.11 million participants met inclusion criteria and were divided into those with and without data on participant sex.

Exposures: The primary exposure variable was clinical trial disease category. Secondary exposure variables included funding, study design, and study phase.

Main Outcomes And Measures: Sex reporting and female proportion of participants in clinical trials.

Results: Among 20 020 clinical trials from 2000 to 2020, 19 866 studies (99.2%) reported sex, and 154 studies (0.8%) did not. Clinical trials in the fields of oncology (46% of disability-adjusted life-years [DALYs]; 43% of participants), neurology (56% of DALYs; 53% of participants), immunology (49% of DALYs; 46% of participants), and nephrology (45% of DALYs; 42% of participants) had the lowest female representation relative to corresponding DALYs. Male participants were underrepresented in 8 disease categories, with the greatest disparity in clinical trials of musculoskeletal disease and trauma (11.3% difference between representation and proportion of DALYs). Clinical trials of preventive interventions were associated with greater female enrollment (adjusted relative difference, 8.48%; 95% CI, 3.77%-13.00%). Clinical trials in cardiology (adjusted relative difference, -18.68%; 95% CI, -22.87% to -14.47%) and pediatrics (adjusted relative difference, -20.47%; 95% CI, -25.77% to -15.16%) had the greatest negative association with female enrollment.

Conclusions And Relevance: In this study, sex differences in clinical trials varied by clinical trial disease category, with male and female participants underrepresented in different medical fields. Although sex equity has progressed, these findings suggest that sex bias in clinical trials persists within medical fields, with negative consequences for the health of all individuals.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.13749DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8214160PMC
June 2021

Diverse Racial/Ethnic Group Underreporting and Underrepresentation in High-Impact Cholesterol Treatment Trials.

Circulation 2021 Jun 14;143(24):2409-2411. Epub 2021 Jun 14.

Division of Cardiovascular Medicine and the Cardiovascular Institute (A.S., J.W.K., D.J.M., F.R.).

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http://dx.doi.org/10.1161/CIRCULATIONAHA.120.050034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8210460PMC
June 2021

Automated coronary calcium scoring using deep learning with multicenter external validation.

NPJ Digit Med 2021 Jun 1;4(1):88. Epub 2021 Jun 1.

Department of Radiology, Mayo Clinic, Scottsdale, AZ, USA.

Coronary artery disease (CAD), the most common manifestation of cardiovascular disease, remains the most common cause of mortality in the United States. Risk assessment is key for primary prevention of coronary events and coronary artery calcium (CAC) scoring using computed tomography (CT) is one such non-invasive tool. Despite the proven clinical value of CAC, the current clinical practice implementation for CAC has limitations such as the lack of insurance coverage for the test, need for capital-intensive CT machines, specialized imaging protocols, and accredited 3D imaging labs for analysis (including personnel and software). Perhaps the greatest gap is the millions of patients who undergo routine chest CT exams and demonstrate coronary artery calcification, but their presence is not often reported or quantitation is not feasible. We present two deep learning models that automate CAC scoring demonstrating advantages in automated scoring for both dedicated gated coronary CT exams and routine non-gated chest CTs performed for other reasons to allow opportunistic screening. First, we trained a gated coronary CT model for CAC scoring that showed near perfect agreement (mean difference in scores = -2.86; Cohen's Kappa = 0.89, P < 0.0001) with current conventional manual scoring on a retrospective dataset of 79 patients and was found to perform the task faster (average time for automated CAC scoring using a graphics processing unit (GPU) was 3.5 ± 2.1 s vs. 261 s for manual scoring) in a prospective trial of 55 patients with little difference in scores compared to three technologists (mean difference in scores = 3.24, 5.12, and 5.48, respectively). Then using CAC scores from paired gated coronary CT as a reference standard, we trained a deep learning model on our internal data and a cohort from the Multi-Ethnic Study of Atherosclerosis (MESA) study (total training n = 341, Stanford test n = 42, MESA test n = 46) to perform CAC scoring on routine non-gated chest CT exams with validation on external datasets (total n = 303) obtained from four geographically disparate health systems. On identifying patients with any CAC (i.e., CAC ≥ 1), sensitivity and PPV was high across all datasets (ranges: 80-100% and 87-100%, respectively). For CAC ≥ 100 on routine non-gated chest CTs, which is the latest recommended threshold to initiate statin therapy, our model showed sensitivities of 71-94% and positive predictive values in the range of 88-100% across all the sites. Adoption of this model could allow more patients to be screened with CAC scoring, potentially allowing opportunistic early preventive interventions.
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http://dx.doi.org/10.1038/s41746-021-00460-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8169744PMC
June 2021

Racial and Ethnic Disparities in Heart and Cerebrovascular Disease Deaths During the COVID-19 Pandemic in the United States.

Circulation 2021 06 18;143(24):2346-2354. Epub 2021 May 18.

Cardiovascular Division, Washington University School of Medicine, Saint Louis, MO (K.E.J.M.).

Background: Cardiovascular deaths increased during the early phase of the COVID-19 pandemic in the United States. However, it is unclear whether diverse racial/ethnic populations have experienced a disproportionate rise in heart disease and cerebrovascular disease deaths.

Methods: We used the National Center for Health Statistics to identify heart disease and cerebrovascular disease deaths for non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and Hispanic individuals from March to August 2020 (pandemic period), as well as for the corresponding months in 2019 (historical control). We determined the age- and sex-standardized deaths per million by race/ethnicity for each year. We then fit a modified Poisson model with robust SEs to compare change in deaths by race/ethnicity for each condition in 2020 versus 2019.

Results: There were a total of 339 076 heart disease and 76 767 cerebrovascular disease deaths from March through August 2020, compared with 321 218 and 72 190 deaths during the same months in 2019. Heart disease deaths increased during the pandemic in 2020, compared with the corresponding period in 2019, for non-Hispanic White (age-sex standardized deaths per million, 1234.2 versus 1208.7; risk ratio for death [RR], 1.02 [95% CI, 1.02-1.03]), non-Hispanic Black (1783.7 versus 1503.8; RR, 1.19 [95% CI, 1.17-1.20]), non-Hispanic Asian (685.7 versus 577.4; RR, 1.19 [95% CI, 1.15-1.22]), and Hispanic (968.5 versus 820.4; RR, 1.18 [95% CI, 1.16-1.20]) populations. Cerebrovascular disease deaths also increased for non-Hispanic White (268.7 versus 258.2; RR, 1.04 [95% CI, 1.03-1.05]), non-Hispanic Black (430.7 versus 379.7; RR, 1.13 [95% CI, 1.10-1.17]), non-Hispanic Asian (236.5 versus 207.4; RR, 1.15 [95% CI, 1.09-1.21]), and Hispanic (264.4 versus 235.9; RR, 1.12 [95% CI, 1.08-1.16]) populations. For both heart disease and cerebrovascular disease deaths, Black, Asian, and Hispanic populations experienced a larger relative increase in deaths than the non-Hispanic White population (interaction term, <0.001).

Conclusions: During the COVID-19 pandemic in the United States, Black, Hispanic, and Asian populations experienced a disproportionate rise in deaths caused by heart disease and cerebrovascular disease, suggesting that these groups have been most impacted by the indirect effects of the pandemic. Public health and policy strategies are needed to mitigate the short- and long-term adverse effects of the pandemic on the cardiovascular health of diverse populations.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.121.054378DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8191372PMC
June 2021

Antithrombotic Therapy after Acute Coronary Syndromes. Reply.

N Engl J Med 2021 05;384(19):1873-1874

Stanford University, Stanford, CA

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http://dx.doi.org/10.1056/NEJMc2103789DOI Listing
May 2021

Long versus short biliopancreatic limb in Roux-en-Y gastric bypass: short-term results of a randomized clinical trial.

Surg Obes Relat Dis 2021 Aug 9;17(8):1425-1430. Epub 2021 Apr 9.

The Obesity Clinic at Hospital General Tláhuac, Mexico City, Mexico.

Background: The Roux-en-Y gastric bypass continues to be one of the most performed bariatric surgeries because of its adequate balance of outcomes, complications, and durability. Recently, the role of the biliopancreatic limb on weight loss and co-morbidity control has gained attention because it seems to have a positive impact based on limb length.

Objective: To compare results at 12 months of a "standard" (group 1) versus a long (group 2) biliopancreatic limb bypass. Biliopancreatic limbs were 50 cm and 200 cm, and alimentary limbs were 150 cm and 50 cm, respectively.

Setting: Academic Referal Center; Mexico City; Public Seeting.

Methods: Randomized study with patients undergoing both types of surgeries at a single academic center from 2016 to 2018. The analysis included weight loss, co-morbidity control (diabetes and hypertension), biochemical panel, operative outcomes, and complications.

Results: Two-hundred ten patients were included (105 in each group). Almost all data were homogenous at baseline. Female sex comprised 86.1% of cases, with a mean body mass index of 43.5 kg/m. Excess weight loss (77.6 ± 15.7% versus 83.6 ± 16.7%; P = .011) and total weight loss (33.5 ± 6.4% versus 37.1 ± 7.1%; P < .001) was higher in group 2; better HbA1C levels were also observed. Co-morbidity outcomes, operative data, and complications were similar between groups.

Conclusion: The Roux-en-Y gastric bypass with 200 cm of biliopancreatic limb length induces more weight loss at 12 months than a 50 cm limb length. Better HbA1C levels were also observed, but similar effects on co-morbidities and complications were noted.
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http://dx.doi.org/10.1016/j.soard.2021.03.030DOI Listing
August 2021

Trends in Patient Characteristics and COVID-19 In-Hospital Mortality in the United States During the COVID-19 Pandemic.

JAMA Netw Open 2021 05 3;4(5):e218828. Epub 2021 May 3.

Division of Cardiology, Department of Medicine, University of Washington, Seattle.

Importance: In-hospital mortality rates from COVID-19 are high but appear to be decreasing for selected locations in the United States. It is not known whether this is because of changes in the characteristics of patients being admitted.

Objective: To describe changing in-hospital mortality rates over time after accounting for individual patient characteristics.

Design, Setting, And Participants: This was a retrospective cohort study of 20 736 adults with a diagnosis of COVID-19 who were included in the US American Heart Association COVID-19 Cardiovascular Disease Registry and admitted to 107 acute care hospitals in 31 states from March through November 2020. A multiple mixed-effects logistic regression was then used to estimate the odds of in-hospital death adjusted for patient age, sex, body mass index, and medical history as well as vital signs, use of supplemental oxygen, presence of pulmonary infiltrates at admission, and hospital site.

Main Outcomes And Measures: In-hospital death adjusted for exposures for 4 periods in 2020.

Results: The registry included 20 736 patients hospitalized with COVID-19 from March through November 2020 (9524 women [45.9%]; mean [SD] age, 61.2 [17.9] years); 3271 patients (15.8%) died in the hospital. Mortality rates were 19.1% in March and April, 11.9% in May and June, 11.0% in July and August, and 10.8% in September through November. Compared with March and April, the adjusted odds ratios for in-hospital death were significantly lower in May and June (odds ratio, 0.66; 95% CI, 0.58-0.76; P < .001), July and August (odds ratio, 0.58; 95% CI, 0.49-0.69; P < .001), and September through November (odds ratio, 0.59; 95% CI, 0.47-0.73).

Conclusions And Relevance: In this cohort study, high rates of in-hospital COVID-19 mortality among registry patients in March and April 2020 decreased by more than one-third by June and remained near that rate through November. This difference in mortality rates between the months of March and April and later months persisted even after adjusting for age, sex, medical history, and COVID-19 disease severity and did not appear to be associated with changes in the characteristics of patients being admitted.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.8828DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8094014PMC
May 2021

Impact of HIV Infection on COVID-19 Outcomes Among Hospitalized Adults in the U.S.

medRxiv 2021 Apr 7. Epub 2021 Apr 7.

Background: Whether HIV infection is associated with differences in clinical outcomes among people hospitalized with COVID-19 is uncertain.

Objective: To evaluate the impact of HIV infection on COVID-19 outcomes among hospitalized patients.

Methods: Using the American Heart Association's COVID-19 Cardiovascular Disease registry, we used hierarchical mixed effects models to assess the association of HIV with in-hospital mortality accounting for patient demographics and comorbidities and clustering by hospital. Secondary outcomes included major adverse cardiac events (MACE), severity of illness, and length of stay (LOS).

Results: The registry included 21,528 hospitalization records of people with confirmed COVID-19 from 107 hospitals in 2020, including 220 people living with HIV (PLWH). PLWH were younger (56.0+/-13.0 versus 61.3+/-17.9 years old) and more likely to be male (72.3% vs 52.7%), Non-Hispanic Black (51.4% vs 25.4%), on Medicaid (44.5% vs 24.5), and active tobacco users (12.7% versus 6.5%).Of the study population, 36 PLWH (16.4%) had in-hospital mortality compared with 3,290 (15.4%) without HIV (Risk ratio 1.06, 95%CI 0.79-1.43; risk difference 0.9%, 95%CI -4.2 to 6.1%; p=0.71). After adjustment for age, sex, race, and insurance, HIV was not associated with in-hospital mortality (aOR 1.13; 95%CI 0.77-1.6; p 0.54) even after adding body mass index and comorbidities (aOR 1.15; 95%CI 0.78-1.70; p=0.48). HIV was not associated with MACE (aOR 0.99, 95%CI 0.69-1.44, p=0.91), severity of illness (aOR 0.96, 95%CI 0.62-1.50, p=0.86), or LOS (aOR 1.03; 95% CI 0.76-1.66, p=0.21).

Conclusion: HIV was not associated with adverse outcomes of COVID-19 including in-hospital mortality, MACE, or severity of illness.

Condensed Abstract: We studied 21,528 patients hospitalized with COVID-19 at 107 hospitals in AHA's COVID-19 registry to examine the association between HIV and COVID-19 outcomes. More patients with HIV were younger, male, non-Hispanic Black, on Medicaid and current smokers. HIV was not associated with worse COVID-19 in-hospital mortality (Risk ratio 1.06, 95%CI 0.79-1.43; p=0.71) even after adjustment (aOR 1.15; 95%CI 0.78-1.70; p=0.48). HIV was also not associated with MACE (aOR 0.99, 95%CI 0.69-1.44, p=0.91) or severity of illness (aOR 0.96, 95%CI 0.62-1.50, p=0.86. Our findings do not support that HIV is a major risk factor for adverse COVID-19 outcomes.
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http://dx.doi.org/10.1101/2021.04.05.21254938DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8043485PMC
April 2021

The Hispanic paradox in the prevalence of obesity at the county-level.

Obes Sci Pract 2021 Feb 23;7(1):14-24. Epub 2020 Oct 23.

Division of Cardiovascular Medicine and Cardiovascular Institute Stanford University School of Medicine Stanford California USA.

Objective: The percentage of Hispanics in a county has a negative association with prevalence of obesity. Because Hispanic individuals are unevenly distributed in the United States, this study examined whether this protective association persists when stratifying counties into quartiles based on the size of the Hispanic population and after adjusting for county-level demographic, socioeconomic, healthcare, and environmental factors.

Methods: Data were extracted from the 2018 Robert Wood Johnson Foundation County Health Rankings. Counties were categorized into quartiles based on their percentage of Hispanics, 0%-5% ( = 1794), 5%-20% ( = 962), 20%-50% ( = 283), and >50% ( = 99). For each quartile, univariate and multivariate regression models were used to evaluate the association between prevalence of obesity and demographic, socioeconomic, healthcare, and environmental factors.

Results: Counties with the top quartile of Hispanic individuals had the lowest prevalence of obesity compared to counties at the bottom quartile (28.4 ± 3.6% vs. 32.7 ± 4.0%). There was a negative association between county-level percentage of Hispanics and prevalence of obesity in unadjusted analyses that persisted after adjusting for all county-level factors.

Conclusions: Counties with a higher percentage of Hispanics have lower levels of obesity, even after controlling for demographic, socioeconomic, healthcare, and environmental factors. More research is needed to elucidate why having more Hispanics in a county may be protective against county-level obesity.
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http://dx.doi.org/10.1002/osp4.461DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7909595PMC
February 2021

Racial and Ethnic Disparities in Household Contact with Individuals at Higher Risk of Exposure to COVID-19.

J Gen Intern Med 2021 05 5;36(5):1470-1472. Epub 2021 Mar 5.

Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, CA, USA.

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http://dx.doi.org/10.1007/s11606-021-06656-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7934987PMC
May 2021

County-Level Factors Associated With Cardiovascular Mortality by Race/Ethnicity.

J Am Heart Assoc 2021 03 3;10(6):e018835. Epub 2021 Mar 3.

Division of Cardiovascular Medicine and the Cardiovascular Institute Stanford University School of Medicine Stanford CA.

Background Persistent racial/ethnic disparities in cardiovascular disease (CVD) mortality are partially explained by healthcare access and socioeconomic, demographic, and behavioral factors. Little is known about the association between race/ethnicity-specific CVD mortality and county-level factors. Methods and Results Using 2017 county-level data, we studied the association between race/ethnicity-specific CVD age-adjusted mortality rate (AAMR) and county-level factors (demographics, census region, socioeconomics, CVD risk factors, and healthcare access). Univariate and multivariable linear regressions were used to estimate the association between these factors; values were used to assess the factors that accounted for the greatest variation in CVD AAMR by race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic/Latinx individuals). There were 659 740 CVD deaths among non-Hispanic White individuals in 2698 counties; 100 475 deaths among non-Hispanic Black individuals in 717 counties; and 49 493 deaths among Hispanic/Latinx individuals across 267 counties. Non-Hispanic Black individuals had the highest mean CVD AAMR (320.04 deaths per 100 000 individuals), whereas Hispanic/Latinx individuals had the lowest (168.42 deaths per 100 000 individuals). The highest CVD AAMRs across all racial/ethnic groups were observed in the South. In unadjusted analyses, the greatest variation () in CVD AAMR was explained by physical inactivity for non-Hispanic White individuals (32.3%), median household income for non-Hispanic Black individuals (24.7%), and population size for Hispanic/Latinx individuals (28.4%). In multivariable regressions using county-level factor categories, the greatest variation in CVD AAMR was explained by CVD risk factors for non-Hispanic White individuals (35.3%), socioeconomic factors for non-Hispanic Black (25.8%), and demographic factors for Hispanic/Latinx individuals (34.9%). Conclusions The associations between race/ethnicity-specific age-adjusted CVD mortality and county-level factors differ significantly. Interventions to reduce disparities may benefit from being designed accordingly.
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http://dx.doi.org/10.1161/JAHA.120.018835DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8174200PMC
March 2021

Wilderness Cardiology: A Case of Envenomation-Associated Cardiotoxicity Following a Rattlesnake Bite.

Cardiol Ther 2021 Jun 23;10(1):271-276. Epub 2021 Feb 23.

Department of Medicine, Stanford University, Stanford, CA, USA.

Cardiac injury is infrequently described as a complication of snake bite envenomation. We present the case of a 62-year-old male with shortness of breath, right lower extremity edema, and elevated cardiac troponin 6 days after a Northern Pacific rattlesnake bite.
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http://dx.doi.org/10.1007/s40119-021-00215-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8126537PMC
June 2021

Metabolic Surgery and Class 1 Obesity (< 35 kg/m): a Prospective Study with Short-, Mid-, and Long-term Results Among Latinos.

Obes Surg 2021 06 17;31(6):2401-2409. Epub 2021 Feb 17.

The Obesity Clinic at Hospital General Tláhuac, Avenida la Turba # 655, Col. Villa Centroamericana y del Caribe, Delegación Tláhuac, 13250, Mexico City, Mexico.

Introduction: Metabolic surgery for managing class 1 obesity and type 2 diabetes mellitus has recently gained popularity. The Latino population presents high rates of these diseases. Reports on surgical outcomes in this population are scarce.

Methods: Prospective study with Mexican patients diagnosed with diabetes and class 1 obesity submitted to Roux-en-Y gastric bypass. The objective was to determine short-, mid-, and long-term outcomes (weight loss, metabolic, morbidity, and diabetes remission). Sub-analysis was included, based on preoperative usage of one (group A) or more (group B) oral hypoglycemic agents ± insulin.

Results: Fifty-one patients with a mean body mass index of 33.1 ± 1.9 kg/m, and glycated hemoglobin 7.2 ± 1.7% were included. Significant improvements were observed in almost every parameter. At 24, 36, and 60 months, complete diabetes remission was achieved in 73.8%, 52.2%, and 50% of patients with glycated hemoglobin levels of 5.7% ± 0.8%, 5.8% ± 0.5%, and 6.1% ± 0.8%, respectively. At 24, 36, and 60 months, patients in group A (N=28) showed 90.9%, 69.2%, and 75% remission, respectively, versus patients in group B (N=23), who had remission rates of 50%, 30%, and 25% during the same period. Diabetes relapse was higher in patients using ≥ 2 oral hypoglycemic agents ± insulin before surgery.

Conclusion: Gastric bypass is a safe and effective metabolic surgery that results in excellent mid- and long-term results among Mexicans. Patients using one drug preoperatively showed improved results and remission rates, which underscores the importance of intervening in the early stages of the disease.

Trial Registration: Clinical Trials identifier: NCT04595396 ( www.ClinicalTrials.gov ).
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http://dx.doi.org/10.1007/s11695-021-05275-3DOI Listing
June 2021

Educational Attainment and Prevalence of Cardiovascular Health (Life's Simple 7) in Asian Americans.

Int J Environ Res Public Health 2021 02 4;18(4). Epub 2021 Feb 4.

Division of Cardiovascular Medicine, Stanford University, Quarry Road, Falk CVRC, Stanford, CA 94305, USA.

Asian Americans have a high burden of cardiovascular disease, yet little is known about the social patterning of cardiovascular health (CVH) in this population. We examined if education (10+ years, and 15.9% for the U.S.-born. All models showed that low education compared to high education was associated with lower odds of having ideal CVH. This pattern remained in adjusted models but became non-significant when controlling for nativity (odds ratio = 0.34, 95% confidence interval: 0.10, 1.13). Models stratified by time in the U.S. were less consistent but showed similar education gradients in CVH. Low education is a risk factor for attaining ideal cardiovascular health among Asian Americans, regardless of time in the U.S.
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http://dx.doi.org/10.3390/ijerph18041480DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7914420PMC
February 2021

Management of Antithrombotic Therapy after Acute Coronary Syndromes.

N Engl J Med 2021 Feb;384(5):452-460

From the Division of Cardiovascular Medicine, Department of Medicine, and the Stanford Cardiovascular Institute (F.R., R.A.H.), Stanford University, Palo Alto, CA.

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http://dx.doi.org/10.1056/NEJMra1607714DOI Listing
February 2021
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