Publications by authors named "Khurram Nasir"

670 Publications

Determinants of Influenza Vaccine Uptake in Patients With Cardiovascular Disease and Strategies for Improvement.

J Am Heart Assoc 2021 Jul 28:e019671. Epub 2021 Jul 28.

Division Health Equity & Disparities Research Center for Outcomes Research Houston Methodist Hospital Houston TX.

Cardiovascular disease (CVD) is the leading cause of death and disability worldwide. Influenza infection is associated with an increased risk of cardiovascular events (myocardial infarction, stroke, and heart failure exacerbation) and mortality, and all-cause mortality in patients with CVD. Infection with influenza leads to a systemic inflammatory and thrombogenic response in the host body, which further causes destabilization of atherosclerotic plaques. Influenza vaccination has been shown to be protective against cardiovascular and cerebrovascular events in several observational and prospective studies of at-risk populations. Hence, many international guidelines recommend influenza vaccination for adults of all ages, especially for individuals with high-risk conditions such as CVD. Despite these long-standing recommendations, influenza vaccine uptake among US adults with CVD remains suboptimal. Specifically, vaccination uptake is strikingly low among patients aged <65 years, non-Hispanic Black individuals, those without health insurance, and those with diminished access to healthcare services. Behavioral factors such as perceived vaccine efficacy, vaccine safety, and attitudes towards vaccination play an important role in vaccine acceptance at the individual and community levels. With the ongoing COVID-19 pandemic, there is a potential threat of a concurrent epidemic with influenza. This would be devastating for vulnerable populations such as adults with CVD, further stressing the need for ensuring adequate influenza vaccination coverage. In this review, we describe a variety of strategies to improve the uptake of influenza vaccination in patients with CVD through improved understanding of key sociodemographic determinants and behaviors that are associated with vaccination, or the lack thereof. We further discuss the potential use of relevant strategies for COVID-19 vaccine uptake among those with CVD.
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http://dx.doi.org/10.1161/JAHA.120.019671DOI Listing
July 2021

Social Determinants of Health and Cardiovascular Disease: Current State and Future Directions Towards Healthcare Equity.

Curr Atheroscler Rep 2021 Jul 26;23(9):55. Epub 2021 Jul 26.

Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA.

Purpose Of Review: We sought to examine the role of social and environmental conditions that determine an individual's behaviors and risk of disease-collectively known as social determinants of health (SDOH)-in shaping cardiovascular (CV) health of the population and giving rise to disparities in risk factors, outcomes, and clinical care for cardiovascular disease (CVD), the leading cause of death in the United States (US).

Recent Findings: Traditional CV risk factors have been extensively targeted in existing CVD prevention and management paradigms, often with little attention to SDOH. Limited evidence suggests an association between individual SDOH (e.g., income, education) and CVD. However, inequities in CVD care, risk factors, and outcomes have not been studied using a broad SDOH framework. We examined existing evidence of the association between SDOH-organized into 6 domains, including economic stability, education, food, neighborhood and physical environment, healthcare system, and community and social context-and CVD. Greater social adversity, defined by adverse SDOH, was linked to higher burden of CVD risk factors and poor outcomes, such as stroke, myocardial infarction (MI), coronary heart disease, heart failure, and mortality. Conversely, favorable social conditions had protective effects on CVD. Upstream SDOH interact across domains to produce cumulative downstream effects on CV health, via multiple physiologic and behavioral pathways. SDOH are major drivers of sociodemographic disparities in CVD, with a disproportionate impact on socially disadvantaged populations. Efforts to achieve health equity should take into account the structural, institutional, and environmental barriers to optimum CV health in marginalized populations. In this review, we highlight major knowledge gaps for each SDOH domain and propose a set of actionable recommendations to inform CVD care, ensure equitable distribution of healthcare resources, and reduce observed disparities.
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http://dx.doi.org/10.1007/s11883-021-00949-wDOI Listing
July 2021

Assessment of Coronary Artery Calcium Scoring to Guide Statin Therapy Allocation According to Risk-Enhancing Factors: The Multi-Ethnic Study of Atherosclerosis.

JAMA Cardiol 2021 Jul 14. Epub 2021 Jul 14.

Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Maryland.

Importance: The 2018 American Heart Association/American College of Cardiology Guideline on the Management of Blood Cholesterol recommends the use of risk-enhancing factor assessment and the selective use of coronary artery calcium (CAC) scoring to guide the allocation of statin therapy among individuals with an intermediate risk of atherosclerotic cardiovascular disease (ASCVD).

Objective: To examine the association between risk-enhancing factors and incident ASCVD by CAC burden among those at intermediate risk of ASCVD.

Design, Setting, And Participants: The Multi-Ethnic Study of Atherosclerosis is a multicenter population-based prospective cross-sectional study conducted in the US. Baseline data for the present study were collected between July 15, 2000, and July 14, 2002, and follow-up for incident ASCVD events was ascertained through August 20, 2015. Participants were aged 45 to 75 years with no clinical ASCVD or diabetes at baseline, were at intermediate risk of ASCVD (≥7.5% to <20.0%), and had a low-density lipoprotein cholesterol level of 70 to 189 mg/dL.

Exposures: Family history of premature ASCVD, premature menopause, metabolic syndrome, chronic kidney disease, lipid and inflammatory biomarkers, and low ankle-brachial index.

Main Outcomes And Measures: Incident ASCVD over a median follow-up of 12.0 years.

Results: A total of 1688 participants (mean [SD] age, 65 [6] years; 976 men [57.8%]). Of those, 648 individuals (38.4%) were White, 562 (33.3%) were Black, 305 (18.1%) were Hispanic, and 173 (10.2%) were Chinese American. A total of 722 participants (42.8%) had a CAC score of 0. Among those with 1 to 2 risk-enhancing factors vs those with 3 or more risk-enhancing factors, the prevalence of a CAC score of 0 was 45.7% vs 40.3%, respectively. Over a median follow-up of 12.0 years (interquartile range [IQR], 11.5-12.6 years), the unadjusted incidence rate of ASCVD among those with a CAC score of 0 was less than 7.5 events per 1000 person-years for all individual risk-enhancing factors (with the exception of ankle-brachial index, for which the incidence rate was 10.4 events per 1000 person-years [95% CI, 1.5-73.5]) and combinations of risk-enhancing factors, including participants with 3 or more risk-enhancing factors. Although the individual and composite addition of risk-enhancing factors to the traditional risk factors was associated with improvement in the area under the receiver operating curve, the use of CAC scoring was associated with the greatest improvement in the C statistic (0.633 vs 0.678) for ASCVD events. For incident ASCVD, the net reclassification improvement for CAC was 0.067.

Conclusions And Relevance: In this cross-sectional study, among participants with CAC scores of 0, the presence of risk-enhancing factors was generally not associated with an overall ASCVD risk that was higher than the recommended treatment threshold for the initiation of statin therapy. The use of CAC scoring was associated with significant improvements in the reclassification and discrimination of incident ASCVD. The results of this study support the utility of CAC scoring as an adjunct to risk-enhancing factor assessment to more accurately classify individuals with an intermediate risk of ASCVD who might benefit from statin therapy.
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http://dx.doi.org/10.1001/jamacardio.2021.2321DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8281019PMC
July 2021

Prevalence and predictors of cost-related medication nonadherence in individuals with cardiovascular disease: Results from the Behavioral Risk Factor Surveillance System (BRFSS) survey.

Prev Med 2021 Jul 7;153:106715. Epub 2021 Jul 7.

Section of Cardiology, 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:

Medication nonadherence is highly prevalent among patients with chronic cardiovascular disease. Poor adherence has been associated with increased morbidity and mortality. Medication cost is a major driver for medication nonadherence. Utilizing data from the 2016 to 2018 Behavioral Risk Factor Surveillance System (BRFSS) survey, we estimated the prevalence of cost-related medication nonadherence (CRMNA) among the overall population and among individuals who reported a history of diabetes, atherosclerotic cardiovascular disease (ASCVD), or hypertension. We then performed multivariable logistic regression to analyze sociodemographic factors associated with CRMNA. Our study population consisted of 142,577 individuals of whom 24% were older than 65 years, 47% were men, 66% were White, 17% Black, 35% had hypertension, 13% had diabetes mellitus, and 10% had ASCVD. CRMNA was reported in 10% of the overall population, 12% among those with hypertension, 17% among those with diabetes, and 17% among those with ASCVD. Age below 65 years, female gender, unemployment, lower income, lower educational attainment, having at least 1 comorbidity, and living in a state that did not expand Medicaid were independently associated with CRMNA. The prevalence of CRMNA increased with greater number of these high-risk sociodemographic factors. We conclude that the prevalence of CRMNA is 10% among U.S. adults overall and is higher among those with common chronic diseases. Risk factors associated with CRMNA should be addressed in order to improve adherence rates and health outcomes among high-risk individuals.
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http://dx.doi.org/10.1016/j.ypmed.2021.106715DOI Listing
July 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

Stroke-Related Mortality in the United States-Mexico Border Area of the United States, 1999 to 2018.

J Am Heart Assoc 2021 Jul 2;10(13):e019993. Epub 2021 Jul 2.

Department of Cardiovascular Medicine Mayo Clinic Rochester MN.

BACKGROUND The United States (US)-Mexico border is a socioeconomically underserved area. We sought to investigate whether stroke-related mortality varies between the US border and nonborder counties. METHODS AND RESULTS We used death certificates from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database to examine stroke-related mortality in border versus nonborder counties in California, Texas, New Mexico, and Arizona. We measured average annual percent changes (AAPCs) in age-adjusted mortality rates (AAMRs) per 100 000 between 1999 and 2018. Overall, AAMRs were higher for nonborder counties, older adults, men, and non-Hispanic Black adults than their counterparts. Between 1999 and 2018, AAMRs reduced from 55.8 per 100 000 to 34.4 per 100 000 in the border counties (AAPC, -2.70) and 64.5 per 100 000 to 37.6 per 100 000 in nonborder counties (AAPC, -2.92). The annual percent change in AAMR initially decreased, followed by stagnation in both border and nonborder counties since 2012. The AAPC in AAMR decreased in all 4 states; however, AAMR increased in California's border counties since 2012 (annual percent change, 3.9). The annual percent change in AAMR decreased for older adults between 1999 and 2012 for the border (-5.10) and nonborder counties (-5.01), followed by a rise in border counties and stalling in nonborder counties. Although the AAPC in AAMR decreased for both sexes, the AAPC in AAMR differed significantly for non-Hispanic White adults in border (-2.69) and nonborder counties (-2.86). The mortality decreased consistently for all other ethnicities/races in both border and nonborder counties. CONCLUSIONS Stroke-related mortality varied between the border and nonborder counties. Given the substantial public health implications, targeted interventions aimed at vulnerable populations are required to improve stroke-related outcomes in the US-Mexico border area.
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http://dx.doi.org/10.1161/JAHA.120.019993DOI Listing
July 2021

COVID-19-related state-wise racial and ethnic disparities across the USA: an observational study based on publicly available data from The COVID Tracking Project.

BMJ Open 2021 06 21;11(6):e048006. Epub 2021 Jun 21.

Houston Methodist Hospital, Houston, Texas, USA

Objective: To evaluate COVID-19 infection and mortality disparities in ethnic and racial subgroups in a state-wise manner across the USA.

Methods: Publicly available data from The COVID Tracking Project at The Atlantic were accessed between 9 September 2020 and 14 September 2020. For each state and the District of Columbia, % infection, % death, and % population proportion for subgroups of race (African American/black (AA/black), Asian, American Indian or Alaska Native (AI/AN), and white) and ethnicity (Hispanic/Latino, non-Hispanic) were recorded. Crude and normalised disparity estimates were generated for COVID-19 infection (CDI and NDI) and mortality (CDM and NDM), computed as absolute and relative difference between % infection or % mortality and % population proportion per state. Choropleth map display was created as thematic representation proportionate to CDI, NDI, CDM and NDM.

Results: The Hispanic population had a median of 158% higher COVID-19 infection relative to their % population proportion (median 158%, IQR 100%-200%). This was followed by AA, with 50% higher COVID-19 infection relative to their % population proportion (median 50%, IQR 25%-100%). The AA population had the most disproportionate mortality, with a median of 46% higher mortality than the % population proportion (median 46%, IQR 18%-66%). Disproportionate impact of COVID-19 was also seen in AI/AN and Asian populations, with 100% excess infections than the % population proportion seen in nine states for AI/AN and seven states for Asian populations. There was no disproportionate impact in the white population in any state.

Conclusions: There are racial/ethnic disparities in COVID-19 infection/mortality, with distinct state-wise patterns across the USA based on racial/ethnic composition. There were missing and inconsistently reported racial/ethnic data in many states. This underscores the need for standardised reporting, attention to specific regional patterns, adequate resource allocation and addressing the underlying social determinants of health adversely affecting chronically marginalised groups.
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http://dx.doi.org/10.1136/bmjopen-2020-048006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8219486PMC
June 2021

Financial Hardship Among Nonelderly Adults With CKD in the United States.

Am J Kidney Dis 2021 Jun 15. Epub 2021 Jun 15.

Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX; Center for Outcomes Research, Houston Methodist, Houston, TX. Electronic address:

Rationale Objective: The burden of financial hardship among individuals with CKD has not been extensively studied. Therefore, we aimed to describe the scope and determinants of financial hardship among a nationally representative sample of adults with CKD.

Study Design: Cross-sectional.

Setting: & Participants: Non-elderly adults with CKD from the 2014-2018 National Health Interview Survey.

Exposure: Sociodemographic and clinical characteristics.

Outcomes: Financial hardship based on medical bills and consequences of financial hardship (high financial distress, food insecurity, cost-related medication non-adherence, delayed/forgone care due to cost). Financial hardship was categorized into 3 levels: no financial hardship, financial hardship but able to pay bills, and unable to pay bills at all. Financial hardship was then modeled in two different ways: a) any financial hardship (regardless of ability to pay) vs no financial hardship and b) inability to pay bills vs no financial hardship and financial hardship but able to pay bills.

Analytic Approach: Nationally representative estimates of financial hardship from medical bills were computed. Multivariable logistic regression models were used to examine the associations of sociodemographic and clinical factors with the outcomes of financial hardship based on medical bills.

Results: A total 1,425 individuals, representing approximately 2.1 million Americans, reported a diagnosis of CKD within the past year, of whom 46.9% (95% CI, 43.7-50.2) reported experiencing financial hardship from medical bills; 20.9% (95% CI, 18.5-23.6) reported inability to pay medical bills at all. Lack of insurance was the strongest determinant of financial hardship in this population (OR=4.06 [95% CI, 2.18-7.56]).

Limitations: Self-reported nature of CKD diagnosis.

Conclusion: Approximately half of the non-elderly US population with CKD experiences financial hardship from medical bills that is associated strongly with lack of insurance. Evidence-based clinical and policy interventions are needed to address these hardships.
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http://dx.doi.org/10.1053/j.ajkd.2021.04.011DOI Listing
June 2021

Inequitable COVID-19 vaccine distribution and its effects.

Bull World Health Organ 2021 06;99(6):406-406A

Milken Institute School of Public Health, George Washington University, 950 New Hampshire Ave. NW, Washington, DC 20052, United States of America (USA).

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http://dx.doi.org/10.2471/BLT.21.285616DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8164189PMC
June 2021

Obesity Prevalence and Risks Among Chinese Adults: Findings From the China PEACE Million Persons Project, 2014-2018.

Circ Cardiovasc Qual Outcomes 2021 Jun 10;14(6):e007292. Epub 2021 Jun 10.

National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China (J.L., C.W., B.C., J.L., X.Y., Z.Z., X.Z.).

Background: China has seen a burgeoning epidemic of obesity in recent decades, but few studies reported nationally on obesity across socio-demographic subgroups. We sought to assess the prevalence and socio-demographic associations of obesity nationwide.

Methods: We assessed the prevalence of overall obesity (body mass index ≥28 kg/m) and abdominal obesity (waist circumference ≥85/90 cm for women/men) among 2.7 million community-dwelling adults aged 35 to 75 years in the China PEACE Million Persons Project from 2014 to 2018 and quantified the socio-demographic associations of obesity using multivariable mixed models.

Results: Age-standardized rates of overall and abdominal obesity were 14.4% (95% CI, 14.3%-14.4%) and 32.7% (32.6%-32.8%) in women and 16.0% (15.9%-16.1%) and 36.6% (36.5%-36.8%) in men. Obesity varied considerably across socio-demographic subgroups. Older women were at higher risk for obesity (eg, adjusted relative risk [95% CI] of women aged 65-75 versus 35-44 years: 1.29 [1.27-1.31] for overall obesity, 1.76 [1.74-1.77] for abdominal obesity) while older men were not. Higher education was associated with lower risk in women (eg, adjusted relative risk [95% CI] of those with college or university education versus below primary school: 0.47 [0.46-0.48] for overall obesity, 0.61 [0.60-0.62] for abdominal obesity) but higher risk in men (1.07 [1.05-1.10], 1.17 [1.16-1.19]).

Conclusions: In China, over 1 in 7 individuals meet criteria for overall obesity, and 1 in 3 for abdominal obesity. Wide variation exists across socio-demographic subgroups. The associations of age and education with obesity are significant and differ by sex. Understanding obesity in contemporary China has broad domestic policy implications and provides a valuable international reference.
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http://dx.doi.org/10.1161/CIRCOUTCOMES.120.007292DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8204767PMC
June 2021

Coronary artery calcium is associated with increased risk for lung and colorectal cancer in men and women: the Multi-Ethnic Study of Atherosclerosis (MESA).

Eur Heart J Cardiovasc Imaging 2021 Jun 4. Epub 2021 Jun 4.

Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Blalock 524D1, 600 N Wolfe St, Baltimore, MD 21287, USA.

Aims: This study explored the association of coronary artery calcium (CAC) with incident cancer subtypes in the Multi-Ethnic Study of Atherosclerosis (MESA). CAC is an established predictor of cardiovascular disease (CVD), with emerging data also supporting independent predictive value for cancer. The association of CAC with risk for individual cancer subtypes is unknown.

Methods And Results: We included 6271 MESA participants, aged 45-84 and without known CVD or self-reported history of cancer. There were 777 incident cancer cases during mean follow-up of 12.9 ± 3.1 years. Lung and colorectal cancer (186 cases) were grouped based on their strong overlap with CVD risk profile; prostate (men) and ovarian, uterine, and breast cancer (women) were considered as sex-specific cancers (in total 250 cases). Incidence rates and Fine and Gray competing risks models were used to assess relative risk of cancer-specific outcomes stratified by CAC groups or Log(CAC+1). The mean age was 61.7 ± 10.2 years, 52.7% were women, and 36.5% were White. Overall, all-cause cancer incidence increased with CAC scores, with rates per 1000 person-years of 13.1 [95% confidence interval (CI): 11.7-14.7] for CAC = 0 and 35.8 (95% CI: 30.2-42.4) for CAC ≥400. Compared with CAC = 0, hazards for those with CAC ≥400 were increased for lung and colorectal cancer in men [subdistribution hazard ratio (SHR): 2.2 (95% CI: 1.1-4.7)] and women [SHR: 2.2 (95% CI: 1.0-4.6)], but not significantly for sex-specific cancers across sexes.

Conclusion: CAC scores were associated with cancer risk in both sexes; however, this was stronger for lung and colorectal when compared with sex-specific cancers. Our data support potential synergistic use of CAC scores in the identification of both CVD and lung and colorectal cancer risk.
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http://dx.doi.org/10.1093/ehjci/jeab099DOI Listing
June 2021

Familial hypercholesterolemia related admission for acute coronary syndrome in the United States: Incidence, predictors, and outcomes.

J Clin Lipidol 2021 May-Jun;15(3):460-465. Epub 2021 Apr 29.

Section on Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA. Electronic address:

Background: Individuals with Familial Hypercholesterolemia (FH) are at high risk for atherosclerotic cardiovascular disease (ASCVD) events.

Objectives: The purpose of this study was to evaluate the incidence, predictors, and outcomes of admissions for acute coronary syndromes (ACS) in this high-risk group.

Methods: Utilizing the National Readmission Databases, we identified individuals with or without FH admitted to participating hospitals for ACS. The primary outcome was admission for recurrent ACS at 11 month follow-up.

Results: There were a total of 1,697,513 ACS admissions from 10/2016 to 12/2017 (non-FH=1,696,979 and FH=534). Individuals with FH admitted for ACS were younger (median age 57 vs 69 y), had fewer comorbidities (hypertension 74.7% vs 79.6%; diabetes mellitus 30.5% vs 39.0%;p<0.01), were more likely to present with ST-elevation-myocardial infarction (32.8% vs 22.6%;p<0.01) and more likely to undergo multivessel percutaneous coronary intervention (11.4% vs 7.6%;p<0.01) than patients without FH. After propensity-score matching, FH patients more commonly experienced in-hospital VT arrest (11.8% vs 8.0%;p<0.01) and required more mechanical circulatory support (8.6% vs 3.3%; p<0.01). The 30-day readmission in those with FH was more frequently for cardiovascular disease (81.5% vs 46.5%; =p<0.01). At 11-month follow-up, FH patients were more likely to be readmitted with recurrent ACS compared to those without FH (hazard ratio=2.34; 95% confidence interval=1.30-4.23; p<0.01).

Conclusions: Individuals with FH admitted for ACS are younger, have fewer comorbidities, and more frequently present with STEMIs compared to those without FH. FH patients were more likely to suffer in-hospital cardiac complications and have a higher incidence of recurrent ACS.
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http://dx.doi.org/10.1016/j.jacl.2021.04.005DOI Listing
April 2021

Association Between Omega-3 Fatty Acid Levels and Risk for Incident Major Bleeding Events and Atrial Fibrillation: MESA.

J Am Heart Assoc 2021 Jun 27;10(11):e021431. Epub 2021 May 27.

Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology Johns Hopkins University School of Medicine Baltimore MD.

Background Randomized trials of pharmacologic strength omega-3 fatty acid (n3-FA)-based therapies suggest a dose-dependent cardiovascular benefit. Whether blood n3-FA levels also mediate safety signals observed in these trials, such as increased bleeding and atrial fibrillation (AF), remains uncertain. We hypothesized that higher baseline n3-FA levels would be associated with incident bleeding and AF events in MESA (Multi-Ethnic Study of Atherosclerosis), which included a population free of clinical cardiovascular disease at baseline. Methods and Results We examined the association between baseline plasma n3-FA levels (expressed as percent mass of total fatty acid) with incident bleeding and AF in MESA, an ongoing prospective cohort study. Bleeding events were identified from review of hospitalization (), and (), codes, and AF from participant report, discharge diagnoses, Medicare claims data, and study ECGs performed at MESA visit 5. Separate multivariable Cox proportional hazard modeling was used to estimate hazard ratios of the association of continuous n3-FA (log eicosapentaenoic acid [EPA], log docosahexaenoic acid [DHA], log [EPA+DHA]) and incident hospitalized bleeding events and AF. Among 6546 participants, the mean age was 62.1 years and 53% were women. For incident bleeding, consistent statistically significant associations with lower rates were seen with increasing levels of EPA and EPA+DHA in unadjusted and adjusted models including medications that modulate bleeding risk (aspirin, NSAIDS, corticosteroids, and proton pump inhibitors). For incident AF, a significant association with lower rates was seen with increasing levels of DHA, but not for EPA or EPA+DHA. Conclusions In MESA, higher plasma levels of n3-FA (EPA and EPA+DHA, but not DHA) were associated with significantly fewer hospitalized bleeding events, and higher DHA levels (but not EPA or EPA+DHA) with fewer incident AF events.
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http://dx.doi.org/10.1161/JAHA.121.021431DOI Listing
June 2021

Association of vitamins, minerals, and lead with Lipoprotein(a) in a cross-sectional cohort of US adults.

Int J Vitam Nutr Res 2021 May 24:1-12. Epub 2021 May 24.

Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.

Lipoprotein(a)(Lp[a]) is a low-density lipoprotein-cholesterol (LDL-C)-like particle with potent pro-atherothrombotic properties. The association of Lp(a) with several circulating factors, including vitamins, remains unresolved. We performed an observational analysis using the National Health and Nutrition Examination Survey III cohort, a cohort used to monitor the nutrition status of US-citizens. We used multivariable linear regression to test associations of Lp(a) and LDL-C with levels of serum vitamins and minerals and whole-blood lead. Analyses controlled for factors known to associate with Lp(a) (age, sex, race/ethnicity, statin use, hemoglobin A1c, body mass index, hypertension, diabetes, glomerular filtration rate, alcohol intake, and saturated fat intake). LDL-C was corrected for Lp(a) mass. Multiple sensitivity tests were performed, including considering factors as categorical variables (deficient, normal, elevated). Among 7,662 subjects, Lp(a) correlated (β-coefficient) positively (change per 1 conventional unit increase) with carotenoids (lycopene (0.17(0.06,0.28), p=0.005), lutein (0.19(0.07,0.30), p=0.002), β-cryptoxanthin (0.21(0.05,0.37), p=0.01), β-carotene (0.05(0.02,0.09), p=0.003), and α-carotene (0.15(0.01,0.30), p=0.04)) and lead (0.54(0.03,1.05), p=0.04) levels when tested as continuous variables. LDL-C had similar associations. Lp(a) did not associate with vitamins A, B12, C, or E retinyl esters, folate, RBC-folate, selenium, ferritin, transferrin saturation, or calcium. With factors as categorical variables, Lp(a) but not LDL-C negatively associated with elevated vitamin B12 (-5.41(-9.50, -1.53), p=0.01) and folate (-2.86(-5.09, -0.63), p=0.01). In conclusion, Lp(a) associated similarly to LDL-C when vitamins, minerals, and lead were tested as continuous variables, while only Lp(a) correlated with vitamin B12 and folate when tested as categorical variables. These observations are hypotheses generating and require further studies to determine causality.
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http://dx.doi.org/10.1024/0300-9831/a000709DOI Listing
May 2021

Association of Socioeconomic Disadvantage With Long-term Mortality After Myocardial Infarction: The Mass General Brigham YOUNG-MI Registry.

JAMA Cardiol 2021 May 19. Epub 2021 May 19.

Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Importance: Socioeconomic disadvantage is associated with poor health outcomes. However, whether socioeconomic factors are associated with post-myocardial infarction (MI) outcomes in younger patient populations is unknown.

Objective: To evaluate the association of neighborhood-level socioeconomic disadvantage with long-term outcomes among patients who experienced an MI at a young age.

Design, Setting, And Participants: This cohort study analyzed patients in the Mass General Brigham YOUNG-MI Registry (at Brigham and Women's Hospital and Massachusetts General Hospital in Boston, Massachusetts) who experienced an MI at or before 50 years of age between January 1, 2000, and April 30, 2016. Each patient's home address was mapped to the Area Deprivation Index (ADI) to capture higher rates of socioeconomic disadvantage. The median follow-up duration was 11.3 years. The dates of analysis were May 1, 2020, to June 30, 2020.

Exposures: Patients were assigned an ADI ranking according to their home address and then stratified into 3 groups (least disadvantaged group, middle group, and most disadvantaged group).

Main Outcomes And Measures: The outcomes of interest were all-cause and cardiovascular mortality. Cause of death was adjudicated from national registries and electronic medical records. Cox proportional hazards regression modeling was used to evaluate the association of ADI with all-cause and cardiovascular mortality.

Results: The cohort consisted of 2097 patients, of whom 2002 (95.5%) with an ADI ranking were included (median [interquartile range] age, 45 [42-48] years; 1607 male individuals [80.3%]). Patients in the most disadvantaged neighborhoods were more likely to be Black or Hispanic, have public insurance or no insurance, and have higher rates of traditional cardiovascular risk factors such as hypertension and diabetes. Among the 1964 patients who survived to hospital discharge, 74 (13.6%) in the most disadvantaged group compared with 88 (12.6%) in the middle group and 41 (5.7%) in the least disadvantaged group died. Even after adjusting for a comprehensive set of clinical covariates, higher neighborhood disadvantage was associated with a 32% higher all-cause mortality (hazard ratio, 1.32; 95% CI, 1.10-1.60; P = .004) and a 57% higher cardiovascular mortality (hazard ratio, 1.57; 95% CI, 1.17-2.10; P = .003).

Conclusions And Relevance: This study found that, among patients who experienced an MI at or before age 50 years, socioeconomic disadvantage was associated with higher all-cause and cardiovascular mortality even after adjusting for clinical comorbidities. These findings suggest that neighborhood and socioeconomic factors have an important role in long-term post-MI survival.
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http://dx.doi.org/10.1001/jamacardio.2021.0487DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8135064PMC
May 2021

Out-of-Pocket Annual Health Expenditures and Financial Toxicity From Healthcare Costs in Patients With Heart Failure in the United States.

J Am Heart Assoc 2021 Jul 16;10(14):e022164. Epub 2021 May 16.

Section of Cardiovascular Medicine Department of Internal Medicine Yale School of Medicine New Haven CT.

Background Heart failure (HF) poses a major public health burden in the United States. We examined the burden of out-of-pocket healthcare costs on patients with HF and their families. Methods and Results In the Medical Expenditure Panel Survey, we identified all families with ≥1 adult member with HF during 2014 to 2018. Total out-of-pocket healthcare expenditures included yearly care-specific costs and insurance premiums. We evaluated 2 outcomes of financial toxicity: (1) high financial burden-total out-of-pocket healthcare expense to postsubsistence income ratio of >20%, and (2) catastrophic financial burden with the ratio of >40%-a bankrupting expense defined by the World Health Organization. There were 788 families in the Medical Expenditure Panel Survey with a member with HF representing 0.54% (95% CI, 0.48%-0.60%) of all families nationally. The overall mean annual out-of-pocket healthcare expenses were $4423 (95% CI, $3908-$4939), with medications and health insurance premiums representing the largest categories of cost. Overall, 14% (95% CI, 11%-18%) of families experienced a high burden and 5% (95% CI, 3%-6%) experienced a catastrophic burden. Among the two-fifths of families considered low income, 24% (95% CI, 18%-30%) experienced a high financial burden, whereas 10% (95% CI, 6%-14%) experienced a catastrophic burden. Low-income families had 4-fold greater risk-adjusted odds of high financial burden (odds ratio [OR] , 3.9; 95% CI, 2.3-6.6), and 14-fold greater risk-adjusted odds of catastrophic financial burden (OR, 14.2; 95% CI, 5.1-39.5) compared with middle/high-income families. Conclusions Patients with HF and their families experience large out-of-pocket healthcare expenses. A large proportion encounter financial toxicity, with a disproportionate effect on low-income families.
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http://dx.doi.org/10.1161/JAHA.121.022164DOI Listing
July 2021

Temporal Trends and Interest in Coronary Artery Calcium Scoring Over Time: An Infodemiology Study.

Mayo Clin Proc Innov Qual Outcomes 2021 Apr 8;5(2):456-465. Epub 2021 Apr 8.

Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD.

Objective: To evaluate interest in coronary artery calcium (CAC) among the general public during the past 17 years and to compare trends with real-world data on number of CAC procedures performed.

Methods: We used Google Trends, a publicly available database, to access search query data in a systematic and quantitative fashion to search for CAC-related key terms. Search terms included , , , , and . We accessed Google Trends in January 2021 and analyzed data from 2004 to 2020.

Results: From 2004 to December 31, 2020, CAC-related search interest (in relative search volume) increased continually worldwide (+201.9%) and in the United States (+354.8%). Three main events strongly influenced search interest in CAC: reports of a CAC scan of the president of the United States led to a transient 10-fold increase in early January 2018. American College of Cardiology/American Heart Association guideline release led to a sustained increase, and lockdown after the global pandemic due to COVID-19 led to a transient decrease. Real-world data on performed CAC scans showed an increase between 2006 and 2017 (+200.0%); during the same time period, relative search volume for CAC-related search terms increased in a similar pattern (+70.6%-1511.1%). For the search term , a potential representative of active online search for CAC scanning, we found a +28.8% increase in 2020 compared with 2017.

Conclusion: Google Trends, a valuable tool for assessing public interest in health-related topics, suggests increased overall interest in CAC during the last 17 years that mirrors real-world usage data. Increased interest is seemingly linked to reports of CAC testing in world leaders and endorsement in major guidelines.
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http://dx.doi.org/10.1016/j.mayocpiqo.2021.02.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8105517PMC
April 2021

Clinical and Economic Burden of Stroke Among Young, Midlife, and Older Adults in the United States, 2002-2017.

Mayo Clin Proc Innov Qual Outcomes 2021 Apr 8;5(2):431-441. Epub 2021 Apr 8.

Division of Cardiovascular Prevention and Wellness, Department of Cardiovascular Medicine, Houston Methodist DeBakey Heart and Vascular Center.

Objective: To assess trends of stroke hospitalization rates, inpatient mortality, and health care resource use in young (aged ≤44 years), midlife (aged 45-64 years), and older (aged ≥65 years) adults.

Patients And Methods: We studied the National Inpatient Sample database (January 1, 2002 to December 31, 2017) to analyze stroke-related hospitalizations. We identified data using the codes.

Results: Of 11,381,390 strokes, 79% (n=9,009,007) were ischemic and 21% (n=2,372,383) were hemorrhagic. Chronic diseases were more frequent in older adults; smoking, alcoholism, and migraine were more prevalent in midlife adults; and coagulopathy and intravenous drug abuse were more common in young patients with stroke. The hospitalization rates of stroke per 10,000 increased overall (31.6 to 33.3) in young and midlife adults while decreasing in older adults. Although mortality decreased overall and in all age groups, the decline was slower in young and midlife adults than older adults. The mean length of stay significantly decreased in midlife and older adults and increased in young adults. The inflation-adjusted mean cost of stay increased consistently, with an average annual growth rate of 2.44% in young, 1.72% in midlife, and 1.45% in older adults owing to the higher use of health care resources. These trends were consistent in both ischemic and hemorrhagic stroke.

Conclusion: Stroke-related hospitalization and health care expenditure are increasing in the United States, particularly among young and midlife adults. A higher cost of stay counterbalances the benefits of reducing stroke and mortality in older patients.
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http://dx.doi.org/10.1016/j.mayocpiqo.2021.01.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8105541PMC
April 2021

Burden of cardiovascular risk factors and disease in five Asian groups in Catalonia: a disaggregated, population-based analysis of 121 000 first-generation Asian immigrants.

Eur J Prev Cardiol 2021 May 10. Epub 2021 May 10.

Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, 6565 Fannin St Brown Bldg. B5-019, Houston, TX 77030, USA.

Aims: To evaluate the burden of cardiovascular risk factors and disease (CVD) among five Asian groups living in Catalonia (Spain): Indian, Pakistani, Bangladeshi, Filipino, and Chinese.

Methods And Results: Retrospective cohort study using the Catalan Health Surveillance System database including 42 488 Pakistanis, 40 745 Chinese, 21 705 Indians, 9544 Filipinos, and 6907 Bangladeshis; and 5.3 million native individuals ('locals'). We estimated the age-adjusted prevalence (as of 31 December 2019) and incidence (during 2019) of diabetes, hypertension, hyperlipidaemia, obesity, tobacco use, coronary heart disease (CHD), cerebrovascular disease, atrial fibrillation, and heart failure (HF). Bangladeshis had the highest prevalence of diabetes (17.4% men, 22.6% women) followed by Pakistanis. Bangladeshis also had the highest prevalence of hyperlipidaemia (23.6% men, 18.3% women), hypertension among women (24%), and incident tobacco use among men. Pakistani women had the highest prevalence of obesity (28%). For CHD, Bangladeshi men had the highest prevalence (7.3%), followed by Pakistanis (6.3%); and Pakistanis had the highest prevalence among women (3.2%). For HF, the prevalence in Pakistani and Bangladeshi women was more than twice that of locals. Indians had the lowest prevalence of diabetes across South Asians, and of CHD across South Asian men, while the prevalence of CHD among Indian women was twice that of local women (2.6% vs. 1.3%). Filipinos had the highest prevalence of hypertension among men (21.8%). Chinese men and women had the lowest prevalence of risk factors and CVD.

Conclusions: In Catalonia, preventive interventions adapted to the risk profile of different Asian immigrant groups are needed, particularly for Bangladeshis and Pakistanis.
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http://dx.doi.org/10.1093/eurjpc/zwab074DOI Listing
May 2021

Financial burden, distress, and toxicity in cardiovascular disease.

Am Heart J 2021 Aug 5;238:75-84. Epub 2021 May 5.

Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA; Department of Medicine, Cardiology Section, VA Boston Healthcare System, Boston, MA. Electronic address:

Cardiovascular disease (CVD) is a major source of financial burden and distress, which has 3 main domains: (1) psychological distress; (2) cost-related care non-adherence or medical care deferral, and (3) tradeoffs with basic non-medical needs. We propose 4 ways to reduce financial distress in CVD: (1) policymakers can expand insurance coverage and curtail underinsurance; (2) health systems can limit expenditure on low-benefit, high-cost treatments while developing services for high-risk individuals; (3) physicians can engage in shared-decision-making for high-cost interventions, and (4) community-based initiatives can support patients with system navigation and financial coping. Avenues for research include (1) analysis of how healthcare policies affect financial burden; (2) comparative effectiveness studies examining high and low-cost strategies for CVD management; and (3) studying interventions to reduce financial burden, financial coaching, and community health worker integration.
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http://dx.doi.org/10.1016/j.ahj.2021.04.011DOI Listing
August 2021

Social Determinants of Adherence to COVID-19 Risk Mitigation Measures Among Adults With Cardiovascular Disease.

Circ Cardiovasc Qual Outcomes 2021 06 6;14(6):e008118. Epub 2021 May 6.

Center for Outcomes Research, Houston Methodist, Houston, TX (K.K.H., Z.J., M.C.-A., F.S.V., I.A., B.K., K.N.).

Background: Social determinants of health (SDOH) may limit the practice of coronavirus disease 2019 (COVID-19) risk mitigation guidelines with health implications for individuals with underlying cardiovascular disease (CVD). Population-based evidence of the association between SDOH and practicing such mitigation strategies in adults with CVD is lacking. We used the National Opinion Research Center's COVID-19 Household Impact Survey conducted between April and June 2020 to evaluate sociodemographic disparities in adherence to COVID-19 risk mitigation measures in a sample of respondents with underlying CVD representing 18 geographic areas of the United States.

Methods: CVD status was ascertained by self-reported history of receiving heart disease, heart attack, or stroke diagnosis. We built de novo, a cumulative index of SDOH burden using education, insurance, economic stability, 30-day food security, urbanicity, neighborhood quality, and integration. We described the practice of measures under the broad strategies of personal protection (mask, hand hygiene, and physical distancing), social distancing (avoiding crowds, restaurants, social activities, and high-risk contact), and work flexibility (work from home, canceling/postponing work). We reported prevalence ratios and 95% CIs for the association between SDOH burden (quartiles of cumulative indices) and practicing these measures adjusting for age, sex, race/ethnicity, comorbidity, and interview wave.

Results: Two thousand thirty-six of 25 269 (7.0%) adults, representing 8.69 million in 18 geographic areas of the United States, reported underlying CVD. Compared with the least SDOH burden, fewer individuals with the greatest SDOH burden practiced all personal protection (75.6% versus 89.0%) and social distancing measures (41.9% versus 58.9%) and had any flexible work schedule (26.2% versus 41.4%). These associations remained statistically significant after full adjustment: personal protection (prevalence ratio, 0.83 [95% CI, 0.73-0.96]; =0.009), social distancing (prevalence ratio, 0.69 [95% CI, 0.51-0.94]; =0.018), and work flexibility (prevalence ratio, 0.53 [95% CI, 0.36-0.79]; =0.002).

Conclusions: SDOH burden is associated with lower COVID-19 risk mitigation practices in the CVD population. Identifying and prioritizing individuals whose medical vulnerability is compounded by social adversity may optimize emerging preventive efforts, including vaccination guidelines.
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http://dx.doi.org/10.1161/CIRCOUTCOMES.121.008118DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8204764PMC
June 2021

Role of coronary artery calcium score in the primary prevention of cardiovascular disease.

BMJ 2021 05 4;373:n776. Epub 2021 May 4.

Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA.

First developed in 1990, the Agatston coronary artery calcium (CAC) score is an international guideline-endorsed decision aid for further risk assessment and personalized management in the primary prevention of atherosclerotic cardiovascular disease. This review discusses key international studies that have informed this 30 year journey, from an initial coronary plaque screening paradigm to its current role informing personalized shared decision making. Special attention is paid to the prognostic value of a CAC score of zero (the so called "power of zero"), which, in a context of low estimated risk thresholds for the consideration of preventive therapy with statins in current guidelines, may be used to individuals and thereby inform the safe delay or avoidance of certain preventive therapies. We also evaluate current recommendations for CAC scoring in clinical practice guidelines around the world, and past and prevailing barriers for its use in routine patient care. Finally, we discuss emerging approaches in this field, with a focus on the potential role of CAC informing not only the personalized allocation of statins and aspirin in the general population, but also of other risk-reduction therapies in special populations, such as individuals with diabetes and people with severe hypercholesterolemia.
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http://dx.doi.org/10.1136/bmj.n776DOI Listing
May 2021

Sex-Related Disparities in Cardiovascular Health Care Among Patients With Premature Atherosclerotic Cardiovascular Disease.

JAMA Cardiol 2021 Jul;6(7):782-790

Health Policy, Quality and Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas.

Importance: There is a paucity of data regarding secondary prevention care disparities in women with premature and extremely premature atherosclerotic cardiovascular disease (ASCVD), defined as an ASCVD event at 55 years or younger and 40 years or younger, respectively.

Objective: To evaluate sex-based differences in antiplatelet agents, any statin, high-intensity statin (HIS) therapy, and statin adherence in patients with premature and extremely premature ASCVD.

Design, Setting, And Participants: This was a cross-sectional, multicenter, nationwide VA health care system-based study with patients enrolled in the Veterans With Premature Atherosclerosis (VITAL) registry. The study assessed patients who had at least 1 primary care visit in the Veterans Affairs (VA) health care system from October 1, 2014, to September 30, 2015. Participants included 147 600 veteran patients with premature ASCVD, encompassing ischemic heart disease (IHD), ischemic cerebrovascular disease (ICVD), and peripheral arterial disease (PAD).

Exposures: Women vs men with premature and extremely premature ASCVD.

Main Outcomes And Measures: Antiplatelet use, any statin use, HIS use, and statin adherence (proportion of days covered [PDC] ≥0.8).

Results: We identified 10 413 women and 137 187 men with premature ASCVD (age ≤55 years) and 1340 women and 8145 men with extremely premature (age ≤40 years) ASCVD. Among patients with premature and extremely premature ASCVD, women represented 7.1% and 14.1% of those groups, respectively. When compared with men, women with premature ASCVD had a higher proportion of African American patients (36.1% vs 23.8%) and lower proportions of Asian patients (0.5% vs 0.7%) and White patients (56.1% vs. 68.1%). In the extremely premature ASCVD group, women had a comparatively higher proportion of African American patients (36.8% vs 23.2%) and lower proportion of White patients (55.0% vs 67.8%) and Asian patients (1.3% vs 1.5%) than men. Among patients with premature IHD, women received less antiplatelet (adjusted odds ratio [AOR], 0.47, 95% CI, 0.45-0.50), any statin (AOR, 0.62; 95% CI, 0.59-0.66), and HIS (AOR, 0.63; 95% CI, 0.59-0.66) therapy and were less statin adherent (mean [SD] PDC, 0.68 [0.34] vs 0.73 [0.31]; β coefficient: -0.02; 95% CI, -0.03 to -0.01) compared with men. Similarly, women with premature ICVD and premature PAD received comparatively less antiplatelet agents, any statin, and HIS. Among patients with extremely premature ASCVD, women also received less antiplatelet therapy (AOR, 0.61; 95% CI, 0.53-0.70), any statin therapy (AOR,0.51; 95% CI, 0.44-0.58), and HIS therapy (AOR, 0.45; 95% CI, 0.37-0.54) than men. There were no sex-associated differences in statin adherence among patients with premature ICVD, premature PAD, or extremely premature ASCVD.

Conclusions And Relevance: This cross-sectional study revealed that women veterans with premature ASCVD and extremely premature ASCVD receive less optimal secondary prevention cardiovascular care in comparison with men. Women with premature ASCVD, particularly those with IHD, were also less statin adherent. Multidisciplinary and patient-centered interventions are needed to improve these disparities in women.
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http://dx.doi.org/10.1001/jamacardio.2021.0683DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8060887PMC
July 2021

Rural-Urban Differences in Mortality From Ischemic Heart Disease, Heart Failure, and Stroke in the United States.

Circ Cardiovasc Qual Outcomes 2021 Apr 20;14(4):e007341. Epub 2021 Apr 20.

Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA (M.R.M., C.O., H.J.W.).

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http://dx.doi.org/10.1161/CIRCOUTCOMES.120.007341DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8059762PMC
April 2021

Atherosclerotic cardiovascular disease events among statin eligible individuals with and without long-term healthy arterial aging.

Atherosclerosis 2021 06 26;326:56-62. Epub 2021 Mar 26.

The Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States. Electronic address:

Background And Aims: A large proportion of statin eligible candidates have a baseline absence of coronary artery calcium (CAC) and low 10-year atherosclerotic cardiovascular disease (ASCVD) risk. We sought to determine the proportion of statin eligible individuals who had long-term healthy arterial aging (persistent CAC = 0) and their examined 15-year ASCVD outcomes.

Methods: We included 561 statin eligible candidates from the Multi-Ethnic Study of Atherosclerosis who were not on statin therapy with CAC = 0 at Visit 1 (2000-02) and underwent a subsequent CAC scan at Visit 5 (2010-11). Adjusted Cox proportional hazards regression assessed the association between persistent CAC = 0 and ASCVD events over 15.9 years.

Results: Participants were on average 61.7 years old, 50% were women, and 43% maintained long-term CAC = 0. Individuals with an LDL-C ≥190 mg/dL (54%) and those with an ASCVD risk ≥20% (33%) had the highest and lowest proportion of persistent CAC = 0, respectively. There were 57 ASCVD events, and 15-year ASCVD event rates were low for individuals with and without healthy arterial aging (4.3 versus 8.6 per 1,000 persons-years), but the 10-year number needed to treat to prevent one ASCVD event differed by more than two fold (117 versus 54). In multivariable modeling, persistent CAC = 0 conferred a 51% lower risk of ASCVD compared to those with incident CAC (HR = 0.49, 95% CI: 0.27-0.90, p=0.02).

Conclusions: More than 40% of statin eligible individuals with baseline CAC = 0 had long-term healthy arterial aging. Statin eligible candidates with persistent CAC = 0 had a very low 15-year ASCVD risk, suggesting that statin therapy may be of limited benefit among this group of individuals.
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http://dx.doi.org/10.1016/j.atherosclerosis.2021.03.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8215721PMC
June 2021

Premature Atherosclerotic Cardiovascular Disease Risk Among Patients with Inflammatory Bowel Disease.

Am J Med 2021 Apr 1. Epub 2021 Apr 1.

Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center, Houston, Texas; Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas. Electronic address:

Background: Recent literature has shown an association between atherosclerotic cardiovascular disease and inflammatory bowel disease, potentially mediated through chronic inflammatory pathways. However, there is a paucity of data demonstrating this relationship among young patients with premature atherosclerotic cardiovascular disease.

Methods: Using data from the nationwide Veterans wIth premaTure AtheroscLerosis (VITAL) registry, we assessed the association between extremely premature and premature atherosclerotic cardiovascular disease (age at diagnosis: ≤40 years and ≤55 years, respectively) and inflammatory bowel disease. Patients were compared with age-matched controls without atherosclerotic cardiovascular disease. Multivariable regression models adjusted for traditional risk factors.

Results: We identified 147,600 patients and 9485 patients with premature and extremely premature atherosclerotic cardiovascular disease, respectively. Compared with controls, there was a higher prevalence of overall inflammatory bowel disease among premature (0.96% vs 0.84%; odds ratio [OR] 1.14; 95% confidence interval [CI], 1.08-1.21) and extremely premature (1.36% vs 0.75%; OR 1.82; 95% CI, 1.52-2.17) patients. After adjustment, these associations attenuated in both premature and extremely premature groups (OR 1.07; 95% CI, 1.00-1.14 and OR 1.61; 95% CI, 1.34-1.94, respectively).

Conclusion: Inflammatory bowel disease is associated with higher odds of extremely premature atherosclerotic cardiovascular disease, especially for those age ≤40 years. With increasing age, this risk is attenuated by traditional cardiometabolic factors such as obesity, hypertension, diabetes, smoking, and dyslipidemia. Prospective studies are needed to assess the role of early intervention to decrease cardiovascular risk among young patients with inflammatory bowel disease.
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http://dx.doi.org/10.1016/j.amjmed.2021.02.029DOI Listing
April 2021

Association of inflammatory disease and long-term outcomes among young adults with myocardial infarction: the Mass General Brigham YOUNG-MI Registry.

Eur J Prev Cardiol 2021 Mar 30. Epub 2021 Mar 30.

Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.

Aims: Autoimmune systemic inflammatory diseases (SIDs) are associated with an increased risk of cardiovascular (CV) disease, particularly myocardial infarction (MI). However, there are limited data on the prevalence and effects of SID among adults who experience an MI at a young age. We sought to determine the prevalence and prognostic implications of SID among adults who experienced an MI at a young age.

Methods And Results: The YOUNG-MI registry is a retrospective cohort study from two large academic centres, which includes patients who experienced a first MI at 50 years of age or younger. SID was ascertained through physician review of the electronic medical record (EMR). Incidence of death was ascertained through the EMR and national databases. The cohort consisted of 2097 individuals, with 53 (2.5%) possessing a diagnosis of SID. Patients with SID were more likely to be female (36% vs. 19%, P = 0.004) and have hypertension (62% vs. 46%, P = 0.025). Over a median follow-up of 11.2 years, patients with SID experienced an higher risk of all-cause mortality compared with either the full cohort of non-SID patients [hazard ratio (HR) = 1.95, 95% confidence interval (CI) (1.07-3.57), P = 0.030], or a matched cohort based on age, gender, and CV risk factors [HR = 2.68, 95% CI (1.18-6.07), P = 0.018].

Conclusions: Among patients who experienced a first MI at a young age, 2.5% had evidence of SID, and these individuals had higher rates of long-term all-cause mortality. Our findings suggest that the presence of SID is associated with worse long-term survival after premature MI.
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http://dx.doi.org/10.1093/eurjpc/zwaa154DOI Listing
March 2021

Strengthening the Learning Health System in Cardiovascular Disease Prevention: Time to Leverage Big Data and Digital Solutions.

Curr Atheroscler Rep 2021 Mar 10;23(5):19. Epub 2021 Mar 10.

Department of Medicine, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Harvey Building, Suite 808, Baltimore, MD, 21287, USA.

Purpose Of Review: The past few decades have seen significant technologic innovation for the treatment and diagnosis of cardiovascular diseases. The subsequent growing complexity of modern medicine, however, is causing fundamental challenges in our healthcare system primarily in the spheres of patient involvement, data generation, and timely clinical implementation. The Institute of Medicine advocated for a learning health system (LHS) in which knowledge generation and patient care are inherently symbiotic. The purpose of this paper is to review how the advances in technology and big data have been used to further patient care and data generation and what future steps will need to occur to develop a LHS in cardiovascular disease.

Recent Findings: Patient-centered care has progressed from technologic advances yielding resources like decision aids. LHS can also incorporate patient preferences by increasing and standardizing patient-reported information collection. Additionally, data generation can be optimized using big data analytics by developing large interoperable datasets from multiple sources to allow for real-time data feedback. Developing a LHS will require innovative technologic solutions with a patient-centered lens to facilitate symbiosis in data generation and clinical practice.
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http://dx.doi.org/10.1007/s11883-021-00916-5DOI Listing
March 2021
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