Publications by authors named "Salim S Virani"

460 Publications

Social vulnerability and COVID-19: An analysis of CDC data.

Prog Cardiovasc Dis 2021 Sep 21. Epub 2021 Sep 21.

Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA; 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, USA; Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.

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http://dx.doi.org/10.1016/j.pcad.2021.09.006DOI Listing
September 2021

A comparison of cardiovascular risk factors between Asian-Americans and non-Asian Americans: An analysis from the NHANES database.

Prog Cardiovasc Dis 2021 Sep 21. Epub 2021 Sep 21.

Michael E. DeBakey VA Medical Center, Houston, TX, United States of America; Section of Cardiology, Baylor College of Medicine, Houston, TX, United States of America.

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http://dx.doi.org/10.1016/j.pcad.2021.09.009DOI Listing
September 2021

Cigarette smokers' perceptions of smoking cessation and associated factors in Karachi, Pakistan.

Public Health Nurs 2021 Sep 21. Epub 2021 Sep 21.

College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.

Objectives: The study explored the perceptions of adult smokers with cardiovascular and respiratory diseases regarding cigarette smoking cessation. We also explored factors that may hinder or facilitate smoking cessation process.

Design: Qualitative descriptive exploratory design SAMPLE: Purposive sample of 13 adult smokers with cardiovascular or respiratory diseases visiting outpatient cardiac and respiratory clinics at a private tertiary care hospital MEASUREMENTS: In-depth, face-to-face, and semi-structured interviews were conducted. The interviews were digitally recorded and transcribed verbatim followed by a six steps process of manual thematic analysis of data.

Results: Meaningful statements were assigned codes and grouped into categories. Categories were clustered under three themes representing individual factors, socio-cultural factors, and institutional factors.

Conclusions: Smoking cessation is influenced by personal, cultural, as well as social aspects. Institutionally, there is a need to recognize that smoking is a learned behavior; hence, prohibiting public smoking will potentially contribute to non-smoking behaviors. Although the nature of misconceptions varies, this is imperative to ensure consistency in messaging, programming, and supports led by healthcare professionals.
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http://dx.doi.org/10.1111/phn.12971DOI Listing
September 2021

Methodological Rigor and Temporal Trends of Cardiovascular Medicine Meta-Analyses in Highest-Impact Journals.

J Am Heart Assoc 2021 Sep 17;10(18):e021367. Epub 2021 Sep 17.

Department of Medicine Weill Cornell Medicine-Qatar Doha Qatar.

Background Well-conducted meta-analyses are considered to be at the top of the evidence-based hierarchy pyramid, with an expansion of these publications within the cardiovascular research arena. There are limited data evaluating the trends and quality of such publications. The objective of this study was to evaluate the methodological rigor and temporal trends of cardiovascular medicine-related meta-analyses published in the highest impact journals. Methods and Results Using the Medline database, we retrieved cardiovascular medicine-related systematic reviews and meta-analyses published in between January 1, 2012 and December 31, 2018. Among 6406 original investigations published during the study period, meta-analyses represented 422 (6.6%) articles, with an annual decline in the proportion of published meta-analyses (8.7% in 2012 versus 4.6% in 2018, =0.002). A substantial number of studies failed to incorporate elements of Preferred Reporting Items for Systematic Reviews and Meta-Analyses or Meta-Analysis of Observational Studies in Epidemiology guidelines (51.9%) and only a minority of studies (10.4%) were registered in PROSPERO (International Prospective Register of Systematic Reviews). Fewer manuscripts failed to incorporate the Preferred Reporting Items for Systematic Reviews and Meta-Analyses or Meta-Analysis of Observational Studies in Epidemiology elements over time (60.2% in 2012 versus 40.0% in 2018, <0.001) whereas the number of meta-analyses registered at PROSPERO has increased (2.4% in 2013 versus 17.5% in 2018, <0.001). Conclusions The proportion of cardiovascular medicine-related meta-analyses published in the highest impact journals has declined over time. Although there is an increasing trend in compliance with quality-based guidelines, the overall compliance remains low.
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http://dx.doi.org/10.1161/JAHA.121.021367DOI Listing
September 2021

High-Intensity Statins Benefit High-Risk Patients: Why and How to Do Better.

Mayo Clin Proc 2021 Sep 14. Epub 2021 Sep 14.

Baylor College of Medicine and Michael E. DeBakey VA Medical Center, Houston, TX.

Review of the US and European literature indicates that most patients at high risk for atherosclerotic cardiovascular disease (ASCVD are not treated with high-intensity statins, despite strong clinical-trial evidence of maximal statin benefit. High-intensity statins are recommended for 2 categories of patients: those with ASCVD (secondary prevention) and high-risk patients without clinical ASCVD. Most patients with ASCVD are candidates for high-intensity statins, with a goal for low-density lipoprotein cholesterol reduction of 50% or greater. A subgroup of patients with ASCVD are at very high risk and can benefit by the addition of nonstatin drugs (ezetimibe with or without bile acid sequestrant or bempedoic acid and/or a proprotein convertase subtilisin/kexin type 9 inhibitor). High-risk primary prevention patients are those with severe hypercholesterolemia, diabetes with associated risk factors, and patients aged 40 to 75 years with a 10-year risk for ASCVD of 20% or greater. In patients with a 10-year risk of 7.5% to less than 20%, coronary artery calcium scoring is an option; if the coronary artery calcium score is 300 or more Agatston units, the patient can be up-classified to high risk. If high-intensity statin treatment is not tolerated in high-risk patients, a reasonable approach is to combine a moderate-intensity statin with ezetimibe. In very high-risk patients, proprotein convertase subtilisin/kexin type 9 inhibitors lower low-density lipoprotein cholesterol levels substantially and hence reduce risk as well.
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http://dx.doi.org/10.1016/j.mayocp.2021.02.032DOI Listing
September 2021

Effect of omega-3 fatty acids on cardiovascular outcomes: A systematic review and meta-analysis.

EClinicalMedicine 2021 Aug 8;38:100997. Epub 2021 Jul 8.

Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, 75 Francis Street, Boston, MA 02115, United States.

Background: The effects of omega-3 fatty acids (FAs), such as eicosapentaenoic (EPA) and docosahexaenoic (DHA) acids, on cardiovascular outcomes are uncertain. We aimed to determine the effectiveness of omega-3 FAs on fatal and non-fatal cardiovascular outcomes and examine the potential variability in EPA vs. EPA+DHA treatment effects.

Methods: We searched EMBASE, PubMed, ClinicalTrials.gov, and Cochrane library databases through June 7, 2021. We performed a meta-analysis of 38 randomized controlled trials of omega-3 FAs, stratified by EPA monotherapy and EPA+DHA therapy. We estimated random-effects rate ratios (RRs) with (95% confidence intervals) and rated the certainty of evidence using GRADE. The key outcomes of interest were cardiovascular mortality, non-fatal cardiovascular outcomes, bleeding, and atrial fibrillation (AF). The protocol was registered in PROSPERO (CRD42021227580).

Findings: In 149,051 participants, omega-3 FA was associated with reducing cardiovascular mortality (RR, 0.93 [0.88-0.98];  = 0.01), non-fatal myocardial infarction (MI) (RR, 0.87 [0.81-0.93];  = 0.0001), coronary heart disease events (CHD) (RR, 0.91 [0.87-0.96];  = 0.0002), major adverse cardiovascular events (MACE) (RR, 0.95 [0.92-0.98];  = 0.002), and revascularization (RR, 0.91 [0.87-0.95];  = 0.0001). The meta-analysis showed higher RR reductions with EPA monotherapy (0.82 [0.68-0.99]) than with EPA + DHA (0.94 [0.89-0.99]) for cardiovascular mortality, non-fatal MI (EPA: 0.72 [0.62-0.84]; EPA+DHA: 0.92 [0.85-1.00]), CHD events (EPA: 0.73 [0.62-0.85]; EPA+DHA: 0.94 [0.89-0.99]), as well for MACE and revascularization. Omega-3 FA increased incident AF (RR, 1.26 [1.08-1.48]). EPA monotherapy vs. control was associated with a higher risk of total bleeding (RR: 1.49 [1.20-1.84]) and AF (RR, 1.35 [1.10-1.66]).

Interpretation: Omega-3 FAs reduced cardiovascular mortality and improved cardiovascular outcomes. The cardiovascular risk reduction was more prominent with EPA monotherapy than with EPA+DHA.

Funding: None.
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http://dx.doi.org/10.1016/j.eclinm.2021.100997DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8413259PMC
August 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

Trends in Characteristics and Outcomes of Hospitalized Young Patients Undergoing Coronary Artery Bypass Grafting in the United States, 2004 to 2018.

J Am Heart Assoc 2021 Sep 28;10(17):e021361. Epub 2021 Aug 28.

Department of Cardiology Houston Methodist DeBakey Heart & Vascular Center Houston TX.

Background Data are limited about young adults' characteristics and outcomes undergoing coronary artery bypass grafting (CABG). Methods and Results We used the National Inpatient Sample database to identify adults aged 18 to 45 years who underwent CABG between 2004 and 2018. The data were weighted to generate national estimates of the entire US hospitalized population. We identified 110 463 CABG cases, equivalent to 62.2 per 1 000 000 person-years; 27.1% were women, and 70.2% were White adults. Overall, annual CABG volume per 1 000 000 significantly decreased from 87.3 in 2004 to 45.7 in 2018. The prevalence of obesity, diabetes mellitus, hypertension, drug abuse, and chronic medical conditions increased over time. Overall, inpatient mortality was 1.76%; ST-segment-elevation myocardial infarction, non-ST-segment-elevation myocardial infarction, heart failure, peripheral vascular disease, renal failure, and valvular surgery were associated with higher inpatient mortality. Women had higher inpatient mortality than men (2.29% versus 1.57%), and Black patients had higher deaths than White patients (2.86% versus 1.58%). Inpatient mortality remained stable overall, according to sex, race, or clinical indication of CABG. However, the mean length of stay (8.4 days in 2004 to 9.5 days in 2018) and inflation-adjusted cost of care ($40 522.8 in 2004 to $52 434.2 in 2018) significantly increased during the study period. Conclusions Despite the increased burden of cardiometabolic risk factors, the inpatient mortality in young adults undergoing CABG remained stable during the last 15 years. However, CABG volumes have decreased, but length of stay and inflation-adjusted costs have increased over time.
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http://dx.doi.org/10.1161/JAHA.121.021361DOI Listing
September 2021

Cardiovascular Disease Risk-Based Statin Utilization and Associated Outcomes in a Primary Prevention Cohort: Insights From a Large Health Care Network.

Circ Cardiovasc Qual Outcomes 2021 Sep 30;14(9):e007485. Epub 2021 Aug 30.

Heart and Vascular Institute (A.S., J.Z., O.M., A.A., J.S.L., S.R., S.M.), University of Pittsburgh Medical Center, PA.

Background: Current American College of Cardiology/American Heart Association guidelines recommend using the 10-year atherosclerotic cardiovascular disease (ASCVD) risk to guide statin therapy for primary prevention. Real-world data on adherence and consequences of nonadherence to the guidelines in primary are limited. We investigated the guideline-directed statin intensity (GDSI) and associated outcomes in a large health care system, stratified by ASCVD risk.

Methods: Statin prescription in patients without coronary artery disease, peripheral vascular disease, or ischemic stroke were evaluated within a large health care network (2013-2017) using electronic medical health records. Patient categories constructed by the 10-year ASCVD risk were borderline (5%-7.4%), intermediate (7.5%-19.9%), or high (≥20%). The GDSI (before time of first event) was defined as none or any intensity for borderline, and at least moderate for intermediate and high-risk groups. Mean (±SD) time to start/change to GDSI from first interaction in health care and incident rates (per 1000 person-years) for each outcome were calculated. Cox regression models were used to calculate hazard ratios for incident ASCVD and mortality across risk categories stratified by statin utilization.

Results: Among 282 298 patients (mean age ≈50 years), 29 134 (10.3%), 63 299 (22.4%), and 26 687 (9.5%) were categorized as borderline, intermediate, and high risk, respectively. Among intermediate and high-risk categories, 27 358 (43%) and 8300 (31%) patients did not receive any statin, respectively. Only 17 519 (65.6%) high-risk patients who were prescribed a statin received GDSI. The mean time to GDSI was ≈2 years among the intermediate and high-risk groups. At a median follow-up of 6 years, there was a graded increase in risk of ASCVD events in intermediate risk (hazard ratio=1.15 [1.07-1.24]) and high risk (hazard ratio=1.27 [1.17-1.37]) when comparing no statin use with GDSI therapy. Similarly, mortality risk among intermediate and high-risk groups was higher in no statin use versus GDSI.

Conclusions: In a real-world primary prevention cohort, over one-third of statin-eligible patients were not prescribed statin therapy. Among those receiving a statin, mean time to GDSI was ≈2 years. The consequences of nonadherence to guidelines are illustrated by greater incident ASCVD and mortality events. Further research can develop and optimize health care system strategies for primary prevention.
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http://dx.doi.org/10.1161/CIRCOUTCOMES.120.007485DOI Listing
September 2021

Association Between Cinnamon Consumption and Risk of Cardiovascular Health: A Systematic Review and Meta-Analysis.

Am J Med 2021 Aug 16. Epub 2021 Aug 16.

The Michael E. DeBakey VA Medical Center, Houston, TX; Section of Cardiology, Baylor College of Medicine, Houston, TX.

Background: Cinnamon has been used as a traditional, herbal medication for decades. Several studies have investigated cinnamon consumption and cardiovascular risk. So far, the evidence remains inconclusive. Thus, we aim to systematically review the currently available literature and quantify the evidence if possible.

Methods: We systematically searched Ovid MEDLINE, Ovid Embase, Ovid Cochrane Database of Systematic Reviews, Scopus, and Web of Science from database inception in 1966 through to December 2020. The exposure of interest was cinnamon consumption, the outcome was cardiovascular risk defined as hemoglobin A1C, LDL-c and HDL-c. Two investigators independently reviewed the data. Conflicts were resolved through consensus. Random-effects meta-analyses were used.

Results: Of 23 studies (1070 subjects), the included studies were heterogeneous, generally of very poor quality. We found no difference in LDL-c levels in patients who consumed cinnamon versus those who did not, with a weighted mean difference (WMD) of 0.38, [CI -6.07, 6.83]. We also found no difference in HDL-c between the two groups with WMD 0.40 [CI -1.14, 1.94]. In addition, we found no statistical differences in Hemoglobin A1C between the two groups with WMD of 0.0 [CI -0.44, 0.45].

Conclusions: Our meta-analysis suggests that there is no association between cinnamon consumption and differences in LDL-c, HDL-c and hemoglobin A1C levels. Further randomized control trials studies using a robust design with long-term cinnamon consumption are needed to further investigate any potential effect.
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http://dx.doi.org/10.1016/j.amjmed.2021.07.019DOI Listing
August 2021

Predictors of PCSK9 (Proprotein Convertase Subtilisin/Kexin Type 9) Inhibitor Prescriptions for Secondary Prevention of Clinical Atherosclerotic Cardiovascular Disease.

Circ Cardiovasc Qual Outcomes 2021 Sep 18;14(9):e007237. Epub 2021 Aug 18.

Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA (D.M.B., K.A., J.H.W.).

Background: Little is known about patterns of PCSK9i (proprotein convertase subtilisin/kexin type 9 inhibitor) use among patients with established clinical atherosclerotic cardiovascular disease. This study's objective was to describe PCSK9i prescribing patterns among patients with atherosclerotic cardiovascular disease.

Methods: We used a national outpatient clinic registry linked to zip-code level on household income from the US Census to assess characteristics of patients with atherosclerotic cardiovascular disease and LDL-C (low-density lipoprotein cholesterol) <190 mg/dL between September 1, 2015, and September 30, 2019, who did and did not receive PCSK9i prescriptions and practice-level and temporal variation in PCSK9i prescriptions. We assessed predictors of PCSK9i prescription with a multivariable mixed effects regression model which included patient covariates as fixed effects and the cardiology practice as a random effect. Adjusted practice-level variation in PCSK9i prescribing was evaluated with median odds ratio (OR).

Results: Of 2 148 100 patients meeting study inclusion criteria, 27 249 (1.3%) received PCSK9i prescriptions. Receiving a PCSK9i prescription was associated with White race (versus non-White: OR, 1.78 [95% CI, 1.55-1.83]); high estimated household income (versus low income: OR, 1.18 [95% CI, 1.08-1.29]), and urban or suburban (versus rural) practice location (urban: OR, 1.47 [95% CI, 1.32-1.64]; suburban: OR, 1.25 [95% CI, 1.13-1.39]). Hispanics had lower odds of receiving PCSK9i prescriptions (OR, 0.66 [95% CI, 0.57-0.76]). The adjusted median odds ratio was 2.68 (95% CI, 2.46-2.94), consistent with clinically significant practice-level variation in PCSK9i prescriptions. No differences in quarterly PCSK9i prescription rates were observed before and after price reductions for evolocumab and alirocumab initiated during the fourth quarter of 2018 and first quarter of 2019, respectively.

Conclusions: This study highlights racial, socioeconomic, geographic, and practice-level variations in early PCSK9i prescriptions which persist despite adjustment for clinical and demographic factors. After adjustment, 2 randomly selected practices would differ in likelihood of PCSK9i prescription by a factor of >2.
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http://dx.doi.org/10.1161/CIRCOUTCOMES.120.007237DOI Listing
September 2021

Epidemiology and risk factors for stroke in young individuals: implications for prevention.

Curr Opin Cardiol 2021 09;36(5):565-571

Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas.

Purpose Of Review: Summarize and examine the epidemiology, etiologies, risk factors, and treatment of stroke among young adults and highlight the importance of early recognition, treatment, and primordial prevention of risk factors that lead to stroke.

Recent Findings: Incidence of stroke, predominantly ischemic, among young adults has increased over the past two decades. This parallels an increase in traditional risk factors such as hypertension, diabetes, and use of tobacco, and use of illicit substances among young stroke patients. Compared to older patients, there is a much higher proportion of intracerebral and subarachnoid hemorrhage in young adults. The cause of ischemic stroke in young adults is also more diverse compared to older adults with 1/3rd classified as stroke of undetermined etiology due to inadequate effort or time spent on investigating these diverse and rare etiologies. Young premature Atherosclerotic Cardiovascular Disease patients have suboptimal secondary prevention care compared to older patients with lower use of antiplatelets and statin therapy and lower adherence to statins.

Summary: Among young patients, time-critical diagnosis and management remain challenging, due to atypical stroke presentations, vast etiologies, statin hesitancy, and provider clinical inertia. Early recognition and aggressive risk profile modification along with primary and secondary prevention therapy optimization are imperative to reduce the burden of stroke among young adults and save potential disability-adjusted life years.
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http://dx.doi.org/10.1097/HCO.0000000000000894DOI Listing
September 2021

Atherosclerotic Cardiovascular Disease, Cancer, and Financial Toxicity Among Adults in the United States.

JACC CardioOncol 2021 Jun 15;3(2):236-246. Epub 2021 Jun 15.

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

Background: Financial toxicity (FT) is a well-established side-effect of the high costs associated with cancer care. In recent years, studies have suggested that a significant proportion of those with atherosclerotic cardiovascular disease (ASCVD) experience FT and its consequences.

Objectives: This study aimed to compare FT for individuals with neither ASCVD nor cancer, ASCVD only, cancer only, and both ASCVD and cancer.

Methods: From the National Health Interview Survey, we identified adults with self-reported ASCVD and/or cancer between 2013 and 2018, stratifying results by nonelderly (age <65 years) and elderly (age ≥65 years). We defined FT if any of the following were present: any difficulty paying medical bills, high financial distress, cost-related medication nonadherence, food insecurity, and/or foregone/delayed care due to cost.

Results: The prevalence of FT was higher among those with ASCVD when compared with cancer (54% vs. 41%; p < 0.001). When studying the individual components of FT, in adjusted analyses, those with ASCVD had higher odds of any difficulty paying medical bills (odds ratio [OR]: 1.22; 95% confidence interval [CI]: 1.09 to 1.36), inability to pay bills (OR: 1.25; 95% CI: 1.04 to 1.50), cost-related medication nonadherence (OR: 1.28; 95% CI: 1.08 to 1.51), food insecurity (OR: 1.39; 95% CI: 1.17 to 1.64), and foregone/delayed care due to cost (OR: 1.17; 95% CI: 1.01 to 1.36). The presence of ≥3 of these factors was significantly higher among those with ASCVD and those with both ASCVD and cancer when compared with those with cancer (23% vs. 30% vs. 13%, respectively; p < 0.001). These results remained similar in the elderly population.

Conclusions: Our study highlights that FT is greater among patients with ASCVD compared with those with cancer, with the highest burden among those with both conditions.
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http://dx.doi.org/10.1016/j.jaccao.2021.02.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8352280PMC
June 2021

Greater than expected reduction in low-density lipoprotein-cholesterol (LDL-C) with bempedoic acid in a patient with heterozygous familial hypercholesterolemia (HeFH).

J Clin Lipidol 2021 Jul 10. Epub 2021 Jul 10.

Department of Medicine, Center for Cardiometabolic Disease Prevention, Baylor College of Medicine, 6655 Travis Street, Suite 320, Houston, TX 77030, USA; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA. Electronic address:

Bempedoic acid is an adenosine triphosphate-citrate lyase (ACL) inhibitor that reduces levels of low-density lipoprotein-cholesterol (LDL-C) in the plasma by inhibition of cholesterol synthesis in hepatic cells, which leads to up-regulation of hepatic LDL receptors. Bempedoic acid is approved as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia (HeFH) who require additional lowering of LDL-C. In this case study, we describe a patient with HeFH who had a prior excellent response to statin but unable to take the same, and a less than expected response to PCSK9i, in whom initiation of bempedoic acid led to a substantial reduction of LDL-C. Our findings suggest that patients who are quite responsive to statins may also be quite responsive to bempedoic acid, a medication that works in the same biochemical pathway as HMG-CoA reductase inhibitors. Additionally, this medication may be particularly effective at lowering LDL-C among individuals not on background statin therapy.
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http://dx.doi.org/10.1016/j.jacl.2021.07.002DOI Listing
July 2021

Scope and Social Determinants of Food Insecurity Among Adults With Atherosclerotic Cardiovascular Disease in the United States.

J Am Heart Assoc 2021 Aug 13;10(16):e020028. Epub 2021 Aug 13.

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

Background Atherosclerotic cardiovascular disease (ASCVD) results in high out-of-pocket healthcare expenditures predisposing to food insecurity. However, the burden and determinants of food insecurity in this population are unknown. Methods and Results Using 2013 to 2018 National Health Interview Survey data, we evaluated the prevalence and sociodemographic determinants of food insecurity among adults with ASCVD in the United States. ASCVD was defined as self-reported diagnosis of coronary heart disease or stroke. Food security was measured using the 10-item US Adult Food Security Survey Module. Of the 190 113 study participants aged 18 years or older, 18 442 (adjusted prevalence 8.2%) had ASCVD, representing ≈20 million US adults annually. Among adults with ASCVD, 2968 or 14.6% (weighted ≈2.9 million US adults annually) reported food insecurity compared with 9.1% among those without ASCVD (<0.001). Individuals with ASCVD who were younger (odds ratio [OR], 4.0 [95% CI, 2.8-5.8]), women (OR, 1.2 [1.0-1.3]), non-Hispanic Black (OR, 2.3 [1.9-2.8]), or Hispanic (OR, 1.6 [1.2-2.0]), had private (OR, 1.8 [1.4-2.3]) or no insurance (OR, 2.3 [1.7-3.1]), were divorced/widowed/separated (OR, 1.2 [1.0-1.4]), and had low family income (OR, 4.7 [4.0-5.6]) were more likely to be food insecure. Among those with ASCVD and 6 of these high-risk characteristics, 53.7% reported food insecurity and they had 36-times (OR, 36.2 [22.6-57.9]) higher odds of being food insecure compared with those with ≤1 high-risk characteristic. Conclusion About 1 in 7 US adults with ASCVD experience food insecurity, with more than 1 in 2 adults reporting food insecurity among the most vulnerable sociodemographic subgroups. There is an urgent need to address the barriers related to food security in this population.
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http://dx.doi.org/10.1161/JAHA.120.020028DOI Listing
August 2021

Mentored implementation to initiate a diabetes program in an underserved community: a pilot study.

BMJ Open Diabetes Res Care 2021 Aug;9(1)

Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.

Introduction: Community clinics often face pragmatic barriers, hindering program initiation and replication of controlled research trial results. Mentoring is a potential strategy to overcome these barriers. We piloted an in-person and telehealth mentoring strategy to implement the elehealth-supported, ntegrated Community Health Workers (CHWs), edication-access, group visit ducation (TIME) program in a community clinic.

Research Design And Methods: Participants (n=55) were low-income Latino(a)s with type 2 diabetes. The study occurred in two, 6-month phases. Phase I provided proof-of-concept and an observational experience for the clinic team; participants (n=37) were randomized to the intervention (TIME) or control (usual care), and the research team conducted TIME while the clinic team observed. Phase II provided mentorship to implement TIME, and the research team mentored the clinic team as they conducted TIME for a new single-arm cohort of participants (n=18) with no previous exposure to the program. Analyses included baseline to 6-month comparisons of diabetes outcomes (primary outcome: hemoglobin A1c (HbA1c)): phase I intervention versus control, phase II (within group), and research-run (phase I intervention) versus clinic-run (phase II) arms. We also evaluated baseline to 6-month CHW knowledge changes.

Results: Phase I: compared with the control, intervention participants had superior baseline to 6-month improvements for HbA1c (mean change: intervention: -0.73% vs control: 0.08%, p=0.016), weight (p=0.044), target HbA1c (p=0.035), hypoglycemia (p=0.021), medication non-adherence (p=0.0003), and five of six American Diabetes Association (ADA) measures (p<0.001-0.002). Phase II: participants had significant reductions in HbA1c (mean change: -0.78%, p=0.006), diastolic blood pressure (p=0.004), body mass index (0.012), weight (p=0.010), medication non-adherence (p<0.001), and six ADA measures (p=0.007-0.005). Phase I intervention versus phase II outcomes were comparable. CHWs improved knowledge from pre-test to post-tests (p<0.001).

Conclusions: A novel, mentored approach to implement TIME into a community clinic resulted in improved diabetes outcomes. Larger studies of longer duration are needed to fully evaluate the potential of mentoring community clinics.
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http://dx.doi.org/10.1136/bmjdrc-2021-002320DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8362735PMC
August 2021

Temporal Changes in Cost-Related Medication Nonadherence by Race/Ethnicity and Medicaid Expansion: The Behavioral Risk Factor Surveillance System Survey.

Popul Health Manag 2021 Aug 9. Epub 2021 Aug 9.

Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.

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http://dx.doi.org/10.1089/pop.2021.0183DOI Listing
August 2021

Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) guidelines for management of dyslipidemia and cardiovascular disease risk reduction: Putting evidence in context.

Prog Cardiovasc Dis 2021 Aug 8. Epub 2021 Aug 8.

Section of Cardiology, Baylor College of Medicine, Houston, TX, United States of America; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States of America. Electronic address:

Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of morbidity and mortality in the United States (U.S.) and incurs significant cost to the healthcare system. Management of cholesterol remains central for ASCVD prevention and has been the focus of multiple national guidelines. In this review, we compare the American Heart Association (AHA)/American College of Cardiology (ACC) and the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) Cholesterol guidelines. We review the evidence base that was used to generate recommendations focusing on 4 distinct themes: 1) the threshold of absolute 10-year ASCVD risk to start a clinician-patient discussion for the initiation of statin therapy in primary prevention patients; 2) the utility of coronary artery calcium score to guide clinician-patient risk discussion pertaining to the initiation of statin therapy for primary ASCVD prevention; 3) the use of moderate versus high-intensity statin therapy in patients with established ASCVD; and 4) the utility of ordering lipid panels after initiation or intensification of lipid lowering therapy to document efficacy and monitor adherence to lipid lowering therapy. We discuss why the VA/DoD and AHA/ACC may have reached different conclusions on these key issues.
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http://dx.doi.org/10.1016/j.pcad.2021.08.001DOI Listing
August 2021

Association between circulating Galectin-3 and arterial stiffness in older adults.

Vasa 2021 Aug 4. Epub 2021 Aug 4.

Baylor College of Medicine, Houston, TX, USA.

Galectin-3 (gal-3) is a β-galactoside-binding lectin associated tissue fibrosis and inflammation. There is limited understanding of the relationship between gal-3 and vascular health. Our aim was to assess the association between gal-3 and arterial stiffness in older adults. We conducted a cross-sectional study of 4275 participants (mean age of 75 years) from the Atherosclerosis Risk in Communities (ARIC) Study. Central arterial stiffness was measured by carotid-femoral pulse wave velocity (cfPWV). We evaluated the association of gal-3 with cfPWV using multivariable linear regression. The median (interquartile range) gal-3 concentration was 16.5 (13.8, 19.8) ng/mL and mean cfPWV was 1163±303 cm/s. Higher gal-3 concentration was associated with greater central arterial stiffness after adjustment for age, sex, race-center, heart rate, systolic blood pressure, anti-hypertensive medication use, and current smoking status (β=36.4 cm/s change in cfPWV per log unit change in gal-3; 95% CI: 7.2, 65.5, p=0.015). The association was attenuated after adjusting for additional cardiovascular risk factors (β=17.3, 95% CI: -14.4, 49.0). In community-dwelling older adults, gal-3 concentration was associated with central arterial stiffness, likely sharing common pathways with traditional cardiovascular risk factors.
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http://dx.doi.org/10.1024/0301-1526/a000968DOI Listing
August 2021

Prevalence of cardiovascular risk factors in a nationally representative adult population with inflammatory bowel disease without atherosclerotic cardiovascular disease.

Am J Prev Cardiol 2021 Jun 16;6:100171. Epub 2021 Mar 16.

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

Background And Aims: Chronic inflammation is associated with premature atherosclerotic cardiovascular disease (ASCVD). We studied the prevalence of cardiovascular risk factors (CRFs) amongst individuals with IBD who have not developed ASCVD.

Methods: Our study population was derived from the 2015 - 2016 National Health Interview Survey. Those with ASCVD (defined as myocardial infarction, angina or stroke) were excluded. The prevalence of CRFs among individuals with IBD was compared with those without IBD. The odds CRFs among adults with IBD was assessed using logistic regression models.

Results: In our study population of 60,155 individuals, 786 (1.3%) had IBD. IBD was associated with increased odds hypertension (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.39-2.09), diabetes (OR 1.68, 95% CI 1.22-2.32), hypercholesterolemia (OR 1.62, 95% CI 1.32-2.99) and insufficient physical activity (OR 1.38, 95% CI 1.16-1.66).

Conclusion: IBD is associated with higher prevalence of CRFs. Early screening and risk mitigation strategies are warranted.
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http://dx.doi.org/10.1016/j.ajpc.2021.100171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8315477PMC
June 2021

Hypertension guidelines and coronary artery calcification among South Asians: Results from MASALA and MESA.

Am J Prev Cardiol 2021 Jun 12;6:100158. Epub 2021 Feb 12.

Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, United States.

Untreated hypertension may contribute to increased atherosclerotic cardiovascular disease (ASCVD) risk in South Asians (SA). We assessed HTN prevalence among untreated adults free of baseline ASCVD from the MASALA & MESA studies. The proportion of participants who received discordant recommendations regarding antihypertensive pharmacotherapy use by the 2017-ACC/AHA and JNC7 Guidelines across CAC score categories in each race/ethnic group was calculated. Compared with untreated MESA participants ( = 3896), untreated SA ( = 445) were younger (55±8 versus 59±10 years), had higher DBP (73±10 versus 70±10 mmHg), total cholesterol (199±34 versus 196±34 mg/dL), statin use (16% versus 9%) and CAC=0 prevalence (69% versus 58%), with fewer current smokers (3% versus 15%) and lower 10-year-ASCVD-risk (6.4% versus 9.9%) (all <0.001). A higher proportion of untreated MASALA and MESA participants were diagnosed with hypertension and recommended anti-hypertensive pharmacotherapy according to the ACC/AHA guideline compared to JNC7 (all <0.001). Overall, discordant BP treatment recommendations were observed in 9% SA, 11% Whites, 15% Blacks, 10% Hispanics, and 9% Chinese-American. In each race/ethnic group, the proportion of participants receiving discordant recommendation increased across CAC groups (all <0.05), however was highest among SA (40% of participants). Similar to other race/ethnicities, a higher proportion of SA are recommended anti-hypertensive pharmacotherapy by ACC/AHA as compared with JNC7 guidelines. The increase was higher among those with CAC>100 and thus may be better at informing hypertension management in American South Asians.
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http://dx.doi.org/10.1016/j.ajpc.2021.100158DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8315395PMC
June 2021

Ten things to know about ten cardiovascular disease risk factors.

Am J Prev Cardiol 2021 Mar 23;5:100149. Epub 2021 Jan 23.

CGH Medical Center, Sterling, IL USA.

Given rapid advancements in medical science, it is often challenging for the busy clinician to remain up-to-date on the fundamental and multifaceted aspects of preventive cardiology and maintain awareness of the latest guidelines applicable to cardiovascular disease (CVD) risk factors. The "American Society for Preventive Cardiology (ASPC) Top Ten CVD Risk Factors 2021 Update" is a summary document (updated yearly) regarding CVD risk factors. This "ASPC Top Ten CVD Risk Factors 2021 Update" summary document reflects the perspective of the section authors regarding ten things to know about ten sentinel CVD risk factors. It also includes quick access to sentinel references (applicable guidelines and select reviews) for each CVD risk factor section. The ten CVD risk factors include unhealthful nutrition, physical inactivity, dyslipidemia, hyperglycemia, high blood pressure, obesity, considerations of select populations (older age, race/ethnicity, and sex differences), thrombosis/smoking, kidney dysfunction and genetics/familial hypercholesterolemia. For the individual patient, other CVD risk factors may be relevant, beyond the CVD risk factors discussed here. However, it is the intent of the "ASPC Top Ten CVD Risk Factors 2021 Update" to provide a succinct overview of things to know about ten common CVD risk factors applicable to preventive cardiology.
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http://dx.doi.org/10.1016/j.ajpc.2021.100149DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8315386PMC
March 2021

Same evidence, varying viewpoints: Three questions illustrating important differences between United States and European cholesterol guideline recommendations.

Am J Prev Cardiol 2020 Dec 13;4:100117. Epub 2020 Nov 13.

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

In 2018, the AHA/ACC Multisociety Guideline on the Management of Blood Cholesterol was released. Less than one year later, the 2019 ESC/EAS Dyslipidemia Guideline was published. While both provide important recommendations for managing atherosclerotic cardiovascular disease (ASCVD) risk through lipid management, differences exist. Prior to the publication of both guidelines, important randomized clinical trial data emerged on non-statin lipid lowering therapy and ASCVD risk reduction. To illustrate important differences in guideline recommendations, we use this data to help answer three key questions: 1) Are ASCVD event rates similar in high-risk primary and stable secondary prevention? 2) Does imaging evidence of subclinical atherosclerosis justify aggressive use of statin and non-statin therapy (if needed) to reduce LDL-C levels below 55 ​mg/dL as recommended in the European Guideline? 3) Do LDL-C levels below 70 ​mg/dL achieve a large absolute risk reduction in secondary ASCVD prevention? The US guideline prioritizes both the added efficacy and cost implications of non-statin therapy, which limits intensive therapy to individuals with the highest risk of ASCVD. The European approach broadens the eligibility criteria by incorporating goals of therapy in both primary and secondary prevention. The current cost and access constraints of healthcare worldwide, especially amidst a COVID-19 pandemic, makes the European recommendations more challenging to implement. By restricting non-statin therapy to a subgroup of high- and, in particular, very high-risk individuals, the US guideline provides primary and secondary ASCVD prevention recommendations that are more affordable and attainable. Ultimately, finding a common ground for both guidelines rests on our ability to design trials that assess cost-effectiveness in addition to efficacy and safety.
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http://dx.doi.org/10.1016/j.ajpc.2020.100117DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8315633PMC
December 2020

Stroke in young adults: Current trends, opportunities for prevention and pathways forward.

Am J Prev Cardiol 2020 Sep 9;3:100085. Epub 2020 Sep 9.

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

Cardiovascular disease remains a major contributor to morbidity and mortality in the US and elsewhere, and stroke is a leading cause of disability worldwide. Despite recent success in diminishing stroke incidence in the general US population, in parallel there is now a concerning propensity for strokes to happen at younger ages. Specifically, the incidence of stroke for US adults 20-44 years of age increased from 17 per 100,000 US adults in 1993 to 28 per 100,000 in 2015. Occurrence of strokes in young adults is particularly problematic as these patients are often affected by physical disability, depression, cognitive impairment and loss of productivity, all of which have vast personal, social and economic implications. These concerning trends among young adults are likely due to increasing trends in the prevalence of modifiable risk factors amongst this population including hypertension, hyperlipidemia, obesity and diabetes, highlighting the importance of early detection and aggressive prevention strategies in the general population at early ages. In parallel and compounding to the issue, troublesome trends are evident regarding increasing rates of substance abuse among young adults. Higher rates of strokes have been noted particularly among young African Americans, indicating the need for tailored prevention and social efforts targeting this and other vulnerable groups, including the primordial prevention of risk factors in the first place, reducing stroke rates in the presence of prevalent risk factors such as hypertension, and improving outcomes through enhanced healthcare access. In this narrative review we aim to emphasize the importance of stroke in young adults as a growing public health issue and increase awareness among clinicians and the public health sector. For this purpose, we summarize the available data on stroke in young adults and discuss the underlying epidemiology, etiology, risk factors, prognosis and opportunities for timely prevention of stroke specifically at young ages. Furthermore, this review highlights the gaps in knowledge and proposes future directions moving forward.
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http://dx.doi.org/10.1016/j.ajpc.2020.100085DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8315351PMC
September 2020

Association of cardiovascular risk factor profile and financial hardship from medical bills among non-elderly adults in the United States.

Am J Prev Cardiol 2020 Jun 13;2:100034. Epub 2020 Jul 13.

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

Background: While optimal cardiovascular risk factor (CRF) profile is associated with lower mortality, morbidity, and healthcare expenditures among individuals with atherosclerotic cardiovascular disease (ASCVD), less is known regarding its impact on financial hardship from medical bills. Therefore, we assessed whether an optimal CRF profile is associated with a lower burden of financial hardship from medical bills and a reduction in cost-related barriers to health.

Methods: We used a nationally representative sample of adults between 18 and 64 years from the National Health Interview Survey between 2013 and 2017. We assessed ASCVD status and the number of risk factors to categorize the study population into 4 mutually exclusive categories: ASCVD (irrespective of CRF profile) and non-ASCVD with poor, average, and optimal CRF profile. Adjusted logistic regression model was used to determine the association of ASCVD/CRF profile with financial hardship from medical bills and cost-related barriers to health (cost-related medication non-adherence (CRN), foregone/delayed care, and high financial distress).

Results: We included 119,388 non-elderly adults, representing 189 million individuals annually across the United States. Non-ASCVD/optimal CRF profile individuals had a lower prevalence of financial hardship and an inability paying medical bills when compared with individuals with ASCVD (24% vs 45% and 6% vs 19%, respectively). Among individuals without ASCVD and an optimal CRF profile, the prevalence of each cost-related barrier to health was <50% compared with individuals with ASCVD. Poor/low income and uninsured individuals within non-ASCVD/average CRF profile strata had a lower prevalence of financial hardship and an inability paying medical bills when compared with middle/high income and insured individuals with ASCVD. Non-ASCVD individuals with optimal CRF profile had the lowest odds of all barriers to health.

Conclusion: Optimal CRF profile is associated with a lower prevalence of financial hardship from medical bills and cost-related barriers to health despite lower income and lack of insurance.
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http://dx.doi.org/10.1016/j.ajpc.2020.100034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8315456PMC
June 2020

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

J Am Heart Assoc 2021 08 28;10(15):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
August 2021

Management of type 2 diabetes in chronic kidney disease.

BMJ Open Diabetes Res Care 2021 07;9(1)

VA Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Houston, Texas, USA

The management of patients with type 2 diabetes and chronic kidney disease (CKD) encompasses lifestyle modifications, glycemic control with individualized HbA1c targets, and cardiovascular disease risk reduction. Metformin and sodium-glucose cotransporter-2 inhibitors are first-line agents. Glucagon-like peptide-1 receptor agonists are second-line agents. The use of other antidiabetic agents should consider patient preferences, comorbidities, drug costs, and the risk of hypoglycemia. Renin-angiotensin-aldosterone system inhibitors are strongly recommended for patients with diabetes, hypertension, and albuminuria. Non-steroidal mineralocorticoid receptor antagonists, which pose less risk of hyperkalemia than steroidal agents, are undergoing further evaluation among patients with diabetic kidney disease. Here, we discuss important advancements in the management of patients with type 2 diabetes and CKD.
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http://dx.doi.org/10.1136/bmjdrc-2021-002300DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8314731PMC
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
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