Publications by authors named "Sina Kianoush"

36 Publications

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

Temporal Trends in the Prevalence of Current E-Cigarette and Cigarette Use by Annual Household Income from 2016 to 2018 (from the Behavioral Risk Factor Surveillance System [BRFSS] Survey).

Am J Cardiol 2020 12 17;137:139-140. Epub 2020 Oct 17.

Cardiovascular Research, Michael E. DeBakey VA Medical Center/Baylor College of Medicine, Houston, Texas). Electronic address:

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http://dx.doi.org/10.1016/j.amjcard.2020.10.025DOI Listing
December 2020

Predictors of coronary artery calcium among 20-30-year-olds: The Coronary Artery Calcium Consortium.

Atherosclerosis 2020 05 9;301:65-68. Epub 2020 Apr 9.

Johns Hopkins University, Baltimore, MD, USA. Electronic address:

Background And Aims: We sought to understand the risk factor correlates of very early coronary artery calcium (CAC), and the potential investigational value of CAC phenotyping in adults aged 20-30 years.

Methods: We studied all participants aged 20-30 years at baseline (N = 373) in the Coronary Artery Calcium Consortium, a large multi-center cohort study of patients aged 18 years or older without known atherosclerotic cardiovascular disease (ASCVD) at baseline, referred for CAC scoring for clinical risk stratification. We described the prevalence of CAC in men and women, the frequency of risk factors by the presence of CAC (CAC = 0 vs CAC >0), and assessed the association between traditional non-demographic CVD risk factors (hypertension, hyperlipidemia, smoking, family history of CHD, and diabetes) and prevalent CAC, using age- and sex-adjusted logistic regression models.

Results: The mean age of the study participants was 27.5 ± 2.4 years; 324 (86.9%) had CAC = 0, and 49 (13.1%) had CAC >0. Among the 49 participants with CAC, 38 (77.6%) were men, and median CAC score was low at 4.6. In age- and sex-adjusted models, there was a graded increase in the odds of CAC >0 with increasing traditional cardiovascular disease (CVD) risk factor burden (p = 0.001 for linear trend). Participants with ≥3 traditional risk factors had a statistically significant higher odds of having prevalent CAC (OR 5.57, 95% CI; 1.82-17.03) compared to participants with no risk factors.

Conclusions: Our study demonstrates the non-negligible prevalence of CAC among very high-risk young US adults, reinforcing the critical importance of traditional risk factors in the earliest development of detectable subclinical ASCVD.
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http://dx.doi.org/10.1016/j.atherosclerosis.2020.04.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7260100PMC
May 2020

The association of coronary artery calcium score and mortality risk among smokers: The coronary artery calcium consortium.

Atherosclerosis 2020 02 15;294:33-40. Epub 2019 Dec 15.

Johns Hopkins Ciccarone Center for Prevention of Heart Disease, Baltimore, MD, United States. Electronic address:

Background And Aims: Cardiovascular disease (CVD) and cancer are the two leading causes of death in smokers. Lung cancer screening is recommended in a large proportion of smokers. We examined the implication of coronary artery calcium (CAC) score (quantitative and qualitative) for cardiovascular disease (CVD), coronary heart disease (CHD), and cancer mortality risk prediction among current smokers.

Methods: We included current smokers without known heart disease from the CAC Consortium. Cox regression (for all-cause mortality) and Fine-and-Gray competing-risk regression (for CVD, CHD, and cancer mortality) models, adjusted for traditional CVD risk factors, were used to assess the association between CAC and each mortality outcome, with CAC as a continuous (log2-transformed) or categorical variable (CAC = 0, CAC = 1-99, CAC = 100-399, and CAC ≥400). We used number of vessels with CAC as a surrogate for the qualitative measure of CAC and mortality outcomes. Analyses were repeated for lung cancer screening-eligible population (defined as ever smokers with >30 pack years smoking history) (n = 1,149). Hazard ratios (HR) for all-cause mortality and Subdistribution HRs (sHR) with 95% confidence intervals (CI) were reported.

Results: Over a median of 11.9 years (25th-75th percentile: 10.2-13.3) of follow-up, of 5,147 current smokers (mean age 52.5 ± 9.4, 32.4% women) 337 died (102 of CVD, 54 of CHD, and 123 of cancer). A doubling of CAC score was associated with increased HRs of all-cause mortality (1.10 (1.06-1.14)), and sHRs for CVD (1.15 (1.07-1.24)), CHD (1.26 (1.11-1.42)) and cancer mortality (1.06 (1.00-1.13)). Those with CAC ≥400 had increased sHR of CVD (3.55 (1.70-7.41)), CHD (8.80 (2.41-32.10)), and cancer mortality (1.85 (1.07-3.22)), compared with those with CAC = 0. A diffuse CAC pattern significantly increased the risk of all-cause, CVD, and CHD mortality among smokers. Results were consistent for the lung cancer screening-eligible population.

Conclusions: Qualitative and quantitative CAC scores can prognosticate risk of all-cause, CVD, CHD, and cancer mortality beyond traditional risk factors among all smokers as well as those eligible for lung cancer screening.
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http://dx.doi.org/10.1016/j.atherosclerosis.2019.12.014DOI Listing
February 2020

Using Mobile Health Tools to Assess Physical Activity Guideline Adherence and Smoking Urges: Secondary Analysis of mActive-Smoke.

JMIR Cardio 2020 Jan 6;4(1):e14963. Epub 2020 Jan 6.

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

Background: Rates of cigarette smoking are decreasing because of public health initiatives, pharmacological aids, and clinician focus on smoking cessation. However, a sedentary lifestyle increases cardiovascular risk, and therefore, inactive smokers have a particularly enhanced risk of cardiovascular disease.

Objective: In this secondary analysis of mActive-Smoke, a 12-week observational study, we investigated adherence to guideline-recommended moderate-to-vigorous physical activity (MVPA) in smokers and its association with the urge to smoke.

Methods: We enrolled 60 active smokers (≥3 cigarettes per day) and recorded continuous step counts with the Fitbit Charge HR. MVPA was defined as a cadence of greater than or equal to 100 steps per minute. Participants were prompted to report instantaneous smoking urges via text message 3 times a day on a Likert scale from 1 to 9. We used a mixed effects linear model for repeated measures, controlling for demographics and baseline activity level, to investigate the association between MVPA and urge.

Results: A total of 53 participants (mean age 40 [SD 12] years, 57% [30/53] women, 49% [26/53] nonwhite, and 38% [20/53] obese) recorded 6 to 12 weeks of data. Data from 3633 person-days were analyzed, with a mean of 69 days per participant. Among all participants, median daily MVPA was 6 min (IQR 2-13), which differed by sex (12 min [IQR 3-20] for men vs 3.5 min [IQR 1-9] for women; P=.004) and BMI (2.5 min [IQR 1-8.3] for obese vs 10 min [IQR 3-15] for nonobese; P=.04). The median total MVPA minutes per week was 80 (IQR 31-162). Only 10% (5/51; 95% CI 4% to 22%) of participants met national guidelines of 150 min per week of MVPA on at least 50% of weeks. Adjusted models showed no association between the number of MVPA minutes per day and mean daily smoking urge (P=.72).

Conclusions: The prevalence of MVPA was low in adult smokers who rarely met national guidelines for MVPA. Given the poor physical activity attainment in smokers, more work is required to enhance physical activity in this population.
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http://dx.doi.org/10.2196/14963DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6971509PMC
January 2020

Coronary artery calcium scoring for individualized cardiovascular risk estimation in important patient subpopulations after the 2019 AHA/ACC primary prevention guidelines.

Prog Cardiovasc Dis 2019 Sep - Oct;62(5):423-430. Epub 2019 Nov 9.

Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Baltimore, MD, United States.

The 2018 and 2019 American Heart Association and American College of Cardiology (AHA/ACC) guidelines for primary prevention of atherosclerotic cardiovascular disease (ASCVD) recommend consideration of so-called "risk-enhancing factors" in borderline to intermediate risk individuals. These include high-risk race/ethnicity (e.g. South Asian origin), chronic kidney disease, a family history of premature ASCVD, the metabolic syndrome, chronic inflammatory disorders (e.g. rheumatoid arthritis [RA], psoriasis, or chronic human immunodeficiency virus [HIV]), and conditions specific to women, among others. Studies suggest, however, that risk may be highly heterogeneous within these subgroups. The AHA/ACC guidelines also recommend consideration of coronary artery calcium (CAC) scoring for further risk assessment in borderline to intermediate risk individuals in whom management is uncertain. Although the combination of risk enhancing factors and CAC burden (together with Pooled Cohort estimates) may lead to more accurate ASCVD risk assessment, few publications have closely examined the interplay between risk enhancing factors and CAC scoring for personalized risk estimation. Our aim is to review the relevant literature in this area. Although further research is clearly needed, CAC assessment seems a highly valuable option to inform individualized ASCVD risk management in these important, often highly heterogeneous patient subgroups.
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http://dx.doi.org/10.1016/j.pcad.2019.10.007DOI Listing
January 2020

Relation Between Cigarette Smoking and Heart Failure (from the Multiethnic Study of Atherosclerosis).

Am J Cardiol 2019 06 18;123(12):1972-1977. Epub 2019 Mar 18.

The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland; Department of Medicine, University of Kansas School of Medicine, Wichita, Kansas. Electronic address:

We studied the association between cigarette smoking and incident heart failure (HF) in a racially diverse US cohort. We included 6,792 participants from the Multi-Ethnic Study of Atherosclerosis with information on cigarette smoking at baseline, characterized by status, intensity, burden, and time since quitting. Adjudicated outcomes included total incident HF cases and HF stratified by ejection fraction (EF) into HF with reduced EF (HFrEF; EF ≤ 40%) and preserved EF (HFpEF; EF ≥ 50%). We used Cox proportional hazards models adjusted for traditional cardiovascular risk factors and accounted for competing risk of each HF type. Mean age was 62 ± 10 years; 53% were women, 61% were nonwhite, and 13% were current smokers. A total of 279 incident HF cases occurred over a median follow-up of 12.2 years. The incidence rates of HFrEF and HFpEF were 2.2 and 1.9 cases per 1000 person-years, respectively. Current smoking was associated with higher risk of HF compared with never smoking (hazard ratio [HR], 2.05; 95% confidence interval [CI], 1.36 to 3.09); this was similar for HFrEF (HR, 2.58; 95% CI, 1.27 to 5.25) and HFpEF (HR, 2.51; 95% CI, 1.15 to 5.49). Former smoking was not significantly associated with HF (HR, 1.17; 95% CI, 0.88 to 1.56). Smoking intensity, burden, and time since quitting did not provide additional information for HF risk after accounting for smoking status.
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http://dx.doi.org/10.1016/j.amjcard.2019.03.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6529241PMC
June 2019

Role of Coronary Artery Calcium for Stratifying Cardiovascular Risk in Adults With Hypertension.

Hypertension 2019 05;73(5):983-989

Aetna Foundation, Hartford, CT (G.G.).

We examined the utility of coronary artery calcium (CAC) for cardiovascular risk stratification among hypertensive adults, including those fitting eligibility for SPRINT (Systolic Blood Pressure Intervention Trial). Additionally, we used CAC to identify hypertensive adults with cardiovascular disease (CVD) mortality rates equivalent to those observed in SPRINT who may, therefore, benefit from the most intensive blood pressure therapy. Our study population included 16 167 hypertensive patients from the CAC Consortium, among whom 6375 constituted a "SPRINT-like" population. We compared multivariable-adjusted hazard ratios of coronary heart disease and CVD deaths by CAC category (0, 1-99, 100-399, ≥400). Additionally, we generated a CAC-CVD mortality curve for patients aged >50 years to determine what CAC scores were associated with CVD death rates observed in SPRINT. Mean age was 58.1±10.6 years. During a mean follow-up of 11.6±3.6 years, there were 409 CVD deaths and 207 coronary heart disease deaths. Increasing CAC scores were associated with increased coronary heart disease and CVD mortality (coronary heart disease-CAC 100-399: hazard ratio [95% CI] 1.88 [1.04-3.40], CAC ≥400: 4.16 [2.34-7.39]; CVD-CAC 100-399: 1.93 [1.31-2.83], CAC ≥400: 3.51 [2.40-5.13]). A similar increased risk was observed across 10-year atherosclerotic CVD risk categories and in the SPRINT-like population. A CAC score of 220 (confidence range, 165-270) was associated with the CVD mortality rate observed in SPRINT. CAC risk stratifies adults with hypertension, including those who are SPRINT eligible. A CAC score of 220 can identify hypertensive adults with SPRINT-level CVD mortality risk and, therefore, may be reasonable for identifying candidates for aggressive blood pressure therapy.
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http://dx.doi.org/10.1161/HYPERTENSIONAHA.118.12266DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6458064PMC
May 2019

Breast Arterial Calcium: A Game Changer in Women's Cardiovascular Health?

JACC Cardiovasc Imaging 2019 12 13;12(12):2538-2548. Epub 2019 Mar 13.

Department of Cardiology, Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins Medical Institutions, Baltimore, Maryland; Cardiology Department, Bellvitge University Hospital and Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Spain; Research Triangle Institute Health Solutions, Pharmacoepidemiology and Risk Management, Barcelona, Spain. Electronic address:

In 2018, cardiovascular disease (CVD) was the leading cause of death among women, and current CVD prevention paradigms may not be sufficient in this group. In that context, it has recently been proposed that detection of calcification in breast arteries may help improve CVD risk screening and assessment in apparently healthy women. This review provides an overview of breast arterial anatomy; and the epidemiology, pathophysiology, and measurement of breast artery calcium (BAC); and discusses the features of the BAC-CVD link. The potential clinical applications that BAC may offer for CVD prevention in the context of current clinical practice guidelines and recommendations are also discussed. Finally, current gaps in evidence gaps are outlined, and future directions in the field are explored with a focus on the implementation of BAC mammography as a CVD risk-screening tool in routine clinical practice.
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http://dx.doi.org/10.1016/j.jcmg.2018.07.035DOI Listing
December 2019

Race/Ethnicity-Specific Associations between Smoking, Serum Leptin, and Abdominal Fat: The Multi-Ethnic Study of Atherosclerosis.

Ethn Dis 2018 18;28(4):531-538. Epub 2018 Oct 18.

Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD.

Objective: Smoking is a well-known cardiovascular risk factor associated with weight loss. We aimed to evaluate the association between smoking, serum leptin levels, and abdominal fat.

Design: Cross-sectional.

Setting: Data from examinations 2 or 3 (2002-2005) of the Multi-Ethnic Study of Atherosclerosis (MESA).

Participants: 1,875 asymptomatic, community-dwelling adults.

Main Outcome Measures: We used multivariable linear regression models to assess the race/ethnicity-specific associations between smoking, serum logleptin levels, and computed tomography ascertained abdominal fat. Results were adjusted for demographic and relevantclinical covariates.

Results: Participants (mean age 64.5±9.6 years; 50.6% women; 42.2% former, 11.4% current smokers) were White (40.1%), Hispanic (25.8%), African American (21.1%), and Chinese (13.0%). Overall, median (25th - 75th percentile) leptin levels were significantly lower among current (11.14 ng/mL; 4.13 - 26.18) and former smokers (11.68 ng/mL; 4.72 - 27.57), as compared with never smokers (15.61 ng/mL; 3.05 - 30.12) (P<.001). The difference in median leptin levels between current and never smokers were significantly higher for Hispanics (Δ9.64 ng/mL) and African Americans (Δ8.81 ng/mL) than Whites (Δ2.10 ng/mL) and Chinese (Δ4.70 ng/mL) (P<.001). After adjustment for total abdominal fat, log-leptin levels remained lower for former (-.14 [-.22 - -.07]) and current (-.17 [-.28 - -.05]) smokers, compared with never smokers. Results differed by race/ethnicity, with significantly lower log-leptin levels observed only among current and former African Americans and Hispanic smokers, compared with their never smoker counterparts. (Ps for interaction <.05).

Conclusions: Among smokers, leptin levels significantly vary by race/ethnicity. Former and current smoking are associated with lower leptin levels, although this may be restricted to Hispanics and African Americans.
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http://dx.doi.org/10.18865/ed.28.4.531DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6200307PMC
October 2019

Correction to: Coronary Artery Calcium: Recommendations for Risk Assessment in Cardiovascular Prevention Guidelines.

Curr Treat Options Cardiovasc Med 2018 10 18;20(11):92. Epub 2018 Oct 18.

Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins Medical Institutions, Blalock 524D1, 600 N Wolfe St, Baltimore, MD, 21287, USA.

In the recently published review "Coronary Artery Calcium: Recommendations for Risk Assessment in Cardiovascular Prevention Guidelines," the following author name was inadvertently misspelled as Alison Peng. The correct spelling of the author's name is: Allison Peng as shown above.
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http://dx.doi.org/10.1007/s11936-018-0701-4DOI Listing
October 2018

E-Cigarette Use Without a History of Combustible Cigarette Smoking Among U.S. Adults: Behavioral Risk Factor Surveillance System, 2016.

Ann Intern Med 2019 01 9;170(1):76-79. Epub 2018 Oct 9.

The American Heart Association Tobacco Regulation and Addiction Center, Dallas, Texas, and Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University, Baltimore, Maryland (M.M., O.A.O., S.I.U., M.J.B.).

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http://dx.doi.org/10.7326/M18-1826DOI Listing
January 2019

Coronary Artery Calcium: Recommendations for Risk Assessment in Cardiovascular Prevention Guidelines.

Curr Treat Options Cardiovasc Med 2018 Sep 26;20(11):89. Epub 2018 Sep 26.

Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins Medical Institutions, Blalock 524D1, 600 N Wolfe St, Baltimore, MD, 21287, USA.

Purpose Of Review: In this review, we evaluate the coronary artery calcium (CAC) score as a biomarker for advanced atherosclerotic cardiovascular disease (ASCVD) risk assessment.

Recent Findings: We summarize the evidence from multiple epidemiological studies, which show a clear advantage of CAC compared to traditional and non-traditional cardiovascular risk factors. We then compare the recommendations included in the 2013 American College of Cardiology/American Heart Association (ACC/AHA) and in the 2017 Society of Cardiovascular Computed Tomography (SCCT) guidelines for the use of CAC in ASCVD risk assessment, and examine the recent 2018 US Preventive Services Task Force (USPSTF) document. Finally, based on the currently available evidence, we provide constructive input for the upcoming ACC/AHA guidelines, regarding the population in whom CAC is most likely to be informative, the level of evidence that we believe should be assigned to CAC as an advanced ASCVD risk assessment tool, and the special populations in whom CAC might be beneficial for further risk assessment. We support a pragmatic approach that combines the pooled cohort equations (PCE) for initial ASCVD risk stratification, followed by CAC for refining ASCVD risk assessment among a broad range of intermediate risk patients and other special groups.
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http://dx.doi.org/10.1007/s11936-018-0685-0DOI Listing
September 2018

Prevalence and Distribution of E-Cigarette Use Among U.S. Adults: Behavioral Risk Factor Surveillance System, 2016.

Ann Intern Med 2018 10 28;169(7):429-438. Epub 2018 Aug 28.

The American Heart Association Tobacco Regulation and Addiction Center, Dallas, Texas, and Johns Hopkins University, Baltimore, Maryland (M.M., S.I.U., O.A.O., M.J.B.).

Background: Contemporary data on the prevalence of e-cigarette use in the United States are limited.

Objective: To report the prevalence and distribution of current e-cigarette use among U.S. adults in 2016.

Design: Cross-sectional.

Setting: Behavioral Risk Factor Surveillance System, 2016.

Participants: Adults aged 18 years and older.

Measurements: Prevalence of current e-cigarette use by sociodemographic groups, comorbid medical conditions, and states of residence.

Results: Of participants with information on e-cigarette use (n = 466 842), 15 240 were current e-cigarette users, representing a prevalence of 4.5%, which corresponds to 10.8 million adult e-cigarette users in the United States. Of the e-cigarette users, 15% were never-cigarette smokers. The prevalence of current e-cigarette use was highest among persons aged 18 to 24 years (9.2% [95% CI, 8.6% to 9.8%]), translating to approximately 2.8 million users in this age range. More than half the current e-cigarette users (51.2%) were younger than 35 years. In addition, the age-standardized prevalence of e-cigarette use was high among men; lesbian, gay, bisexual, and transgender (LGBT) persons; current combustible cigarette smokers; and those with chronic health conditions. The prevalence of e-cigarette use varied widely among states, with estimates ranging from 3.1% (CI, 2.3% to 4.1%) in South Dakota to 7.0% (CI, 6.0% to 8.2%) in Oklahoma.

Limitation: Data were self-reported, and no biochemical confirmation of tobacco use was available.

Conclusion: E-cigarette use is common, especially in younger adults, LGBT persons, current cigarette smokers, and persons with comorbid conditions. The prevalence of use differs across states. These contemporary estimates may inform researchers, health care policymakers, and tobacco regulators about demographic and geographic distributions of e-cigarette use.

Primary Funding Source: American Heart Association Tobacco Regulation and Addiction Center, which is funded by the U.S. Food and Drug Administration and National Heart, Lung, and Blood Institute.
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http://dx.doi.org/10.7326/M17-3440DOI Listing
October 2018

Statin Eligibility, Coronary Artery Calcium, and Subsequent Cardiovascular Events According to the 2016 United States Preventive Services Task Force (USPSTF) Statin Guidelines: MESA (Multi-Ethnic Study of Atherosclerosis).

J Am Heart Assoc 2018 06 13;7(12). Epub 2018 Jun 13.

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

Background: The potential impact of the 2016 United States Preventive Services Task Force (USPSTF) guidelines on statins for primary prevention of atherosclerotic cardiovascular disease (ASCVD) warrants further analysis.

Methods And Results: We studied participants from MESA (Multi-Ethnic Study of Atherosclerosis) aged 40 to 75 years and not on statins. We compared statin eligibility at baseline (2000-2002) and over follow-up between USPSTF and the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines. Coronary artery calcium (CAC) was measured at baseline. Absolute ASCVD event rates were calculated according to eligibility categories for each guideline. Among 4962 MESA participants (aged 59.3±8.8 years, 47.2% female), compared with ACC/AHA guidelines, baseline statin eligibility by USPSTF was significantly lower (34.4% versus 49.1%) and increased less over time (39.1% versus 59.1%) at examination 5 [years 2010-2012]). Compared with ACC/AHA, participants eligible by USPSTF were less likely to have zero CAC at baseline (36.6% versus 41.2%) and had higher rates of hard ASCVD events per 1000 person-years (11.6 [95% confidence interval, 10.2-13.3] versus 10.0 [8.9-11.3]). The hard ASCVD event rate in those eligible by ACC/AHA but not USPSTF was 6.5 (4.9-8.5) events per 1000 person-years, with the rate varying significantly according to baseline CAC (4.2 [2.7-6.7] events in those with CAC=0, 12.8 [8.3-19.9] events in those with CAC >100).

Conclusions: In MESA, compared with ACC/AHA, the USPSTF statin guidelines resulted in a 15% absolute decrease in eligibility. Participants with discordant eligibility had ASCVD rates that varied significantly according to baseline CAC, suggesting CAC could aid clinical decision making for statins in these individuals.
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http://dx.doi.org/10.1161/JAHA.118.008920DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6220526PMC
June 2018

mActive-Smoke: A Prospective Observational Study Using Mobile Health Tools to Assess the Association of Physical Activity With Smoking Urges.

JMIR Mhealth Uhealth 2018 May 11;6(5):e121. Epub 2018 May 11.

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

Background: Evidence that physical activity can curb smoking urges is limited in scope to acute effects and largely reliant on retrospective self-reported measures. Mobile health technologies offer novel mechanisms for capturing real-time data of behaviors in the natural environment.

Objective: This study aimed to explore this in a real-world longitudinal setting by leveraging mobile health tools to assess the association between objectively measured physical activity and concurrent smoking urges in a 12-week prospective observational study.

Methods: We enrolled 60 active smokers (≥3 cigarettes per day) and recorded baseline demographics, physical activity, and smoking behaviors using a Web-based questionnaire. Step counts were measured continuously using the Fitbit Charge HR. Participants reported instantaneous smoking urges via text message using a Likert scale ranging from 1 to 9. On study completion, participants reported follow-up smoking behaviors in an online exit survey.

Results: A total of 53 participants (aged 40 [SD 12] years, 57% [30/53] women, 49% [26/53] nonwhite) recorded at least 6 weeks of data and were thus included in the analysis. We recorded 15,365 urge messages throughout the study, with a mean of 290 (SD 62) messages per participant. Mean urge over the course of the study was positively associated with daily cigarette consumption at follow-up (Pearson r=.33; P=.02). No association existed between daily steps and mean daily urge (beta=-6.95×10 per 1000 steps; P=.30). Regression models of acute effects, however, did reveal modest inverse associations between steps within 30-, 60-, and 120-min time windows of a reported urge (beta=-.0191 per 100 steps, P<.001). Moreover, 6 individuals (approximately 10% of the study population) exhibited a stronger and consistent inverse association between steps and urge at both the day level (mean individualized beta=-.153 per 1000 steps) and 30-min level (mean individualized beta=-1.66 per 1000 steps).

Conclusions: Although there was no association between objectively measured daily physical activity and concurrently self-reported smoking urges, there was a modest inverse relationship between recent step counts (30-120 min) and urge. Approximately 10% of the individuals appeared to have a stronger and consistent inverse association between physical activity and urge, a provocative finding warranting further study.
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http://dx.doi.org/10.2196/mhealth.9292DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5970286PMC
May 2018

Usefulness of Lipoprotein-Associated Phospholipase A Activity and C-Reactive Protein in Identifying High-Risk Smokers for Atherosclerotic Cardiovascular Disease (from the Atherosclerosis Risk in Communities Study).

Am J Cardiol 2018 05 6;121(9):1056-1064. Epub 2018 Feb 6.

Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Epidemiology, Johns Hopkins University Bloomberg School of Medicine, Baltimore, Maryland. Electronic address:

Despite the causal role of cigarette smoking in atherosclerotic cardiovascular disease (ASCVD), the underlying mechanisms are not fully understood. We evaluated the joint relation between smoking and inflammatory markers with ASCVD risk. We tested cross-sectional associations of self-reported smoking status (never, former, current) and intensity (packs/day) with lipoprotein-associated phospholipase A (Lp-PLA) activity and high-sensitivity C-reactive protein (hsCRP) in 10,506 Atherosclerosis Risk in Communities participants at Visit 4 (1996 to 1998). Using Cox hazard models adjusted for demographic and traditional ASCVD risk factors, we examined the associations of smoking status and intensity with incident adjudicated ASCVD events (n = 1,745 cases) over an average of 17 years, stratified by Lp-PLA and hsCRP categories. Greater packs/day smoked was linearly associated with higher levels of both Lp-PLA and hsCRP among current smokers. Compared with never smokers, the hazard ratio for incident ASCVD in current smokers was 2.04 (95% CI 1.76 to 2.35). Among current smokers, the risk for ASCVD per 1 pack/day greater was 1.39 (1.10 to 1.76). Both Lp-PLA activity ≥253 nmol/min/ml and hsCRP >3 mg/L identified current smokers at the highest risk for incident ASCVD, with similar hazard ratios. hsCRP risk-stratified current smokers better based on intensity. Among current smokers, hsCRP improved ASCVD prediction beyond traditional risk factors better than Lp-PLA (C-statistic 0.675 for hsCRP vs 0.668 for Lp-PLA2, p = 0.001). In this large cohort with long follow-up, we found a dose-response relation between smoking intensity with Lp-PLA activity, hsCRP, and ASCVD events. Although both Lp-PLA activity and hsCRP categories identified high risk among current smokers, hsCRP may better stratify risk of future ASCVD.
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http://dx.doi.org/10.1016/j.amjcard.2018.01.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5927844PMC
May 2018

High-Intensity Cigarette Smoking Is Associated With Incident Diabetes Mellitus In Black Adults: The Jackson Heart Study.

J Am Heart Assoc 2018 01 12;7(2). Epub 2018 Jan 12.

Department of Medicine, University of Mississippi Medical Center, Jackson, MS

Background: Previous reports on whether smoking is associated with insulin resistance and diabetes mellitus have yielded inconsistent findings. We aimed to evaluate the relationship between cigarette smoking and incident diabetes mellitus in the Jackson Heart Study.

Methods And Results: Jackson Heart Study participants enrolled at baseline without prevalent diabetes mellitus (n=2991) were classified by self-report as current smokers, past smokers (smoked ≥400 cigarettes/life and no longer smoking), or never smokers. We quantified smoking intensity by number of cigarettes smoked daily; we considered ≥20 cigarettes per day (1 pack) "high-intensity." We defined diabetes mellitus as fasting glucose ≥126 mg/dL, hemoglobin A1c ≥6.5% or International Federation of Clinical Chemistry units HbA1c 48 mmol/mol, or use of diabetes mellitus medication. We estimated the adjusted associations of smoking status, intensity, and dose (pack-years) with incident diabetes mellitus using Poisson regression models. At baseline there were 361 baseline current (1-10 cigarettes per day [n=242]; ≥20 [n=119]), 502 past, and 2128 never smokers. From Visit 1 to Visit 3 (mean 8.0±0.9 years), 479 participants developed incident diabetes mellitus. After adjustment for covariates, baseline current smokers who smoked less than a pack/d and past smokers had similar rates of incident diabetes mellitus compared with never smokers (incidence rate ratios 1.04, 95% confidence interval, 0.69-1.58 and 1.08, 95% confidence interval, 0.82-1.42, respectively). Baseline current high-intensity smokers had a 79% (95% confidence interval, 1.14-2.81) higher incidence of diabetes mellitus compared with never smokers. Smoking dose (per 10 pack-years) was also associated with a higher incidence of diabetes mellitus (incidence rate ratios 1.10, 95% confidence interval, 1.03-1.19) in adjusted models.

Conclusions: High-intensity cigarette smoking and smoking pack-years are associated with an increased risk of developing diabetes mellitus in blacks.
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http://dx.doi.org/10.1161/JAHA.117.007413DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5850161PMC
January 2018

Thoracic extra-coronary calcification for the prediction of stroke: The Multi-Ethnic Study of Atherosclerosis.

Atherosclerosis 2017 Dec 7;267:61-67. Epub 2017 Oct 7.

Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins Medical Institutions, Baltimore, MD, USA. Electronic address:

Background And Aims: Atherosclerosis is a systemic disease. We examined whether the cumulative burden of thoracic extra-coronary calcification (ECC) improves prediction of stroke, transient ischemic attack (TIA), and stroke mortality beyond traditional risk factors and coronary artery calcium (CAC).

Methods: We followed a total of 6805 participants (mean age 62.1 ± 10.2 years, 47.2% male) from the Multi-Ethnic Study of Atherosclerosis (MESA) over a median of 12.1 years. The presence or absence of calcification at 4 thoracic ECC sites (mitral valve annulus, aortic valve, aortic root, and thoracic aorta) was determined from baseline cardiac-gated non-contrast CT scans. A multisite thoracic ECC score, ranging 0-4, was calculated by summing the 4 individual sites, which were treated as binary variables. Multivariable Cox proportional hazards regression models, controlled for traditional risk factors and CAC, were used to estimate hazard ratios for ischemic (primary endpoint) and hemorrhagic stroke, total stroke, TIA, and stroke mortality with increasing thoracic ECC.

Results: With an increasing number of thoracic ECC sites, there was a significant (p < 0.05) multivariable adjusted step-wise increase in the risk for ischemic stroke (n = 184), total stroke (n = 235), and TIA (n = 85), but not hemorrhagic stroke (n = 32) and stroke mortality (n = 42). Thoracic ECC increased the c-statistic and net reclassification index beyond traditional risk factors and CAC, but the results were not significant (p > 0.10).

Conclusions: Although multisite thoracic ECC is independently associated with ischemic stroke, total stroke, and TIA, the incremental predictive value of thoracic ECC beyond traditional risk factors and CAC appears to be minimal.
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http://dx.doi.org/10.1016/j.atherosclerosis.2017.10.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5705470PMC
December 2017

Coronary Artery Calcium Scoring in Current Clinical Practice: How to Define Its Value?

Curr Treat Options Cardiovasc Med 2017 Sep 25;19(11):85. Epub 2017 Sep 25.

Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins Hospital, Blalock building Suit 501, 600 N Wolfe Street, Baltimore, MD, 21287, USA.

Opinion Statement: Detecting subclinical atherosclerosis with coronary artery calcium (CAC) is promising for identifying individuals at risk for cardiovascular events and appears to be a robust tool for guiding initiation of appropriate and timely primary prevention strategies. However, how do we best determine its clinical value? It is clear that traditional risk prediction models based primarily on age, gender, and risk factors are insufficient for ideal personalization of risk estimation. It is now well established from epidemiologic studies that CAC adds to traditional risk scores for a more accurate risk prediction. However, such traditional epidemiology studies have limitations in establishing "clinical value," and they must be supplemented by additional data before being translated into strong recommendations in clinical practice guidelines. Fortunately, over the last few years, the research around CAC has matured to include data supporting enhanced clinician-patient risk discussions, shared decision-making, flexible risk factor treatment goals, specific clinical decision algorithms, as well as favorable cost-effectiveness analyses. We had moved from a time when we asked "if CAC adds to the risk score" to a time when we are asking "does CAC facilitate a shared decision-making model matching risk, treatment, and patient preferences?" A new risk calculator incorporating CAC into global risk scoring, and 2017 guidelines on the use of CAC published by the Society of Cardiovascular Computed Tomography (SCCT), reflect this new approach. In this article, we review the recent transition to this more clinically relevant CAC research that may support a stronger recommendation for its use in future prevention guidelines.
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http://dx.doi.org/10.1007/s11936-017-0582-yDOI Listing
September 2017

The association between cigarette smoking and inflammation: The Genetic Epidemiology Network of Arteriopathy (GENOA) study.

PLoS One 2017 18;12(9):e0184914. Epub 2017 Sep 18.

Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins School of Medicine, Baltimore, United States of America.

To inform the study and regulation of emerging tobacco products, we sought to identify sensitive biomarkers of tobacco-induced subclinical cardiovascular damage by testing the cross-sectional associations of smoking with 17 biomarkers of inflammation in 2,702 GENOA study participants belonging to sibships ascertained on the basis of hypertension. Cigarette smoking was assessed by status, intensity (number of cigarettes per day), burden (pack-years of smoking), and time since quitting. We modeled biomarkers as geometric mean (GM) ratios using generalized estimating equations (GEE). The mean age of participants was 61 ±10 years; 64.5% were women and 54.4% African American. The prevalence of smoking was 12.2%. After adjusting for potential confounders, 6 of 17 biomarkers were significantly higher among current smokers at a Bonferroni adjusted p-value threshold (p<0.003). High sensitivity C-reactive protein was the most elevated biomarker among current smokers when compared to never smokers [GM ratio = 1.39 (95% CI: 1.23, 1.57); p <0.001]. Among former smokers, each pack-year of cigarettes smoked was associated with a 0.4% higher serum level of hsCRP [GM ratio = 1.004 (95% CI: 1.001, 1.006); p = 0.002] and each 5-year lapsed since quitting was associated with a 4% lower serum level of hsCRP [GM ratio = 0.96 (95% CI: 0.93, 0.99); p = 0.006]. However, we found no significant association of smoking intensity or burden with biomarkers of inflammation among current smokers. HsCRP appears to be the most sensitive biomarker of inflammation associated with cigarette smoking of those investigated, and could be a useful biomarker of smoking-related injury for the study and regulation of emerging tobacco products.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0184914PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5602636PMC
October 2017

Association Between Smoking and Serum GlycA and High-Sensitivity C-Reactive Protein Levels: The Multi-Ethnic Study of Atherosclerosis (MESA) and Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

J Am Heart Assoc 2017 08 23;6(8). Epub 2017 Aug 23.

Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD

Background: Inflammation is suggested to be a central feature of atherosclerosis, particularly among smokers. We studied whether inflammatory biomarkers GlycA and high-sensitivity C-reactive protein are associated with cigarette smoking.

Methods And Results: A total of 11 509 participants, 6774 from the MESA (Multi-Ethnic Study of Atherosclerosis) and 4735 from ELSA-Brasil (The Brazilian Longitudinal Study of Adult Health) were included. We evaluated the cross-sectional association between multiple measures of smoking behavior and the inflammatory biomarkers, GlycA and high-sensitivity C-reactive protein, using regression models adjusted for demographic, anthropometric, and clinical characteristics. Participants were 57.7±11.1 years old and 46.4% were men. Never, former, and current smokers comprised 51.7%, 34.0%, and 14.3% of the population, respectively. Multivariable-adjusted mean absolute difference in GlycA levels (μmol/L) with 95% confidence interval (CI) were higher for former (4.1, 95% CI, 1.7-6.6 μmol/L) and current smokers (19.9, 95% CI, 16.6-23.2 μmol/L), compared with never smokers. Each 5-unit increase in pack-years of smoking was associated with higher GlycA levels among former (0.7, 95% CI, 0.3-1.1 μmol/L) and current smokers (1.6, 95% CI, 0.8-2.4 μmol/L). Among former smokers, each 5-year increase in time since quitting smoking was associated with lower GlycA levels (-1.6, 95% CI, -2.4 to -0.8 μmol/L) and each 10-unit increase in number of cigarettes/day was associated with higher GlycA among current smokers (2.8, 95% CI, 0.5-5.2 μmol/L). There were similar significant associations between all measures of smoking behavior, and both log-transformed GlycA and high-sensitivity C-reactive protein.

Conclusions: Acute and chronic exposure to tobacco smoking is associated with inflammation, as quantified by both GlycA and high-sensitivity C-reactive protein. These biomarkers may have utility for the study and regulation of novel and traditional tobacco products.
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http://dx.doi.org/10.1161/JAHA.117.006545DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5586473PMC
August 2017

Coronary Artery Calcium Scoring: Is It Time for a Change in Methodology?

JACC Cardiovasc Imaging 2017 08;10(8):923-937

Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland; IDIBELL-Bellvitge Biomedical Research Institute, Barcelona, Spain; RTI Health Solutions, Barcelona, Spain.

Quantification of coronary artery calcium (CAC) has been shown to be reliable, reproducible, and predictive of cardiovascular risk. Formal CAC scoring was introduced in 1990, with early scoring algorithms notable for their simplicity and elegance. Yet, with little evidence available on how to best build a score, and without a conceptual model guiding score development, these scores were, to a large degree, arbitrary. In this review, we describe the traditional approaches for clinical CAC scoring, noting their strengths, weaknesses, and limitations. We then discuss a conceptual model for developing an improved CAC score, reviewing the evidence supporting approaches most likely to lead to meaningful score improvement (for example, accounting for CAC density and regional distribution). After discussing the potential implementation of an improved score in clinical practice, we follow with a discussion of the future of CAC scoring, asking the central question: do we really need a new CAC score?
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http://dx.doi.org/10.1016/j.jcmg.2017.05.007DOI Listing
August 2017

Associations of Cigarette Smoking With Subclinical Inflammation and Atherosclerosis: ELSA-Brasil (The Brazilian Longitudinal Study of Adult Health).

J Am Heart Assoc 2017 Jun 24;6(6). Epub 2017 Jun 24.

Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD

Background: There is a need to identify sensitive biomarkers of early tobacco-related cardiovascular disease. We examined the association of smoking status, burden, time since quitting, and intensity, with markers of inflammation and subclinical atherosclerosis.

Methods And Results: We studied 14 103 participants without clinical cardiovascular disease in ELSA-Brasil (Brazilian Longitudinal Study of Adult Health). We evaluated baseline cross-sectional associations between smoking parameters and inflammation (high-sensitivity C-reactive protein [hsCRP]) and measures of subclinical atherosclerosis (carotid intima-media thickness, ankle-brachial index, and coronary artery calcium [CAC]). The cohort included 1844 current smokers, 4121 former smokers, and 8138 never smokers. Mean age was 51.7±8.9 years; 44.8% were male. After multivariable adjustment, compared with never smokers, current smokers had significantly higher levels of hsCRP (β=0.24, 0.19-0.29 mg/L; <0.001) and carotid intima-media thickness (β=0.03, 0.02-0.04 mm; <0.001) and odds of ankle-brachial index ≤1.0 (odds ratio: 2.52; 95% confidence interval, 2.06-3.08; <0.001) and CAC >0 (odds ratio: 1.83; 95% confidence interval, 1.46-2.30; <0.001). Among former and current smokers, pack-years of smoking (burden) were significantly associated with hsCRP (<0.001 and =0.006, respectively) and CAC (<0.001 and =0.002, respectively). Among former smokers, hsCRP and carotid intima-media thickness levels and odds of ankle-brachial index ≤1.0 and CAC >0 were lower with increasing time since quitting (<0.01). Among current smokers, number of cigarettes per day (intensity) was positively associated with hsCRP (<0.001) and CAC >0 (=0.03) after adjusting for duration of smoking.

Conclusions: Strong associations were observed between smoking status, burden, and intensity with inflammation (hsCRP) and subclinical atherosclerosis (carotid intima-media thickness, ankle-brachial index, CAC). These markers of early cardiovascular disease injury may be used for the further study and regulation of traditional and novel tobacco products.
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http://dx.doi.org/10.1161/JAHA.116.005088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5669156PMC
June 2017

The role of mHealth for improving medication adherence in patients with cardiovascular disease: a systematic review.

Eur Heart J Qual Care Clin Outcomes 2016 Oct;2(4):237-244

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

Cardiovascular disease is a leading cause of morbidity and mortality worldwide, and a key barrier to improved outcomes is medication non-adherence. The aim of this study is to review the role of mobile health (mHealth) tools for improving medication adherence in patients with cardiovascular disease. We performed a systematic search for randomized controlled trials that primarily investigated mHealth tools for improving adherence to cardiovascular disease medications in patients with hypertension, coronary artery disease, heart failure, peripheral arterial disease, and stroke. We extracted and reviewed data on the types of mHealth tools used, preferences of patients and healthcare providers, the effect of the mHealth interventions on medication adherence, and the limitations of trials. We identified 10 completed trials matching our selection criteria, mostly with <100 participants, and ranging in duration from 1 to 18 months. mHealth tools included text messages, Bluetooth-enabled electronic pill boxes, online messaging platforms, and interactive voice calls. Patients and healthcare providers generally preferred mHealth to other interventions. All 10 studies reported that mHealth interventions improved medication adherence, though the magnitude of benefit was not consistently large and in one study was not greater than a telehealth comparator. Limitations of trials included small sample sizes, short duration of follow-up, self-reported outcomes, and insufficient assessment of unintended harms and financial implications. Current evidence suggests that mHealth tools can improve medication adherence in patients with cardiovascular diseases. However, high-quality clinical trials of sufficient size and duration are needed to move the field forward and justify use in routine care.
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http://dx.doi.org/10.1093/ehjqcco/qcw018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5862021PMC
October 2016

Early interventions for optimal control of prediabetes and diabetes: Critical to prevent cardiovascular disease?

Atherosclerosis 2016 10 28;253:265-267. Epub 2016 Aug 28.

The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA.

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http://dx.doi.org/10.1016/j.atherosclerosis.2016.08.039DOI Listing
October 2016

Percutaneous Transhepatic N-Butyl Cyanoacrylate Injection Therapy of an Isolated Bile Duct Associated with a Bronchobiliary Fistula.

J Vasc Interv Radiol 2016 Jun 3;27(6):930-2. Epub 2016 Jun 3.

General Surgery, Tehran University of Medical Sciences, Tehran, Iran.

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http://dx.doi.org/10.1016/j.jvir.2016.02.024DOI Listing
June 2016

Stratifying cardiovascular risk in diabetes: The role of diabetes-related clinical characteristics and imaging.

J Diabetes Complications 2016 Sep-Oct;30(7):1408-15. Epub 2016 Apr 30.

Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins, Baltimore, MD, USA. Electronic address:

Diabetes is a major coronary heart disease (CHD) and cardiovascular disease (CVD) risk factor and has traditionally been classified as a CHD risk equivalent. CVD risk, however, is heterogeneous among diabetic patients and thus further evaluation is warranted before initiating or titrating preventive pharmacotherapy. Prognostic clinical characteristics of diabetes such as age of onset, duration, and severity of diabetes, as well as concomitant cardiometabolic factors account for much of the variability in CHD and CVD risk. This heterogeneity can also be evaluated directly using non-invasive imaging, which allows for a more individualized risk assessment in order to minimize both under and overtreatment. In this paper, we review guideline recommendations for atherosclerotic CVD risk assessment driving the use of statins or aspirin for certain subgroups of patients with diabetes. We further discuss imaging techniques, such as stress myocardial perfusion imaging, coronary computed tomography angiography, and coronary artery calcium (CAC) scoring that can guide the decision to treat high-risk patients. Among imaging tests, current guidelines consider CAC scoring the most appropriate risk stratification tool for asymptomatic individuals with diabetes that can guide initiating/intensifying or withholding the most aggressive pharmacological therapies among high-risk (CAC>100) or low-risk (CAC=0) individuals, respectively.
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http://dx.doi.org/10.1016/j.jdiacomp.2016.04.021DOI Listing
March 2018

An Update on the Utility of Coronary Artery Calcium Scoring for Coronary Heart Disease and Cardiovascular Disease Risk Prediction.

Curr Atheroscler Rep 2016 Mar;18(3):13

Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, 21287, USA.

Estimating cardiovascular disease (CVD) risk is necessary for determining the potential net benefit of primary prevention pharmacotherapy. Risk estimation relying exclusively on traditional CVD risk factors may misclassify risk, resulting in both undertreatment and overtreatment. Coronary artery calcium (CAC) scoring personalizes risk prediction through direct visualization of calcified coronary atherosclerotic plaques and provides improved accuracy for coronary heart disease (CHD) or CVD risk estimation. In this review, we discuss the most recent studies on CAC, which unlike historical studies, focus sharply on clinical application. We describe the MESA CHD risk calculator, a recently developed CAC-based 10-year CHD risk estimator, which can help guide preventive therapy allocation by better identifying both high- and low-risk individuals. In closing, we discuss calcium density, regional distribution of CAC, and extra-coronary calcification, which represent the future of CAC and CVD risk assessment research and may lead to further improvements in risk prediction.
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http://dx.doi.org/10.1007/s11883-016-0565-6DOI Listing
March 2016

Risk of Stent Thrombosis and Major Bleeding with Bivalirudin Compared with Active Control: A Systematic Review and Meta-analysis of Randomized Trials.

Thromb Res 2015 Dec 6;136(6):1087-98. Epub 2015 Jun 6.

Department of Medicine, McMaster University, Hamilton, Ontario, Canada.

Background: Bivalirudin is commonly used for patients undergoing percutaneous coronary intervention (PCI), but there have been recent concerns that it may be associated with an increased risk of stent thrombosis and provide no benefit regarding major bleeding compared with active control.

Methods And Results: We searched PubMed, clinicaltrials.gov, and conference proceedings for randomized controlled trials of bivalirudin versus active control in patients undergoing PCI. The main outcomes of interest were definite stent thrombosis, myocardial infarction, major bleeding, and mortality. We used random-effects modeling to pool the data. We included 25 trials involving 41,243 patients. Overall, use of bivalirudin compared with active control was associated with an increased risk of definite stent thrombosis (11 trials; 16,864 patients; RR, 1.73; 95% CI, 1.24-2.40; P<0.001; I(2)=0%), similar risk of acute myocardial infarction (22 trials; 40,578 patients; RR, 1.00; 95% CI, 0.87-1.16; P=0.96; I(2)=43%), decreased risk of major bleeding (25 trials; 41,243 patients; RR, 0.59; 95% CI, 0.49-0.72; P<0.001; I(2)=31%) and of cardiac death (6 trials; 6,956 patients; RR, 0.72; 95% CI, 0.53-0.99; P=0.05; I(2)=0%), but no change in all-cause mortality (24 trials; 41,058 patients; RR, 0.96; 95% CI, 0.81-1.15; P=0.69; I(2)=0%). Results were consistent across a wide set of subgroup and sensitivity analyses.

Conclusions: Compared with active control, bivalirudin is associated with increased risk of stent thrombosis but lower risk of major bleeding, with no discernible impact on all-cause mortality.
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http://dx.doi.org/10.1016/j.thromres.2015.06.001DOI Listing
December 2015
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