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Highlights • Mechanistic studies illustrate the effects of PD on systemic inflammation, platelet and endothelial function, and lipoproteins. • Trials of PD treatment have not shown reductions in cardiovascular outcomes therefore a definite causal association is lacking. • The morbidity and impact on quality of life, mutual risk factors and systemic inflammation warrant preventive efforts. • Improved screening, better collaboration, and targeted health policies could greatly improve prevention of PD and its sequelae., Periodontal disease (PD) is common in the US and globally. Evidence suggests that poor oral health is associated with atherosclerotic cardiovascular disease (ASCVD); however, this relationship has not been a major focus in clinical cardiology. This manuscript will review the growing evidence linking PD to ASCVD, including pathophysiologic mechanisms and coexistent risk factors. Public health considerations with a focus on disparities, social determinants, preventive strategies, and a call to action to reduce the burden of coincident ASCVD and PD are also reviewed., Graphical abstract Image, graphical abstract

Poor dietary quality is a leading contributor to mortality in the United States, and to most cardiovascular risk factors. By providing education on lifestyle changes and, specifically, dietary changes, hospitals have the opportunity to use the patient experience as a "teachable moment." The food options provided to inpatients and outpatients can be a paradigm for patients to follow upon discharge from the hospital. There are hospitals in the United States that are showcasing novel ways to increase awareness of optimal dietary patterns and can serve as a model for hospitals nationwide.

Acquisition costs and cost-effectiveness have limited access and recommendations to use proprotein convertase subtilisin/kexin type 9 (PCSK9)-inhibiting monoclonal antibodies (mAbs). Recently, prices were reduced by 60% for alirocumab and evolocumab. This statement systematically reviewed subgroup analyses from statin and PCSK9 mAb trials to identify higher risk groups for which PCSK9 mAbs at the new price could be considered a reasonable (

Graphical abstract, Highlights • Cardiac involvement is common in EPGA. • Multimodality images and endomyocardial biopsy are essential in diagnosing EPGA. • Early treatment of EPGA is essential to prevent progression of the disease.

Despite dramatic declines in total cardiovascular disease (CVD) mortality among women in the USA, CVD remains the #1 killer of women, causing almost one out of three female deaths in 2016. Hypercholesterolemia is causal in the development of coronary atherosclerosis and incident atherosclerotic cardiovascular disease (ASCVD) events in women, as it is in men. Statins lower atherogenic lipoproteins to a similar degree in both sexes. Meta-analyses demonstrate that women and men at similar risk of major vascular events achieve similar proportional and absolute benefits from statin therapy, even in primary prevention and among individuals at low baseline risk. The evidence for prevention of ASCVD in women with the use of non-statin drugs is limited as no large randomized controlled trials have been adequately powered to evaluate sex differences in response to non-statin therapies. However, current guidelines for the use of non-statin therapies for management of dyslipidemia for women are the same as those for men. Clinically significant adverse drug effects and self-reported drug allergies have been reported to occur more frequently among women than men for a number of drug classes, and clinicians should be aware of potential sex differences in adverse events. There are important considerations in management of dyslipidemia in women across the lifespan, particularly during conception, pregnancy, and lactation.

Introduction: Black men and women are at higher risk for atherosclerotic cardiovascular disease (ASCVD) and when diagnosed, have greater morbidity and mortality as compared to individuals from European ancestry (EA). In patients with familial hypercholesterolemia (FH), it remains unknown whether Black patients have similarly increased risk for ASCVD. Hypothesis: To characterize the prevalence of ASCVD and to determine the strongest predictors of ASCVD in Black FH patients compared to EAs. Methods: The prevalence of ASCVD in 173 Black adult patients with FH followed in US-based lipid clinics was assessed retrospectively through a multicenter. A multivariate logistic regression model was used to determine the strongest predictors of ASCVD. Covariates included age, sex, diabetes mellitus, hypertension, and current smoking. ASCVD was defined as coronary, peripheral, and cerebrovascular events including angina, myocardial infarction, coronary angioplasty, peripheral arterial surgery, claudication, peripheral angioplasty, transient ischemic attack, stroke, and carotid endarterectomy. Results: Baseline characteristics of the 173 Black adult patients compared to EAs are shown in table 1. Black patients with FH were more likely to have higher BMI, hypertension, diabetes and to be current smokers. The prevalence of ASCVD in Black patients with FH was 38% compared to 30% in EAs, an absolute difference of 8% (p=0.047). The strongest predictors of ASCVD in Black patients with FH were hypertension and current smoking (table 2). Conclusions: Black patients with FH have a significantly higher prevalence of ASCVD when compared to EAs with FH. The strongest predictors of ASCVD in Black patients with FH were hypertension and current smoking. Aggressive primary prevention strategies specifically focused on the management of hypertension and smoking cessation should be tested for impact on the cardiovascular risk profile of Black patients with FH.

Vasculogenic erectile dysfunction has been aptly called the "canary in the coal mine" for cardiovascular disease because it almost always precedes other manifestations of atherosclerotic cardiovascular disease, including myocardial infarction and stroke. It is common, associated with the presence of modifiable cardiovascular risk factors, and impacted by diet and lifestyle choices. This concise review provides an update on the use of dietary and other lifestyle interventions to improve vasculogenic erectile dysfunction and atherosclerotic cardiovascular disease.

It is critical that diet quality be assessed and discussed at the point of care with clinicians and other members of the healthcare team to reduce the incidence and improve the management of diet-related chronic disease, especially cardiovascular disease. Dietary screening or counseling is not usually a component of routine medical visits. Moreover, numerous barriers exist to the implementation of screening and counseling, including lack of training and knowledge, lack of time, sense of futility, lack of reimbursement, competing demands during the visit, and absence of validated rapid diet screener tools with coupled clinical decision support to identify actionable modifications for improvement. With more widespread use of electronic health records, there is an enormous unmet opportunity to provide evidence-based clinician-delivered dietary guidance using rapid diet screener tools that must be addressed. In this scientific statement from the American Heart Association, we provide rationale for the widespread adoption of rapid diet screener tools in primary care and relevant specialty care prevention settings, discuss the theory- and practice-based criteria of a rapid diet screener tool that supports valid and feasible diet assessment and counseling in clinical settings, review existing tools, and discuss opportunities and challenges for integrating a rapid diet screener tool into clinician workflows through the electronic health record.

The secondary prevention (SP) of coronary heart disease (CHD) has become a major public health and economic burden worldwide. In the United States, the prevalence of CHD has risen to 18 million, the incidence of recurrent myocardial infarctions (MI) remains high, and related healthcare costs are projected to double by 2035. In the last decade, practice guidelines and performance measures for the SP of CHD have increasingly emphasized evidence-based lifestyle (LS) interventions, including healthy dietary patterns, regular exercise, smoking cessation, weight management, depression screening, and enrollment in cardiac rehabilitation. However, data show large gaps in adherence to healthy LS behaviors and low rates of enrollment in cardiac rehabilitation in patients with established CHD. These gaps may be related, since behavior change interventions have not been well integrated into traditional ambulatory care models in the United States. The chronic care model, an evidence-based practice framework that incorporates clinical decision support, self-management support, team-care delivery and other strategies for delivering chronic care is well suited for both chronic CHD management and prevention interventions, including those related to behavior change. This article reviews the evidence base for LS interventions for the SP of CHD, discusses current gaps in adherence, and presents strategies for closing these gaps via evidence-based and emerging interventions that are conceptually aligned with the elements of the chronic care model.

Background Nutrition is one of the foundations of cardiovascular guidelines for risk reduction and treatment. However, little is known about whether cardiologists, cardiology fellows-in-training, and cardiovascular team members have the nutrition education and knowledge necessary to implement these guidelines. The aim of this study was to describe the educational experiences, attitudes, and practices relating to nutrition among cardiovascular professionals. Methods Surveys completed by cardiologists, fellows-in-training, and cardiovascular team members inquired about their personal dietary habits, history of nutrition education, and attitudes regarding nutrition interventions. Results A total of 930 surveys were completed. Among cardiologists, 90% reported receiving no or minimal nutrition education during fellowship training, 59% reported no nutrition education during internal medicine training, and 31% reported receiving no nutrition education in medical school. Among cardiologists, 8% described themselves as having "expert" nutrition knowledge. Nevertheless, fully 95% of cardiologists believe that their role includes personally providing patients with at least basic nutrition information. The percentage of respondents who ate ≥5 servings of vegetables and fruits per day was: 20% (cardiologists), 21% (fellows-in-training), and 26% (cardiovascular team members). Conclusions A large proportion of cardiovascular specialists have received minimal medical education and training in nutrition, and current trainees continue to experience significant education and training gaps.

This Roundtable discussion concerns atherogenic risk markers and treatment targets used by clinical lipidologists in daily practice. Our purpose is to understand the risk marker framework that supports and enables the new ACC/AHA/Multisociety Cholesterol Guidelines. Some biomarkers are highly associated with atherogenic risk but fail to qualify as treatment targets. Prominent examples are high-density lipoprotein cholesterol, for which targeted treatment has failed to reduce cardiovascular risk, and lipoprotein(a), which currently lacks a highly effective mode of treatment. As a consequence, guidelines have focused consistently on low-density lipoprotein cholesterol (LDL-C) and more recently on non–high-density lipoprotein cholesterol. We discuss a new calculation for LDL-C that shows greater accuracy than the commonly performed Friedewald calculation. LDL-C treatment goals have renewed prominence in the 2018 Guidelines. Thresholds for treatment initiation or intensification inherently establish goals of reducing atherogenic cholesterol levels below the thresholds. Treatment goals may be absolute, such as less than 70 mg/dL for LDL-C in very high-risk secondary prevention or relative, such as 50% or greater reduction of LDL-C. The timeframe of treatment is another consideration because milder treatment started earlier may sometimes be preferred over stronger treatment given late in the course of atherosclerotic progression. Advanced lipid testing and vascular imaging, particularly coronary artery calcium, also have their place in risk assessment to guide clinical lipid practice.

PURPOSE The impact of cognitive-behavioral strategies and clinical factors on diet change during cardiac rehabilitation (CR) is not well studied. The purpose of this study was to examine the effects of collaborative goal-setting and clinical predictors on diet scores and weight loss in a case management model of CR. METHODS We retrospectively examined the effects of clinical factors and goal-setting facilitated by case managers on diet scores and weight loss in 629 consecutive patients with atherosclerotic cardiovascular disease enrolled in our CR program between 2014 and 2016. The Rate Your Plate (RYP) diet score was used to measure diet quality at baseline and discharge. Logistic regression modeling was used to identify predictors of diet score change in a subsample with goal-setting data (n = 615). Analysis of variance was conducted in the subset with complete weight data (n = 584) to compare weight loss between those who improved their RYP scores versus those who did not. RESULTS Participants were 27.9% female, with a mean age of 63.4 ± 11.5 y. The average body mass index at baseline was 30.3 ± 6.8, and 51.7% reported diet change and/or weight loss as a goal. After an average of 33 CR sessions, 27.3% improved their RYP scores by at least 1 risk category (mean score, 54.0 ± 9.0 vs 58.2 ± 7.3, P < .001) and the average weight loss was 1.5 ± 2.9 kg (P < .001). After logistic regression modeling, dietary goal-setting was significantly associated with improvement in diet scores and with greater weight loss (2.2 ± 3.1 kg vs 0.84 ± 2.6 kg, P < .001). CONCLUSIONS A case management model that incorporates dietary goal-setting is associated with improved measures of diet quality and weight loss during CR.

Growing scientific evidence of the benefits of heart-healthy dietary patterns and of the massive public health and economic burdens attributed to obesity and poor diet quality have triggered national calls to increase diet counseling in outpatients with atherosclerotic cardiovascular disease or risk factors. However, despite evidence that physicians are willing to undertake this task and are viewed as credible sources of diet information, they engage patients in diet counseling at less than desirable rates and cite insufficient knowledge and training as barriers. These data align with evidence of large and persistent gaps in medical nutrition education and training in the United States. Now, major reforms in undergraduate and graduate medical education designed to incorporate advances in the science of learning and to better prepare physicians for 21st century healthcare delivery are providing a new impetus and novel ways to expand medical nutrition education and training. This science advisory reviews gaps in undergraduate and graduate medical education in nutrition in the United States, summarizes reforms that support and facilitate more robust nutrition education and training, and outlines new opportunities for accomplishing this goal via multidimensional curricula, pedagogies, technologies, and competency-based assessments. Real-world examples of efforts to improve undergraduate and graduate medical education in nutrition by integrating formal learning with practical, experiential, inquiry-driven, interprofessional, and population health management activities are provided. The authors conclude that enhancing physician education and training in nutrition, as well as increasing collaborative nutrition care delivery by 21st century health systems, will reduce the health and economic burdens from atherosclerotic cardiovascular disease to a degree not previously realized.

One of the most serious challenges to all physicians is the maintenance of therapy for those chronic disorders that at present cannot be cured. Elevations of low-density lipoprotein and very low-density lipoprotein are among the most common of those disorders. We are now in an era in which 2 fundamental developments of modern technology have come together. These are the supply of effective and safe lipid-lowering drugs as well as the ability to closely monitor pertinent measures in our patients. The rapid conversion of our health care systems into large teams of professionals with direct support from third-party payers has made it possible to coordinate chronic care through electronic medical records and electronic communication. As a result, with effective planning and organization, we can guide our patients toward better adherence to successful medical regimens. These issues are evolving rapidly and have been presented in some detail in the December 2013 issue of the Journal. I was joined in this Roundtable discussion by 3 health professionals who have had extensive experience with the application of health information technology. They are Dr. Karen Aspry and Dr. Alan Brown, both clinical cardiologists, and Dr. Matthew Ito, a Doctor of Pharmacy.

Background Large gaps in lipid treatment and medication adherence persist in high-risk outpatients in the United States. Health information technology (HIT) is being applied to close quality gaps in chronic illness care, but its utility for lipid management has not been widely studied. Objective To perform a qualitative review of the impact of HIT interventions on lipid management processes of care (screening or testing; drug initiation, titration or adherence; or referrals) or clinical outcomes (percent at low density lipoprotein cholesterol goal; absolute lipid levels; absolute risk scores; or cardiac hospitalizations) in outpatients with coronary heart disease or at increased risk. Methods PubMed and Google Scholar databases were searched using Medical Subject Headings related to clinical informatics and cholesterol or lipid management. English language articles that described a randomized controlled design, tested at least one HIT tool in high risk outpatients, and reported at least 1 lipid management process measure or clinical outcome, were included. Results Thirty-four studies that enrolled 87,874 persons were identified. Study ratings, outcomes, and magnitude of effects varied widely. Twenty-three trials reported a significant positive effect from a HIT tool on lipid management, but only 14 showed evidence that HIT interventions improve clinical outcomes. There was mixed evidence that provider-level computerized decision support improves outcomes. There was more evidence in support of patient-level tools that provide connectivity to the healthcare system, as well as system-level interventions that involve database monitoring and outreach by centralized care teams. Conclusion Randomized controlled trials show wide variability in the effects of HIT on lipid management outcomes. Evidence suggests that multilevel HIT approaches that target not only providers but include patients and systems approaches will be needed to improve lipid treatment, adherence and quality.

The HIV-AIDS epidemic has provided one of the more challenging problems in treatment of infectious diseases. As antiretroviral drugs made a very marked improvement in controlling the immunodeficiency state and patients gained in their longevity, the concern with lipid abnormalities came to the fore. The initial drugs produced a form of metabolic syndrome accompanied by very elevated plasma triglyceride concentrations. Furthermore, the drugs used to control the virus were often metabolized in a manner that interfered with lipid lowering drug therapy. The antiviral agents have improved in many respects and the experience in managing the lipid disorders has added greatly to our ability to control these problems as well. This roundtable discussion has been conducted with 4 physicians who have been involved in management of large cohorts of patients with HIV infection and who have had a special interest in reduction of vascular disease risk.

Exercise-based cardiac rehabilitation (CR) is associated with significant improvements in coronary disease outcomes, but has been underutilized. However, new developments within the field, some spurred by healthcare reform and the transition to more accountable and coordinated care, offer hope for closing the large CR treatment gap. This review presents new CR-related research, policy, and analyses, and discusses how evolving eligibility criteria, referral processes, performance measures, care models, and delivery and payment options could increase CR utilization over the next decade and enable this life-saving secondary prevention intervention to thrive in the era of value-based health care.

Numerous studies have shown that patients with peripheral and carotid atherosclerosis have a high prevalence of hyperlipidemia, and clinical trials using either angiography or ultrasonography have now demonstrated regression of both femoral and carotid arterial plaque during lipid-lowering therapy. However, whether patients with peripheral and carotid atherosclerosis receive adequate attention to lipid risk factors has not been studied. To evaluate physician recognition and management of hypercholesterolemia in these two patient populations, we reviewed the charts of 80 consecutive patients undergoing revascularization for symptomatic peripheral and carotid occlusive disease at a university medical center between 1990 and 1993. Physician practices were assessed for each patient by noting whether hypercholesterolemia was (1) screened for during the hospitalization and, if present, (2) documented as a problem, (3) managed in-hospital, or (4) given appropriate intervention at discharge. While 73% of patients received some type of lipid case-finding perioperatively, less than one quarter of these were assessed for hyperlipidemia by the physician during the initial history. Moreover, of the 66% of screened patients found to be hypercholesterolemic, only 16% had documentation of the problem, only 24% received in-hospital management, and only 13% received intervention at discharge. These findings suggest that patients with documented peripheral and carotid atherosclerotic vascular disease probably receive inadequate attention to lipid risk factors and indicate the need for greater awareness and management of lipid disorders in these two patient populations by all involved physicians.

The exercise treadmill test (ETT) in women has been limited by a low positive predictive value (PPV) for coronary artery disease (CAD). However, the reliability of previous studies was unsatisfactory because of the inclusion of younger women with a low prevalence of CAD. To further evaluate the diagnostic properties of the ETT in women, we evaluated a group of women with chest pain who had a positive ETT result and subsequent coronary angiography. Of the 111 women, 56 had significant CAD on angiogram, yielding a PPV of 51% for the group. However, inclusion in the analysis of several pretest attributes and specific exercise test responses improved the PPV of the ETT. Age had a major effect, with the youngest group (35 to 50 years old) having a PPV of 36% compared to 68% in the oldest group (65 years old). Several specific exercise responses (ST-segment depression2 mm and delayed ST-segment recovery3.0 minutes) further separated true from false positives across all age groups, increasing the PPV to approximately 80%. Onset of ischemia at a relatively low cardiac workload of80% maximum predicted heart rate was not a significant predictor. In conclusion, the standard ETT should remain the test of choice in ambulatory women with chest pain and no significant abnormalities on baseline electrocardiogram especially in those65 years of age.

The effects of glucagon, epinephrine, and vasopressin on phospholipid synthesis and glycogen phosphorylase a activity were investigated in rat hepatocytes. There was a stimulation of [32P]Pi ncorporation into phosphatidylinositol by vasopressin and epinephrine but not by glucagon. A mild degree of calcium depletion abolished the activation of glycogen phosphorylase by vasopressin but the increase in [32P]Pi ncorporation into phosphatidylinositol was still present. However, the activation of glycogen phosphorylase by epinephrine was not abolished by any degree of calcium depletion. The increase in [32P]Pi ncorporation into phosphatidylinositol due to epinephrine was mediated through an amechanism which was very sensitive to inhibition by prazosin, inhibited by phentolamine and yohimbine at fairly high concentrations, and unaffected by propranolol. The uptake of [2-3H]inositol into phosphatidylinositol was accelerated by hormones and correlated poorly with 32P uptake into this phospholipid. Depletion of calcium from or the addition of manganese to the incubation medium markedly enhanced the uptake of labeled inositol into phosphatidylinositol. However, these increases in [2-3H]inositol incorporation did not parallel any changes in basal or hormone stimulated 32P incorporation into phosphatidylinositol. The use of labeled inositol to measure phosphatidylinositol synthesis is unreliable since it appears to reflect the activity of the freely reversible Mn2+-dependent enzyme which catalyzes the reaction of CDP-diacylglycerol with inositol to give cytidine monophosphate and phosphatidylinositol. These data support the hypothesis that vasopressin and catecholamine activation of phosphatidylinositol turnover in hepatocytes is linked in an unknown fashion to the release of bound intracellular calcium and the entry of extracellular calcium.