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Absolute coronary artery calcium (CAC) scores and CAC percentiles can identify different patient groups, which could be confusing in clinical practice. We aimed to create a simple "rule of thumb" for identifying the American College of Cardiology/American Heart Association endorsed 75th CAC percentile based on age, gender, and the absolute CAC score. Using the Multi-Ethnic Study of Atherosclerosis, we calculated the age and gender-specific percent likelihood that a guideline-based absolute CAC score group (1 to 100, 100 to 300,gt;300) will place a patient above the 75th percentile. Also, we derived gender-specific age cutoffs by which 95% of participants with any (gt;0), moderate (≥100), or severe (≥300) CAC score would be over the 75th percentile. We repeated the analysis using the 90th percentile threshold and also conducted sensitivity analyses stratified by race. Any CACgt;0 places 95% of women younger than 60 years and over 90% of men younger than 50 years over the 75th percentile. Moderate absolute CAC scores (gt;100) place nearly all menlt;60 years and all womenlt;70 years over the 75th percentile. Confirmatory analysis for age cutoffs was consistent with primary analysis, with cutoffs of 48 years for men and 59 years for women indicating a 95% likelihood that any CAC would place patients over the 75th percentile. In conclusion, our study provides a simple rule of thumb (menlt;50 years and womenlt;60 years with any CAC, menlt;60 years and womenlt;70 years with CACgt;100) for identifying CACgt;75th percentile that might be readily adopted in clinical practice.

INTRODUCTION: Factors predisposing asymptomatic individuals within the community to venous thromboembolism (VTE) are not fully understood. This study characterizes the incidence and determinants of VTE among the Multi-Ethnic Study of Atherosclerosis cohort with a focus on race/ethnicity and obesity. METHODS: This study (analyzed in 2020–2021) used the Multi-Ethnic Study of Atherosclerosis cohort (2000–2017), which includes participants with diverse ethnic/racial backgrounds aged 45–84 years without cardiovascular disease at baseline. The primary endpoint was time to diagnosis of VTE defined using ICD codes (415, 451, 453, 126, 180, and 182). Multivariable adjusted hazard ratios of the predictors of VTE were calculated with a focus on the interaction between obesity and race/ethnicity categories. RESULTS: Over a median follow-up period of 14 years, 233 individuals developed VTE. Incidence rates (per 1,000 person-years) varied across racial/ethnic groups with the highest incidence among Black (4.02) followed by White (2.98), Hispanic (2.08), and Chinese (0.79) participants. There was a stepwise increase in the incidence rate of VTE with increasing BMI regardless of race/ethnicity: normal (1.95), overweight (2.52), obese (3.63), and morbidly obese (4.55). The association between BMI and VTE was strongest among non-White women with the highest incidence rate for obese (4.8) compared with non-obese (1.6). The interaction for obesity, gender, and race was statistically significant (p=0.01) in non-White obese women. Risk of VTE increased with age for all race/ethnicities. Other significant predictors of VTE were cancer at baseline and follow-up, long-term warfarin use, smoking, and D-dimer levels, whereas statin use was associated with lower VTE events. CONCLUSIONS: This study finds that obesity may confer an increased risk for VTE among non-White women as compared with other groups—White men, White women, and non-White men.

BACKGROUND AND AIMS: Coronary artery calcium (CAC) burden displays a stepwise association with atherosclerotic cardiovascular disease (ASCVD) risk. Among primary prevention patients, we sought to determine the CAC scores equivalent to ASCVD mortality rates observed in the FOURIER trial, a modern secondary prevention cohort.METHODS AND RESULTS: For the main analysis, we included participants from the CAC Consortium ≥50 years old with a 10-year ASCVD risk ≥7.5% (n = 20,207). Poisson regression was used to define the relationship between CAC and annual ASCVD mortality. Equations generated from the regression models were then used to derive CAC scores associated with equivalent annual ASCVD mortality as observed in FOURIER placebo participants from the overall trial and in key trial subgroups. The CAC Consortium participants had a similar age (65.5 versus 62.5 years) and sex (22% versus 24% female) distribution as FOURIER. The annualized ASCVD mortality rate in FOURIER participants (0.766 per 100 person-years) corresponded to a CAC score of 781 (418-1467). A CAC score of 255 (162-394) corresponded to an ASCVD mortality rate equivalent to the lowest risk FOURIER subgroup (presence of myocardial infarction >2 years prior to trial enrollment). No CAC score produced a risk equivalent to high-risk FOURIER subgroups, particularly those with symptomatic peripheral arterial disease and/or multivessel coronary heart disease.CONCLUSIONS: Primary prevention individuals with increased CAC burden may have annualized ASCVD mortality rates equivalent to persons with stable secondary prevention-level risk. These findings argue for a risk continuum between higher risk primary prevention and stable secondary prevention patients, as their ASCVD risks may overlap.

Background: Psychosocial stressors may influence tobacco use. Few studies have examined the association of stressors and e-cigarette use in adolescents. Therefore, we examined the associations between psychosocial stressors and e-cigarette use among adolescents in the United States (U.S.). Methods: Using the 2019 Youth Risk Behavior Survey data (YRBS) (N=13,677), students were categorized as non, e-cigarette, and combustible cigarette users based on past 30-day use. The prevalence of use was assessed by participants’ sociodemographic characteristics. Poisson regression models were used to examine the association between stressors and e-cigarette and combustible cigarette use. To estimate the stressor burden score, stressors were grouped into scores: 0, 1-2, 3-4, and 5-7. Results: Overall, 65.0%, 32.7% and 6.0% were non, e-cigarette and combustible cigarettes users, respectively. E-cigarette use prevalence was higher among students who experienced stressors than those who did not ([bullying: 43.9% vs 29.0%]; [skipping school due to safety concerns: 48.0% vs 29.0%]; [depressive symptoms: 43.5% vs 26.5%]; [suicidal thoughts: 47.6% vs 29.3%]; [physical fight: 51.1% vs 28.3%]; [threatened with a weapon56.4% vs 30.9%]). Similar patterns were observed with combustible cigarette use. Students who experienced stressors were more likely to use e-cigarettes (Prevalence Ratio [PR] range: 1.08-1.21) and combustible cigarettes (PR range: 1.34-2.06) than students who did not. Students with higher burden scores had a higher prevalence and PR of e-cigarette use than those with score of zero (1-2 [1.28; 95% CI:1.15-1.42]; 3-4 [1.42; 95% CI:1.23-1.65]; 5-7 [1.45; 95% CI:1.22-1.73]) (ptrends Conclusion: This study demonstrated significant association between psychosocial stressors and e-cigarette use.

IntroductionE-cigarette use among youth and young adults remains of public health concern. Pod-based e-cigarettes, including JUUL, significantly changed the e-cigarette landscape in the United States (US). Using an online survey, we aimed to explore the socio-behavioral correlates, predisposing factors, and addictive behaviors among young adult pod-mod users within a University in Maryland, USA.Methods112 eligible college students aged 18-24 years recruited from a University in Maryland who reported using pod-mods were included in this study. Participants were categorized into current/non-current users based on past-30-day use. Descriptive statistics were used to analyze participants’ responses.ResultsOf the 112 participants with mean age 20.5±1.2 years, 56.3% were female, 48.2% White, and 40.2% reported past-30-day (current) use of pod-mods. The mean age of first experimentation with pod-mods was 17.8±1.4 years, while the mean age of regular use was 18.5±1.4 years, with the majority (67.9%) citing social influence as the reason for initiation. Of current users, 62.2% owned their own devices, and 82.2% predominantly used JUUL and menthol flavor (37.8%). A significant proportion of current users (73.3%) reported buying pods in person, 45.5% of whom were below the age of 21. Among all participants, 67% had had a past serious quit attempt. Among them, 89.3% neither used nicotine replacement therapy nor prescription medications. Finally, current use (adjusted odds ratio (aOR):4.52; 95%CI:1.76,11.64), JUUL use (aOR:2.56; 95%CI:1.08,6.03), and menthol flavor (aOR:6.52; 95%CI:1.38,30.89) were associated with reduced nicotine autonomy, a measure of addiction.ConclusionOur findings provide specific data to inform the development of public health interventions targeted at college youth, including the need for more robust cessation support for pod-mod users.

Thoracic aortic calcium(TAC) is an important marker of extracoronary atherosclerosis with established predictive value for all-cause mortality. We sought to explore the predictive value of TAC for stroke mortality, independent of the more established coronary artery calcium (CAC) score. The CAC Consortium is a retrospectively assembled database of 66,636 patients aged ≥18 years with no previous history of cardiovascular disease, baseline CAC scans for risk stratification, and follow-up for 12 ± 4 years. CAC scans capture the adjacent thoracic aorta, enabling assessment of TAC from the same images. TAC was available in 41,066 (62%), and was primarily analyzed as present or not present. To account for competing risks for nonstroke death, we utilized multivariable-adjusted Fine and Gray competing risk regression models adjusted for traditional cardiovascular risk factors and CAC score. The mean age of participants was 53.8 ± 10.3 years, with 34.4% female. There were 110 stroke deaths during follow-up. The unadjusted subdistribution hazard ratio (SHR) for stroke mortality in those who had TAC present compared with those who did not was 8.80 (95% confidence interval [CI]: 5.97, 12.98). After adjusting for traditional risk factors and CAC score, the SHR was 2.21 (95% CI:1.39,3.49). In sex-stratified analyses, the fully adjusted SHR for females was 3.42 (95% CI: 1.74, 6.73) while for males it was 1.55 (95% CI: 0.83, 2.90). TAC was associated with stroke mortality independent of CAC and traditional risk factors, more so in women. The presence of TAC appears to be an independent risk marker for stroke mortality.

Updated data on the patterns of e-cigarette use among adults in the US are needed.To examine recent patterns in current and daily e-cigarette use among US adults.This repeated cross-sectional study used data from the 2017, 2018, and 2020 Behavioral Risk Factor Surveillance System, a nationally representative state-based survey of noninstitutionalized US adults. A total of 994 307 adults 18 years and older who were living in states and territories that provided data on e-cigarette use in 2017 (53 states and territories), 2018 (36 states and Guam), and 2020 (42 states and Guam) were included.The weighted prevalence of current (past 30 days) and daily e-cigarette use was estimated for each year, and changes in prevalence from 2017 to 2020 were assessed, first overall and then stratified by participant characteristics, including state or territory of residence.Among 994 307 adults from states with data on e-cigarette use, 429 370 individuals (weighted 51.3% female) were participants in the 2017 survey, 280 184 (weighted 52.1% female) were participants in the 2018 survey, and 284 753 (weighted 52.1% female) were participants in the 2020 survey. The weighted proportions of young adults aged 18 to 24 years were 12.6% in 2017, 11.8% in 2018, and 11.9% in 2020. Across all 3 years, 17 035 participants (weighted, 1.0%) were American Indian or Alaska Native, 22 313 (weighted, 4.6%) were Asian, 75 780 (weighted, 12.2%) were Black, 72 190 (weighted, 15.1%) were Hispanic, 4817 (weighted, 0.2%) were Native Hawaiian, 757 140 (weighted, 65.1%) were White, 20 332 (weighted, 1.3%) were multiracial, and 6245 (weighted, 0.5%) were of other races and/or ethnicities. The prevalence of current e-cigarette use was 4.4% (95% CI, 4.3%-4.5%) in 2017, which increased to 5.5% (95% CI, 5.4%-5.7%) in 2018 and decreased slightly to 5.1% (95% CI, 4.9%-5.3%) in 2020. The recent decrease, though modest, was observed mainly among young adults aged 18 to 20 years (from 18.9% [95% CI, 17.2%-20.7%] to 15.6% [95% CI, 14.1%-17.1%]; P = .004). However, the prevalence of daily e-cigarette use increased consistently from 1.5% (95% CI, 1.4%-1.6%) in 2017 to 2.1% (95% CI, 2.0%-2.2%) in 2018 and 2.3% (95% CI, 2.2%-2.4%) in 2020. Among young adults aged 21 to 24 years, there was a slight, albeit insignificant, increase in the prevalence of current e-cigarette use (from 13.5% [95% CI, 12.3%-14.7%] to 14.5% [95% CI, 13.2%-15.9%]; P = .28) but a significant increase in the prevalence of daily e-cigarette use (from 4.4% [95% CI, 3.8%-5.1%] to 6.6% [95% CI, 5.6%-7.6%]; P .001) between 2018 and 2020. State-level patterns in the prevalence of current e-cigarette use were heterogeneous, with states like Massachusetts (from 5.6% [95% CI, 4.8%-6.5%] to 4.1% [95% CI, 3.1%-5.3%]; P = .03) and New York (from 5.4% [95% CI, 4.9%-5.9%] to 4.1% [95% CI, 3.5%-4.7%]; P = .001) recording significant decreases between 2018 and 2020. In contrast, Guam (from 5.9% [95% CI, 4.5%-7.9%] to 11.4% [95% CI, 8.7%-14.8%]; P = .002) and Utah (from 6.1% [95% CI, 5.5%-6.7%] to 7.2% [95% CI, 6.5%-8.0%]; P = .02) recorded significant increases in current e-cigarette use over the same period.In this study, a slight decrease in the prevalence of current e-cigarette use was found between 2018 and 2020; this decrease was mainly observed among young adults aged 18 to 20 years. In contrast, daily e-cigarette use consistently increased, particularly among young adults aged 21 to 24 years. This increase in daily use suggests greater nicotine dependence among those who use e-cigarettes, warranting continued surveillance.

The prevalence of aortic valve calcification (AVC) increases with age. However, the sex-and race-specific burden of AVC and associated cardiovascular risk factors among adults ≥75 years are not well studied.We calculated the sex-and race-specific burden of AVC among 2283 older Black and White adults (mean age:80.5 [SD:4.3] years) without overt coronary heart disease from the Atherosclerosis Risk in Communities Study who underwent non-contrast cardiac-gated CT-imaging at visit 7 (2018-2019). Using Poisson regression with robust variance, we calculated the adjusted prevalence ratios (aPR) of the association of AVC with cardiovascular risk factors.The overall AVC prevalence was 44.8%, with White males having the highest prevalence at 58.2%. The prevalence was similar for Black males (40.5%), White females (38.9%), and Black females (36.8%). AVC prevalence increased significantly with age among all race-sex groups. The probability of any AVC at age 80 years was 55.4%, 40.0%, 37.3%, and 36.2% for White males, Black males, White females, and Black females, respectively. Among persons with prevalent AVC, White males had the highest median AVC score (100.9 Agatston Units [AU]), followed by Black males (68.5AU), White females (52.3AU), and Black females (46.5AU). After adjusting for cardiovascular risk factors, Black males (aPR:0.53; 95%CI:0.33-0.83), White females (aPR:0.68; 95%CI:0.61-0.77), and Black females (aPR:0.49; 95%CI:0.31-0.77) had lower AVC prevalence compared to White males. In addition, systolic blood pressure, non-HDL-cholesterol, and lipoprotein (a) were independently associated with AVC, with no significant race/sex interactions.AVC, although highly prevalent, was not universally present in this cohort of older adults. White males had ∼50-60% higher prevalence than other race-sex groups. Moreover, cardiovascular risk factors measured in older age showed significant association with AVC.

The e-cigarette or vaping product-use-associated lung injury (EVALI) epidemic was primarily associated with the use of e-cigarettes containing tetrahydrocannabinol (THC)- the principal psychoactive substance in cannabis, and vitamin-E-acetate- an additive sometimes used in informally sourced THC-containing e-liquids. EVALI case burden varied across states, but it is unclear whether this was associated with state-level cannabis vaping prevalence. We, therefore, used linear regression models to assess the cross-sectional association between state-level cannabis vaping prevalence (obtained from the 2019 behavioral Risk Factor Surveillance System) and EVALI case burden (obtained from the Centers for Disease Control and Prevention) adjusted for state cannabis policies. Cannabis vaping prevalence ranged from 1.14%(95%CI, 0.61%-2.12%) in Wyoming to 3.11%(95%CI, 2.16%-4.44%) in New Hampshire. EVALI cases per million population ranged from 1.90(0.38–3.42) in Oklahoma to 59.10(19.70–96.53) in North Dakota. There was no significant positive association but an inverse association between state cannabis vaping prevalence and EVALI case burden (Coefficient, -18.6; 95%CI, -37.5–0.4; p-value, 0.05). Thus, state-level cannabis vaping prevalence was not positively associated with EVALI prevalence, suggesting that there may not be a simple direct link between state cannabis vaping prevalence and EVALI cases, but rather the relationship is likely more nuanced and possibly reflective of access to informal sources of THC-containing e-cigarettes.

The 2018 and 2019 guidelines from the American College of Cardiology and American Heart Association reflect the complexity of individualized cholesterol management. The documents address more detailed risk assessment, newer nonstatin cholesterol-lowering drugs, special attention to patient subgroups, and consideration of the value of therapy, all with the aim of creating personalized treatment plans for each patient. Overall, the guidelines recommend shared decision-making to meet the individual needs of each patient.

Introduction The association between e-cigarette use and chronic bronchitis, emphysema, and chronic obstructive pulmonary disease has not been studied thoroughly, particularly in populations defined by concomitant combustible smoking status. Methods Using pooled 2016 and 2017 data from the Behavioral Risk Factor Surveillance System, investigators studied 705,159 participants with complete self-reported information on e-cigarette use, combustible cigarette use, key covariates, and chronic bronchitis, emphysema, or chronic obstructive pulmonary disease. Current e-cigarette use was the main exposure, with current use further classified as daily or occasional use. The main outcome was defined as reported ever having a diagnosis of chronic bronchitis, emphysema, or chronic obstructive pulmonary disease. For all the analyses, multivariable adjusted logistic regression was used, with the study population stratified by combustible cigarette use status (never, former, or current). All the analyses were conducted in 2019. Results Of 705,159 participants, 25,175 (3.6%) were current e-cigarette users, 64,792 (9.2%) current combustible cigarette smokers, 207,905 (29.5%) former combustible cigarette smokers, 432,462 (61.3%) never combustible cigarette smokers, and 14,036 (2.0%) dual users of e-cigarettes and combustible cigarettes. A total of 53,702 (7.6%) participants self-reported chronic bronchitis, emphysema, or chronic obstructive pulmonary disease. Among never combustible cigarette smokers, current e-cigarette use was associated with 75% higher odds of chronic bronchitis, emphysema, or chronic obstructive pulmonary disease compared with never e-cigarette users (OR=1.75, 95% CI=1.25, 2.45), with daily users of e-cigarettes having the highest odds (OR=2.64, 95% CI=1.43, 4.89). Similar associations between e-cigarette use and chronic bronchitis, emphysema, or chronic obstructive pulmonary disease were noted among both former and current combustible cigarette smokers. Conclusions The results suggest possible e-cigarette–related pulmonary toxicity across all the categories of combustible cigarette smoking status, including those who had never smoked combustible cigarettes.

BACKGROUND:The Coronary Artery Calcium Data and Reporting System (CAC-DRS), which takes into account the Agatston score category (A) and the number of calcified vessels (N) has not yet been validated in terms of its prognostic significance. METHODS:We included 54,678 patients from the CAC Consortium, a large retrospective clinical cohort of asymptomatic individuals free of baseline cardiovascular disease (CVD). CAC-DRS groups were derived from routine, cardiac-gated CAC scans. Cox proportional hazards regression models, adjusted for traditional CVD risk factors, were used to assess the association between CAC-DRS groups and CHD, CVD, and all-cause mortality. CAC-DRS was then compared to CAC score groups and regional CAC distribution using area under the curve (AUC) analysis. RESULTS:The study population had a mean age of 54.2 ± 10.7, 34.4% female, and mean ASCVD score 7.3% ± 9.0. Over a mean follow-up of 12 ± 4 years, a total of 2,469 deaths (including 398 CHD deaths and 762 CVD deaths) were recorded. There was a graded risk for CHD, CVD and all-cause mortality with increasing CAC-DRS groups ranging from an all-cause mortality rate of 1.2 per 1,000 person-years for A0 to 15.4 per 1,000 person-years for A3/N4. In multivariable-adjusted models, those with CAC-DRS A3/N4 had significantly higher risk for CHD mortality (HR 5.9 (95% CI 3.6-9.9), CVD mortality (HR4.0 (95% CI 2.8-5.7), and all-cause mortality a (HR 2.5 (95% CI 2.1-3.0) compared to CAC-DRS A0. CAC-DRS had higher AUC than CAC score groups (0.762 vs 0.754, P

Introduction: Social environment and neighborhood factors, including perceived social cohesion, represent key determinants of health. While evidence has shown that low cohesion may be adversely associated with cardiovascular health and higher levels may be cardioprotective, few studies have assessed the association between cohesion and sociodemographic factors among adults with atherosclerotic cardiovascular disease (ASCVD). Methods: Using a U.S. nationally representative sample (National Health Interview Survey [NHIS], 2013-18), we examined the association between sociodemographic characteristics and neighborhood social cohesion in adults with ASCVD. Social cohesion was categorized based on the sum of the four subscales: 1) people in this neighborhood help each other out; 2) there are people I can count on; 3) people can be trusted; and 4) this is a close-knit neighborhood. The composite score was then split at or above and below the median. Results: Among 17,017 NHIS participants with ASCVD (representing 18.3 million adults annually), 8,988 (54%) reported low neighborhood social cohesion, corresponding to 9.9 million adults. A higher proportion of those aged 18-39 years (71%), non-Hispanic Black (67%) and Hispanic (68%) individuals, uninsured (71%) adults, and immigrants (65%) reported low social cohesion compared to other groups. In multivariable logistic regression, those aged 18-39 years and 40-64 years, non-Hispanic Black and Hispanic adults, individuals with a low-income, and immigrants had increased odds of low social cohesion (Figure). Overall, 80% of adults with 4 of these characteristics had low social cohesion. Conclusion: Sociodemographic factors are associated with disparities in neighborhood social cohesion among adults with ASCVD. Future studies should assess the causal relationship between social determinants and neighborhood cohesion, the consequences of low social cohesion, and potential approaches to ameliorate it.

Coronary artery calcium (CAC) is a marker of plaque burden. Whether CAC improves risk stratification for incident sudden cardiac death (SCD) beyond atherosclerotic cardiovascular disease (ASCVD) risk factors is unknown.SCD is a common initial manifestation of coronary heart disease (CHD); however, SCD risk prediction remains elusive.The authors studied 66,636 primary prevention patients from the CAC Consortium. Multivariable competing risks regression and C-statistics were used to assess the association between CAC and SCD, adjusting for demographics and traditional risk factors.The mean age was 54.4 years, 33% were women, 11% were of non-White ethnicity, and 55% had CAC0. A total of 211 SCD events (0.3%) were observed during a median follow-up of 10.6 years, 91% occurring among those with baseline CAC0. Compared with CAC = 0, there was a stepwise higher risk (P trend 0.001) in SCD for CAC 100 to 399 (subdistribution hazard ratio [SHR]: 2.8; 95% CI: 1.6-5.0), CAC 400 to 999 (SHR: 4.0; 95% CI: 2.2-7.3), and CAC1,000 (SHR: 4.9; 95% CI: 2.6-9.9). CAC provided incremental improvements in the C-statistic for the prediction of SCD among individuals with a 10-year risk 7.5% (ΔC-statistic = +0.046; P = 0.02) and 7.5% to 20% (ΔC-statistic = +0.069; P = 0.003), which were larger when compared with persons with a 10-year risk20% (ΔC-statistic = +0.01; P = 0.54).Higher CAC burden strongly associates with incident SCD beyond traditional risk factors, particularly among primary prevention patients with low-intermediate risk. SCD risk stratification can be useful in the early stages of CHD through the measurement of CAC, identifying patients most likely to benefit from further downstream testing.

The e-cigarette or vaping product-use-associated lung injury outbreak in the United States has raised concerns about the potential health effects of cannabis vaping, a method of cannabis use that is becoming increasingly popular. We used 2017–2019 Behavioral Risk Factor Surveillance System data to estimate yearly prevalence and trends of past-30-day cannabis use and vaping among US adults. We used multivariable logistic regression to evaluate the associations of cannabis vaping with high-risk behaviors, asthma, and other respiratory symptoms. Our sample size was 160,209 (53,945–2017; 55,475–2018; and 50,789–2019). Past-30-day cannabis use prevalence increased from 10.0% (95% CI, 9.4%–10.7%) in 2017 to 13.4% (12.8%–12.0%) in 2019. Similarly, past-30-day cannabis vaping prevalence increased from 1.0% (0.8%–1.2%) to 2.0% (1.7%–2.2%) over the same period, with the greatest increase, 1.2% to 3.9%, observed among young adults (18-24 years). Individuals who vaped cannabis were more likely to concurrently vape nicotine. Cannabis vaping was associated with increased odds of heavy alcohol use (aOR, 1.95; 95% CI, 1.45–2.63), binge drinking (aOR, 2.82; 95% CI, 2.25–3.54), and other high-risk behaviors (aOR, 2.47; 95% CI, 1.89–3.24). In analyses adjusting for sociodemographic characteristics and body mass index, cannabis vaping was not associated with asthma (aOR, 1.03; 95% CI, 0.64–1.64) or other respiratory symptoms (aOR, 1.08; 95% CI, 0.44–2.63). Adjusting for nicotine vaping did not substantively alter these associations. The prevalence of past-30-day cannabis vaping has increased, particularly among young adults, and was associated with high-risk behaviors. Although there was no association between cannabis vaping and asthma or other respiratory symptoms, the increasing trends of cannabis vaping, particularly among young adults, raise concern and underscore the need for continued surveillance.

Background E-cigarette use prevalence has grown rapidly in the US. Despite the popularity of these products, few acute exposure toxicity studies exist, and studies on long-term pulmonary health effects are limited. E-cigarette users who are never combustible cigarette smokers (sole users) constitute a unique group of young adults that may be at increased risk of bronchial hyperreactivity and development of asthma. Given the public health concern about the potential pulmonary health effects of sole e-cigarette use, we aimed to examine the association between e-cigarette use and asthma among never combustible cigarette smokers. Methods We pooled 2016 and 2017 data of the Behavioral Risk Factor Surveillance System (BRFSS), a large, cross-sectional telephone survey of adults aged 18 years and older in the U.S. We included 402,822 participants without any history of combustible cigarette smoking (defined as lifetime smoking Results Of 402,822 never combustible cigarette smokers, there were 3103 (0.8%) current e-cigarette users and 34,074 (8.5%) with asthma. The median age group of current e-cigarette users was 18–24 years. Current e-cigarette use was associated with 39% higher odds of self-reported asthma compared to never e-cigarette users (Odds Ratio [OR], 1.39; 95% confidence interval: 1.15, 1.68). There was a graded increased odds of having asthma with increase of e-cigarette use intensity. The odds ratio of self-reported asthma increased from 1.31 (95% confidence interval: 1.05, 1.62) in occasional users to 1.73 (95% confidence interval: 1.21, 2.48) in daily e-cigarette users, compared to never e-cigarette users. Conclusion Our findings from a large, nationally representative survey suggest increased odds of asthma among never combustible smoking e-cigarette users. This may have potential public health implications, providing a strong rationale to support future longitudinal studies of pulmonary health in young e-cigarette-using adults.

Background: Given the relatively modest benefit of currently available treatments in improving COVID-19 clinical outcomes, there is an urgent need for novel therapeutic strategies, especially in reversing associated lung inflammation. Attention has focused on repurposing existing agents with immune modulatory properties to accelerate their incorporation into clinical practice. Recent evidence has demonstrated that the cholesterol-lowering agents, statins, are associated with reduced mortality in patients with influenza, sepsis, community-acquired pneumonia, and chronic obstructive pulmonary diseases (COPD). We sought to investigate the relationship between statin use and COVID-19 disease severity in hospitalized patients. Methods: A retrospective analysis of COVID-19 patients admitted to the Johns Hopkins Medical Institutions between March 1, 2020 and June 30, 2020 was performed. The outcomes of interest were mortality and severe COVID-19 infection, as defined by prolonged hospital stay (≥ 7 days) and/ or invasive mechanical ventilation. Logistic regression, Cox proportional hazards regression and propensity score matching were used to obtain both univariable and multivariable associations between covariates and outcomes in addition to the average treatment effect of statin use. Results: Of the 4,447 patients who met our inclusion criteria, 594 (13.4%) patients were exposed to statins on admission, of which 340 (57.2%) were male. The mean age was higher in statin users compared to non-users [64.9 ± 13.4 vs. 45.5 ± 16.6 years, p

Introduction: Sudden cardiac death (SCD) commonly presents as the initial manifestation of coronary heart disease in the general population. Coronary artery calcium (CAC), a sub-clinical marker of atherosclerosis, is a strong predictor of cardiovascular events. We assessed the ability of CAC to stratify risk of SCD. Methods: We studied 66,636 adults from the CAC Consortium, a large multi-center cohort of asymptomatic patients free of clinical CVD at baseline. We categorized participants into 4 CAC score groups—CAC=0, CAC 1-99, CAC 100-399, and CAC≥400. The primary outcome was defined by identifying accepted International Classification of Diseases codes for SCD on official death certificates obtained for all deaths from the National Death Index. Predictive value of CAC for SCD was assessed using Cox proportional hazards regression models adjusted for age, sex and traditional risk factors. We performed standard area under receiver operating curve (AUC) analyses from fully adjusted logistic regression models, with and without CAC. All analyses were also repeated among participants aged 45-75 years. Results: Mean age of the study population was 54.4 years, and 33% were females and 89% were Whites. Over a mean follow up of 12.3±3.9 years, there were 211 SCD events. Participants with CAC=0 had lower absolute SCD rates compared to those with CAC≥400 (0.05 vs 1.28 per 1000 person-years, respectively). Increasing CAC scores (reference CAC=0) were associated with increasing SCD risk [CAC 100-399: HR (95% CI) 2.8(1.6-5.0), CAC≥400: 4.3(2.4-7.7)]. Addition of CAC to the fully adjusted model (vs without CAC) improved AUC for SCD among the whole study population (0.88 vs 0.86, P P Conclusions: We demonstrate the predictive value of CAC for SCD. CAC could be a cost-effective risk-stratification tool that can be used to help identify individuals at high risk of SCD who could undergo additional screening and management.

Introduction: Thoracic aortic calcium(TAC) is an important marker of extra-coronary atherosclerosis with known predictive value for all-cause mortality. We sought to explore the predictive value of TAC for stroke mortality, independent of the more established coronary artery calcium score. Methods: The Coronary Artery Calcium(CAC) Consortium is a retrospectively assembled database of 66,636 patients aged ≥18 years with no prior history of cardiovascular disease, who had CAC scans done for risk stratification and were followed-up for an average of 12±4years. CAC scans capture a view of the adjacent thoracic aorta, enabling us to assess TAC at no extra cost. TAC was analyzed as present or not present and we restricted analysis to those with this information available. To account for competing risks for death from other causes, we utilized multivariable-adjusted competing risk regression models adjusted for traditional cardiovascular risk factors (age, sex, hypertension, hyperlipidemia, cigarette smoking, diabetes, family history of CHD) and CAC score. We report the relationship between TAC and stroke mortality using sub-distribution hazard ratios(SHR) with 95% CI. Results: There were 41,066 patients with information on TAC, 110 of whom had stroke mortality. The mean age of participants was 53.8±10.3 years, with 34.4% female. The unadjusted SHR for stroke mortality among those who had TAC compared to those who did not was 8.80(95%CI:5.97,12.98). After adjusting for traditional risk factors and CAC score, the SHR was 2.21(95%CI:1.39,3.49). The fully adjusted SHR for females was 3.42(95%CI:1.74,6.73) while for males it was 1.55(95%CI:0.83,2.90). Conclusion: TAC was predictive of stroke mortality independent of traditional risk factors and CAC, more so in females. The presence of TAC appears to be an independent marker of stroke mortality risk though further research is needed to study its incremental value over existing cardiovascular risk prediction models.

Introduction: The recent decline in use of cigarette products has been offset by an increase in non-cigarette tobacco products (NCP) among young individuals. In this study, we assess the prevalence and association of NCP use across the range of social determinants of health (SDOH) among a nationally representative population of young U.S. adults. Hypothesis: Lower SDOH is associated with higher likelihood of NCP use. Methods: We utilized cross-sectional data from the 2014-2017 National Health Interview Survey (NHIS). Current use of e-cigarettes, smokeless tobacco, and other NCP was self-reported. Relevant SDOH features were identified based on published literature and included 39 key items from 6 major domains. Each of these items was scored 1 if unfavorable and 0 if favorable and summed to derive a total SDOH risk score. Weighted multivariable logistic regression was used to assess the association between computed SDOH risk quartiles and NCP use. Results: The study population consisted of 53,023 participants (mean age 30 [SD 7] years, 50% men, 58% white), which translates to 113M US adults. Of them, 4.2%, 3.0% and 6.1% reported current use of e-cigarettes, smokeless tobacco and other NCP products, respectively with overall (any) NCP use at 11.6%. The respective prevalence in non-cigarette users was 2.3%, 2.4% and 4.4%. A graded increase in age-adjusted prevalence of specific and overall NCP was noted across increasing SDOH risk score quartiles ( Figure). Accounting for demographics and comorbidities, those in the highest SDOH risk score quartile vs lowest had 1.86-fold higher odds of use of e-cigarettes (1.49-2.34), smokeless tobacco (1.33 [1.05-1.68]) and overall NCP (1.44 [1.26-1.65]). Conclusions: In a nationally representative sample, 1 in 14 young adults with the most unfavorable SDOH profile reported NCP use. Evaluation of SDOH may provide opportunities for targeted public health approaches to prevent NCP use and its ensuing complications.

OBJECTIVES: This study sought to assess the value, in terms of sample size and cost, of using the coronary artery calcium (CAC) score to enrich the study population of primary prevention randomized controlled trials (RCTs) with participants at high absolute risk of atherosclerotic cardiovascular disease (ASCVD) events. BACKGROUND: The feasibility of RCTs assessing the efficacy of novel add-on therapies for primary prevention among high-risk individuals treated with statins may be limited by sample size and cost. METHODS: We evaluated 3,075 statin-naive participants from the Multi-Ethnic Study of Atherosclerosis with estimated 10-year ASCVD risk of ≥7.5%. CAC of >100, CAC of >400, high sensitivity C-reactive protein levels of >2 and >3 mg/l, ankle-brachial index of 175 mg/dl were each evaluated as enrichment criteria on top of estimated ASCVD risk of ≥7.5%, ≥10%, ≥15% and ≥20%. For each criterion, using the observed 5-year incidence of CVD, we projected the incidence of CVD assuming a 28% relative risk reduction with high-intensity statin therapy and after addition of novel therapy with additive relative risk reductions of 15% and 25%. Sample size and cost of a hypothetical primary prevention 5-year RCT of a novel therapy on top of statins versus statins alone were then computed by using the projected incidences. Yearly costs per included participant of $6,000 to $9,000 and of $500/$600 per screened nonparticipant were assumed. RESULTS: CAC of >400, present in 15% to 23% participants, consistently identified the subgroups with highest 5-year incident events and outperformed the other features yielding the smallest projected sample size, ranging 33% to 58% lower than using risk estimations alone for participant selection. CAC of >400 also yielded the lowest projected RCT costs, at least $40 million lower than using risk estimations alone. CAC of >100 showed the second-best performance in most scenarios. CONCLUSIONS: High CAC scores used as study entry criteria can improve the efficiency and feasibility of primary prevention RCTs evaluating the incremental efficacy of novel add-on therapies.

This cross-sectional study uses data from the Behavioral Risk Factor Surveillance System to assess trends in e-cigarette use in the United States.

The increasing popularity and prevalence of electronic cigarettes (e-cigarettes) use in the USA necessitates careful evaluation of their proposed benefits and potential public health harms. This report provides a detailed review of current scientific evidence on potential benefits and health risks associated with e-cigarette use. E-cigarettes were introduced as a less harmful alternative to combustible cigarette smoking. However, evidence on their use as effective and safe smoking cessation aids remains inconclusive. Their rapid uptake among tobacco-naive individuals can lead to nicotine addiction and subsequent cigarette smoking. Although e-cigarettes appear to be relatively safer than combustible cigarettes, they expose users to known harmful constituents whose long-term health risks remain unknown. While e-cigarettes have the potential to aid in cessation of cigarette smoking when used as part of a structured cessation program, use among tobacco-naive youth and long-term dual use with combustible cigarettes should be strongly discouraged due to excess risk with dual use.

Background and aimsStatins do not decrease coronary artery calcium (CAC) and may increase existing calcification or its density. Therefore, we examined the prognostic significance of CAC among statin users at the time of CAC scanning.MethodsWe included 28,025 patients (6151 statin-users) aged 40-75 years from the CAC Consortium. Cox regression models were used to assess the association of CAC with coronary heart disease (CHD) and cardiovascular disease (CVD) mortality. Models were adjusted for traditional CVD risk factors. Additionally, we examined the predictive performance of CAC components including CAC area, volume, and density using an age- and sex-adjusted Cox regression model.ResultsParticipants (mean age 53.9±10.3 years, 65.0% male) were followed for median 11.2 years. There were 395 CVD and 182 CHD deaths. One unit increase in log CAC score was associated with increased risk of CVD mortality (hazard ratio (HR), 1.2; 95% CI=1.1-1.3) and CHD mortality (HR, 1.2; 95% CI=1.1-1.4)) among statin users. There was a small but significant negative interaction between CAC score and statin use for the prediction of CHD (p-value=0.036) and CVD mortality (p-value=0.025). The volume score and CAC area were similarly associated with outcomes in statin users and non-users. Density was associated with CVD and CHD mortality in statin naïve patients, but with neither in statin users.ConclusionCAC scoring retains robust risk prediction in statin users, and the changing relationship of CAC density with outcomes may explain the slightly weaker relationship of CAC with outcomes in statin users.

Coronary artery calcium (CAC) is a highly specific marker for coronary atherosclerosis. The CAC Consortium, a multicenter, retrospective, real-world cohort study, was established to investigate the association between CAC and long-term, cause-specific mortality. This review summarizes findings from CAC Consortium studies published between 2016 and 2020, aiming to demystify CAC as a clinical decision-guiding tool and push the limits of who might benefit from CAC in clinical practice. CAC has been shown to effectively stratify cardiovascular risk across ethnicities irrespective of age, sex, and risk factor burden. In comparison to other widely used risk scores, CAC appears to be most consistent in its ability to add to cardiovascular disease (CVD) event prediction. Beyond risk stratification, CAC has been shown to identify high-risk patient subgroups. While currently recommended only for patients at borderline or intermediate risk by the American College of Cardiology/American Heart Association (10-year atherosclerotic CVD event risk, 5% to < 20%), CAC scoring may also provide value in select young patients aged 30-49 years and in low-risk patients with a family history. While new studies emphasize that patients with a CAC greater than or equal to 1000 be considered a distinct patient group, a CAC of 0 has additionally emerged to be a reliable negative risk factor, identifying patients at low risk of both CVD and non-CVD mortality. © RSNA, 2020.

Background and aimsWe 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.MethodsWe studied all participants aged 20-30yearsat 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.ResultsThe 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.ConclusionsOur 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.

Key Points Question What is the association between electronic cigarette (e-cigarette) use and depression? Findings In this cross-sectional study of 892 394 participants in the Behavioral Risk Factor Surveillance System from 2016 to 2017, e-cigarette users had higher odds of reporting a history of clinical diagnosis of depression compared with participants who never used e-cigarettes. In addition, increased frequency of e-cigarette use was associated with incrementally higher odds of reporting depression. Meaning These findings highlight the need for longitudinal studies to examine the association between e-cigarette use and depression, which may be bidirectional., This cross-sectional study examines the association between electronic cigarette (e-cigarette) use and depression in a nationally representative sample of the adult population in the United States., Importance The prevalence of the use of electronic cigarettes (e-cigarettes) in the United States has grown rapidly since their introduction to the market more than a decade ago. While several studies have demonstrated an association between combustible cigarette smoking and depression, the association between e-cigarette use and depression has not been thoroughly studied. Objective To examine the association between e-cigarette use and depression in a nationally representative sample of the adult population in the United States. Design, Setting, and Participants Cross-sectional study of the Behavioral Risk Factor Surveillance System database, 2016 to 2017. The Behavioral Risk Factor Surveillance System is the largest national telephone-based survey of randomly sampled adults in the United States. A total of 892 394 participants with information on e-cigarette use and depression were included. Data analysis was conducted in May 2019. Exposures Electronic cigarette use status defined by self-report as never, former, or current use. Main Outcomes and Measures Self-reported history of a clinical diagnosis of depression. Results Of the 892 394 participants (414 326 [29.0%] aged ≥60 years; 502 448 [51.3%] women), there were 28 736 (4.4%) current e-cigarette users, of whom 13 071 (62.1%) were aged between 18 and 39 years. Compared with never e-cigarette users, current e-cigarette users were more likely to be single, male, younger than 40 years, and current combustible cigarette smokers (single, 120 797 [24.3%] vs 10 517 [48.4%]; men, 318 970 [46.6%] vs 14 962 [60.1%]; aged 18-39 years, 129 085 [32.2%] vs 13 071 [62.1%]; current combustible cigarette use, 217 895 [7.9%] vs 8823 [51.8%]). In multivariable adjusted models, former e-cigarette users had 1.60-fold (95% CI, 1.54-1.67) higher odds of reporting a history of clinical diagnosis of depression than never users, whereas current e-cigarette users had 2.10 (95% CI, 1.98-2.23) times higher odds. Additionally, higher odds of reporting depression were observed with increased frequency of use among current e-cigarette users compared with never users (daily use: odds ratio, 2.39; 95% CI, 2.19-2.61; occasional use: odds ratio, 1.96; 95% CI, 1.82-2.10). Similar results were seen in subgroup analyses by sex, race/ethnicity, smoking status, and student status. Conclusions and Relevance This study found a significant cross-sectional association between e-cigarette use and depression, which highlights the need for prospective studies analyzing the longitudinal risk of depression with e-cigarette use. If confirmed by other study designs, the potential mental health consequences may have regulatory implications for novel tobacco products.

Background The popularity of electronic cigarettes (E-cigarettes) has risen considerably. Several studies have suggested that nicotine may affect insulin resistance, however, the impact of E-cigarette exposure on insulin resistance, an early measure of cardiometabolic risk, is not known. Methods and results Using experimental animals and human data obtained from 3,989 participants of the United States National Health and Nutrition Examination Survey (NHANES), respectively, we assessed the association between E-cigarette and conventional cigarette exposures and insulin resistance, as modelled using the homeostatic model assessment of insulin resistance (HOMA-IR) and glucose tolerance tests (GTT). C57BL6/J mice (on standard chow diet) exposed to E-cigarette aerosol or mainstream cigarette smoke (MCS) for 12 weeks showed HOMA-IR and GTT levels comparable with filtered air-exposed controls. In the NHANES cohort, there was no significant association between defined tobacco product use categories (non-users; sole E-cigarette users; cigarette smokers and dual users) and insulin resistance. Compared with non-users of e-cigarettes/conventional cigarettes, sole E-cigarette users showed no significant difference in HOMA-IR or GTT levels following adjustment for age, sex, race, physical activity, alcohol use and BMI. Conclusion E-cigarettes do not appear to be linked with insulin resistance. Our findings may inform future studies assessing potential cardiometabolic harms associated with E-cigarette use.

BackgroundThere is an urgent need for novel therapeutic strategies for reversing COVID-19-related lung inflammation. Recent evidence has demonstrated that the cholesterol-lowering agents, statins, are associated with reduced mortality in patients with various respiratory infections. We sought to investigate the relationship between statin use and COVID-19 disease severity in hospitalized patients.MethodsA retrospective analysis of COVID-19 patients admitted to the Johns Hopkins Medical Institutions between March 1, 2020 and June 30, 2020 was performed. The outcomes of interest were mortality and severe COVID-19 infection, as defined by prolonged hospital stay (≥ 7 days) and/ or invasive mechanical ventilation. Logistic regression, Cox proportional hazards regression and propensity score matching were used to obtain both univariable and multivariable associations between covariates and outcomes in addition to the average treatment effect of statin use.ResultsOf the 4,447 patients who met our inclusion criteria, 594 (13.4%) patients were exposed to statins on admission, of which 340 (57.2%) were male. The mean age was higher in statin users compared to non-users [64.9 ± 13.4 vs. 45.5 ± 16.6 years, p ConclusionStatin use was not associated with altered mortality, but with an 18% increased risk of severe COVID-19 infection.