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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.

During the first months of the coronavirus disease 2019 (COVID‐19) pandemic in early 2020, Google Trends data in the United States showed a strong increase in search query frequency for chest pain symptoms despite a concurrent decrease in search interest for myocardial infarction. This suggests a reduced attention to acute coronary syndrome (ACS) and chest pain as its main symptom during this time period. These observations could help explain why cardiovascular mortality rose dramatically despite a strong decrease in hospitalisation rates for ACS.

Objective Current evidence suggests a decrease in elective diagnostic imaging procedures during the COVID-19 pandemic with potentially severe long-term consequences. The aim of this study was to quantify recent trends in public interest and related online search behavior for a range of imaging modalities, and “nowcast” future scenarios with respect to imaging use. Methods We used Google Trends, a publicly available database to access search query data in systematic and quantitative fashion, to search for key terms related to clinical imaging. We queried the search volume for multiple imaging modalities, identified the most common terms, extracted data for the United States over the time range from August 1, 2016 to August 1, 2020. Results were given in relative terms, using the Google metric ‘search volume index’. Results We report a decrease in public interest across all imaging modalities since March 2020 with a subsequent slow increase starting in May 2020. Mean relative search volume (RSV) has changed by −19.4%, −38.3%, and −51.0% for the search terms “Computed tomography”, “Magnetic resonance imaging”, and “Mammography”, respectively, and comparing the two months prior to and following March 1, 2020. RSV has since steadily recuperated reaching all-year highs. Conclusion Decrease in public interest coupled with delays and deferrals of diagnostic imaging will likely result in a high demand for healthcare in the coming months. To respond to this challenge, measures such as risk-stratification algorithms must be developed to allocate resources and avoid the risk of overstraining the healthcare system.

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.

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.

While the prevalence of cardiovascular risk factors has decreased in the United States in recent years, cardiovascular disparities by sex and race persist. Among the factors contributing to these disparities is the physical environment in which individuals live. Neighborhood characteristics, ranging from air pollution exposure to residential segregation, have been found to be related to cardiovascular health (CVH) and stroke risk. Through the use of cross‐sectional, longitudinal, and analytic regression modeling, we are gaining clarity about the relationship between an individual's external environment and CVH. Moreover, differences in CVH vary by sex and/or race within the same neighborhood. The mechanism by which these disparities exist is still being explored. In this review, we examine the literature that has accumulated regarding how external environments and community factors affect individuals and populations by race and sex.

Dharam J. Kumbhani, MD, SM, FACC, Chair Cathleen Biga, MSN, RN, FACC Thomas J. Lewandowski, MD, FACC Thomas M. Maddox, MD, MSc, FACC James K. Min, MD, FACC Michael J. Wolk, MD, MACC Healthcare transformation is the product of a shared vision between a broad range of stakeholders to

Digital and mhealth interventions can be effective in improving health outcomes among minority patients with diabetes, congestive heart failure, and chronic respiratory diseases. A number of electronic and digital approaches to individual and population-level interventions involving telephones, internet and web-based resources, and mobile platforms have been deployed to improve chronic disease outcomes. This paper summarizes the evidence supporting the efficacy of various behavioral and digital interventions targeting intermediate outcomes and hospitalizations with particular emphasis on studies examining the effects of these interventions on racial and ethnic minority population.

Racial and ethnic disparities in cardiovascular disease (CVD) outcomes are widely reported, but research has largely focused on differences in quality of inpatient and urgent care to explain these disparate outcomes. The objective of this review is to synthesize recent evidence on racial and ethnic disparities in management of CVD in the ambulatory setting. Database searches yielded 550 articles of which 25 studies met the inclusion criteria. Reviewed studies were categorized into non-interventional studies examining the association between race and receipt of ambulatory CVD services with observational designs, and interventional studies evaluating specific clinical courses of action intended to ameliorate disparities. Based on the Donabedian framework, this review demonstrates that significant racial/ethnic disparities persist in process and outcome measures of quality of ambulatory CVD care. Multimodal interventions were most effective in reducing disparities in CVD outcomes.

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.

Hospitalizations due to ambulatory care sensitive conditions (ACSCs) result in high morbidity and economic burden on the American healthcare system. Admissions due to chronic ACSCs, in particular, cost the American healthcare system over 30 billion dollars annually.This paper presents the current research on racial and ethnic disparities in the burden of hospitalizations due to chronic ACSCs. For this narrative review, we evaluated over 800 abstracts from MEDLINE and Google Scholar and cited 62 articles.Since 1998, racial and ethnic disparities in hospitalizations from chronic ACSCs have increased resulting in over 430,000 excess hospitalizations among non-Hispanic Blacks compared to non-Hispanic Whites.Racial disparities in chronic ACSCs hospitalizations are pervasive in the USA. There is need for more research on the pathways through which an individual's race modifies the risk for hospitalizations due to chronic ACSCs.

Background Patients with diabetes mellitus (DM) experience higher rates of in-stent restenosis and greater benefit from drug-eluting stents implant at the time of percutaneous coronary intervention (PCI), necessitating prolonged dual anti-platelet therapy (DAPT). While DAPT reduces risk of ischemic events post-PCI, it also increases risk of bleeding. Whether bleeding rates differ among patients with and without DM, receiving long-term DAPT is unknown. Methods Among patients who underwent PCI and were maintained on DAPT for 1 year in a multicenter US registry, we assessed patient-reported bleeding over one year following PCI in patients with and without DM. Multivariable, hierarchical Poisson regression was used to evaluate the association of DM with bleeding during follow-up. Results Among 2334 PCI patients from 10 US hospitals (mean age 64, 54% ACS), 32.6% had DM. In unadjusted analyses, patients with DM had fewer bleeding events over the year following PCI (DM vs no DM: BARC=1: 78.0% vs 87.7%, P P = .33). Following adjustment, patients with (vs without DM) had a lower risk of BARC ≥1 bleeding during follow-up (relative risk [RR] 0.89, 95% CI 0.83–0.96). This decreased bleeding risk persisted after removing bruising from the endpoint definition. Conclusions In a real-world PCI registry, patients with DM experienced lower risk of bleeding risk on DAPT. As patients with DM also derive greater ischemic benefit from drug-eluting stents, which requires prolonged DAPT, our findings suggest that the balance between benefit and risk of this therapeutic approach may be even more favorable in patients with DM than previously considered.

Background and aims Left main (LM) coronary artery disease is associated with greater myocardial infarction-related mortality, however, coronary artery calcium (CAC) scoring does not account for disease location. We explored whether LM CAC predicts excess mortality in asymptomatic adults. Methods Cause-specific cardiovascular and all-cause mortality was studied in 28,147 asymptomatic patients with non-zero CAC scores in the CAC Consortium. Multivariate regression was performed to evaluate if the presence and burden of LM CAC predict mortality after adjustment for clinical risk factors and the Agatston CAC score. We further analyzed the per-unit hazard associated with LM CAC in comparison to CAC in other arteries. Results The study population had mean age of 58.3 ± 10 years and CAC score of 301 ± 631. LM CAC was present in 21.7% of the cases. During 312,398 patient-years of follow-up, 1,907 deaths were observed. LM CAC was associated with an increased burden of clinical risk factors and total CAC, and was independently predictive of increased hazard for all-cause (HR 1.2 [1.1, 1.3]) and cardiovascular disease death (HR 1.3 [1.1, 1.5]). The hazard for death increased proportionate to the percentage of CAC localized to the LM. On a per-100 Agatston unit basis, LM CAC was associated with a 6–9% incremental hazard for death beyond knowledge of CAC in other arteries. Conclusions The presence and high burden of left main CAC are independently associated with a 20–30% greater hazard for cardiovascular and total mortality in asymptomatic adults, arguing that LM CAC should be routinely noted in CAC score reports when present.

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 aged50 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.

Key Points Question Does race serve as a surrogate for socioeconomic and clinical factors, and, after adjusting for those factors, do long-term mortality rates differ between black patients and white patients following acute myocardial infarction? Findings In this cohort study of 6402 patients from 2 acute myocardial infarction registries, self-identified black patients and white patients differed in several clinical and socioeconomic characteristics. The higher the prevalence of characteristics associated with being a black patient, the higher the 5-year mortality rate, but no differences were observed between black patients and white patients with similar characteristics. Meaning A greater prevalence of characteristics associated with black race, but not race itself, was associated with higher mortality risk after acute myocardial infarction., Importance Black patients experience worse outcomes than white patients following acute myocardial infarction (AMI). Objective To examine the degree to which nonrace characteristics explain observed survival differences between white patients and black patients following AMI. Design, Setting, and Participants This cohort study used the extensive socioeconomic and clinical characteristics from patients recovering from an AMI that were prospectively collected at 31 hospitals across the contiguous United States between 2003 and 2008 for the Prospective Registry Evaluating Myocardial Infarction: Events and Recovery registry and the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients’ Health Status registry. Survival was assessed using data from the National Death Index. Data were analyzed from December 2016 to July 2018. Main Outcomes and Measures Patient characteristics were categorized into 8 domains, and the degree to which each domain discriminated self-identified black patients from white patients was determined by calculating propensity scores associated with black race for each domain as well as cumulatively across all domains. The final propensity score was associated with 1- and 5-year mortality rates. Results Among 6402 patients (mean [SD] age, 60 [13] years; 2127 [33.2%] female; 1648 [25.7%] black individuals), the 5-year mortality rate following AMI was 28.9% (476 of 1648) for black patients and 18.0% (856 of 4754) for white patients (hazard ratio, 1.72; 95% CI, 1.54-1.92; P, This cohort study uses data from 2 US myocardial infarction registries to assess whether demographic or clinical characteristics differ between self-identified black patients and white patients or are associated with 1- or 5-year survival after acute myocardial infarction.

BACKGROUND: The Society of Cardiovascular Computed Tomography (SCCT) recommends consideration of coronary artery calcium (CAC) scoring among individuals with a family history (FH) of coronary heart disease (CHD) and atherosclerotic cardiovascular disease (ASCVD) risk 100 had a 2.2 (95% CI 1.5–3.3) higher risk of all-cause mortality, 4.3 (95% CI 1.9–9.5) times higher risk of CVD-specific mortality, and a 10.4 (95% CI 3.2–33.7) times higher risk of CHD-specific mortality compared to individuals with CAC=0. The NNS to detect CAC >100 in this sample was 9. CONCLUSION: In otherwise low risk patients with FH of CHD, CAC>100 were associated with increased risk of all-cause and CHD mortality with event rates in a range that may benefit with preventive pharmacotherapy. These data strongly support new SCCT recommendations regarding testing of patients with a family history of CHD.

BackgroundEvidence 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. ObjectiveThis 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. MethodsWe 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. ResultsA 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=−6.95×10−3 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

Improving symptoms, functions, and quality-of-life (ie, health status) is one of the important goals in treatment of patients with peripheral artery disease (PAD).1 However, it is unknown whether health status responses differ by race (black versus white) with alternative PAD treatment modalities. Such differences may exist given the disproportionate burden of PAD in minority populations, and rapid disease progression as compared with white,2 as well as differences in psychosocial and economic factors and possibly differences in exercise level, which is known to improve outcomes in patients with PAD.3,4 Understanding whether black and white respond differently to treatments can help us better support targeted therapy to improve quality of care. This is relevant because until now, supervised exercise (SE) programs for PAD were not available in the United States, and recently, the Centers for Medicare and Medicaid Services agreed to reimburse for SE therapy.5 If there is heterogeneity in response to SE, knowing this difference is important to provide patient-centered care and to get maximum treatment benefit for each unique patient population. The CLEVER trial (Claudication: Exercise Versus Endoluminal Revascularization) randomized patients with claudication from aortoiliac disease to SE, stent therapy (ST), or optimal medical care (OMC). Short-term results indicated superior treadmill walking performance (ie, peak walking time and claudication onset time) with SE than either ST or OMC. Conversely, benefit in PAD-specific health status (Peripheral Artery Questionnaire [PAQ] summary score)6 was more favorable for ST than either SE or OMC.3 Similarly, general quality-of-life benefit as assessed with Short Form-12 Physical Component Summary (SF-12 PCS)7 was similar for ST and SE when compared with OMC.3 Long-term results, however, showed similar and sustained benefits for both ST and SE over OMC in treadmill walking performance, but PAQ summary score was more favorable …

In the United States, different races, ethnicities, and their subgroups experience disparities regarding acute coronary syndrome (ACS) and myocardial infarction (MI). This review highlights these differences across 4 stages that comprise the ACS/MI narrative: (1) patient demographics, (2) patient comorbidities and health risks, (3) treatments and their delays, and (4) outcomes. Overall, black and Hispanic ACS/MI patients are more likely to present with comorbidities, experience longer delays before treatment, and suffer worse outcomes when compared with non-Hispanic white patients. More specifically, across the studies analyzed, black and Hispanic ACS/MI patients were consistently more likely to be younger or female, or to have hypertension or diabetes, than non-Hispanic white patients. ACS/MI disparities also exist among Asian populations, and these are briefly outlined. However, black, Hispanic, and non-Hispanic white ACS/MI patients were the 3 most-studied racial and ethnic groups, indicating that additional studies of other minority groups, such as Native Americans, Asian populations, and black and Hispanic subgroups, are needed for their utility in reducing disparities. Despite notable improvement in ACS/MI treatment quality measures over recent decades, disparities persist. Causes are complex and extend beyond the healthcare system to culture and patients' personal characteristics; sophisticated solutions will be required. Continued research has the potential to further reduce or eliminate disparities in the comorbidities, delays, and treatments surrounding ACS and MI, extending healthy lifespans of many underserved and minority populations, while reducing healthcare costs.

This is a comprehensive narrative review of the literature on the current science and evidence of population-level differences in risk factors for heart disease among different racial and ethnic population in the United States (U.S.). It begins by discussing the importance of population-level risk assessment of heart disease in light of the growth rate of specific minority populations in the U.S. It describes the population-level dynamics for racial and ethnic minorities: a higher overall prevalence of risk factors for coronary artery disease that are unrecognized and therefore not treated, which increases their likelihood of experiencing adverse outcome and, therefore, potentially higher morbidity and mortality. It discusses the rate of Acute Coronary Syndrome (ACS) in minority communities. Minority patients with ACS are at greater risk of myocardial infarction (MI), rehospitalization, and death from ACS. They also are less likely than non-minority patients to receive potentially beneficial treatments such as angiography or percutaneous coronary intervention. This paper looks at the data surrounding the increased rate of heart disease in racial and ethnic minorities, where the risk is related to the prevalence of comorbidities with hypertension or diabetes mellitus, which, in combination with environmental factors, may largely explain CHF disparity. The conclusion is that it is essential that healthcare providers understand these various communities, including nuances in disease presentation, risk factors, and treatment among different racial and ethnic groups. Awareness of these communities' attributes, as well as differences in incidence, risk factor burdens, prognosis and treatment are necessary to mitigate racial and ethnic disparities in heart disease.

Previous studies have found marked differences in survival after in-hospital cardiac arrest by race. Whether racial differences in survival have narrowed as overall survival has improved remains unknown.To examine whether racial differences in survival after in-hospital cardiac arrest have narrowed over time and if such differences could be explained by acute resuscitation survival, postresuscitation survival, and/or greater temporal improvement in survival at hospitals with higher proportions of black patients.In this cohort study from Get With the Guidelines-Resuscitation, performed from January 1, 2000, through December 31, 2014, a total of 112 139 patients with in-hospital cardiac arrest who were hospitalized in intensive care units or general inpatient units were studied. Data analysis was performed from April 7, 2015, to May 24, 2017.Race (black or white).The primary outcome was survival to discharge. Secondary outcomes were acute resuscitation survival and postresuscitation survival. Multivariable hierarchical (2-level) regression models were used to calculate calendar-year rates of survival for black and white patients after adjusting for baseline characteristics.Among 112 139 patients with in-hospital cardiac arrest, 30 241 (27.0%) were black (mean [SD] age, 61.6 [16.4] years) and 81 898 (73.0%) were white (mean [SD] age, 67.5 [15.2] years). Risk-adjusted survival improved over time in black (11.3% in 2000 and 21.4% in 2014) and white patients (15.8% in 2000 and 23.2% in 2014; P for trend.001 for both), with greater survival improvement among black patients on an absolute (P for trend = .02) and relative scale (P for interaction = .01). A reduction in survival differences between black and white patients was attributable to elimination of racial differences in acute resuscitation survival (black individuals: 44.7% in 2000 and 64.1% in 2014; white individuals: 47.1% in 2000 and 64.0% in 2014; P for interaction.001). Compared with hospitals with fewer black patients, hospitals with a higher proportion of black patients with in-hospital cardiac arrest achieved larger survival gains over time.A substantial reduction in racial differences in survival after in-hospital cardiac arrest has occurred that has been largely mediated by elimination of racial differences in acute resuscitation survival and greater survival improvement at hospitals with a higher proportion of black patients. Further understanding of the mechanisms of this improvement could provide novel insights for the elimination of racial differences in survival for other conditions.

Despite nearly 30 years of treatment guidelines for cardiovascular diseases and risk factors and a parallel growth in the understanding of cardiovascular disease disparities by sex and race/ethnicity, such disparities persist. The goals of this review are to consider the possible role of three factors: the one-size-fits-all approach of most treatment guidelines, adoption of guideline-recommended treatments in clinical practice, and patient adherence to recommended practice, especially the relationship between adherence and patient perceptions. Guideline authors repeatedly call for more inclusion of women and minorities in the clinical trials that make guidelines possible, but despite challenges, guidelines are largely effective when implemented, as shown by a wealth of post hoc analyses. However, the data also suggest that one-size-fits-all treatment guidelines are not sufficiently generalizable and there is evidence of a distinct lag time between definitive clinical evidence and its widespread implementation. Patient perspectives may also play both a direct and indirect role in adherence to treatments. What emerges from the literature is an important continuing need for increased inclusion of women and minority subgroups in clinical trials to allow analyses that can provide evidence for differential treatments when needed. Increased effort is needed to implement definitive clinical improvements more rapidly. Patient input and feedback may also help inform clinical practice and clinical research with a better understanding of how to enhance patient adherence, but evidence for this is lacking for the groups most affected by disparities.

Background: The purpose of this study was to evaluate diabetes control, as measured by hemoglobin A1c (HbA1c) improvements among African American and Hispanic patients receiving conventional clinical treatment combined with a bilingual diabetes educator using culturally and linguistically appropriate educational materials. This study also sought to estimate the healthcare cost savings resulting from any A1c improvements and assess the cost-effectiveness of this approach. Materials and Methods: This was a multistage, face-to-face observational study undertaken in Texas, United States and focused on 153 African American and Hispanic patients with poor blood glucose control (baseline A1c >8.0%). For two years, a bilingual care coordinator motivated patient behavior changes that could lead to improvements in glucose control. The primary evaluation measure was change in %HbA1c, with secondary measures being change in blood pressure (BP) and low-density lipoprotein (LDL). We also sought to gauge the program's potential cost-effectiveness. Results: Within the study group, A1c levels decreased over the study period from a mean of 10.0% to 8.4%. The same group saw no statistically significant improvement (reduction) in blood concentrations of LDL. The African American subgroup had a small reduction in systolic BP while changes for non-White Hispanics were not statistically significant. The average A1c reduction realized in this observational study provided estimated cost savings that are nearly twice pilot expenditures. Conclusions: Combining standard diabetes care with a bilingual educational care coordinator results in significant reductions in mean A1c (−1.6% HbA1c) in patients with poorly controlled blood glucose and African American/non-White Hispanic heritage, an intervention that also was shown to be cost-effective. This may be an effective model for improving diabetes care in provider practices.

Background: The CLEVER trial (Claudication: Exercise versus Endoluminal Revascularization) showed significant improvement in peripheral artery disease (PAD)-specific health status (Peripheral Artery Questionnaire, PAQ) at 6 and 18 months for both supervised exercise (SE) and stent therapy (ST) compared with optimal medical care (OMC) in PAD patients. However, it is unknown whether there is variation in treatment by age, gender or race, or if recovery is similar across these groups over time. Methods: A total of 111 patients from 22 sites with hemodynamically significant aortoiliac arterial stenosis were randomized to SE, ST, or OMC. Using maximum likelihood methods for longitudinal analyses, we analyzed change from baseline in PAQ summary scores at 6 and 18 months and tested interactions between demographic factors (≥65 vs. Results: The mean age of the study population was 64.4 years (53.1% Conclusion: There was a significant interaction between treatment and race, with only ST showing significant improvement in PAQ scores in Caucasians, whereas both ST and SE showed significant improvements in PAQ among non-Caucasians. Further studies should validate and explore the mechanisms of different racial responses to PAD treatment.

Background: Despite the higher prevalence and excess morbidity associated with peripheral arterial disease (PAD) in blacks, as compared with whites, little is known about racial differences in clinical characteristics, treatment referral and health status outcomes (symptoms, functioning, quality of life) at the time of PAD presentation. Methods: We used data from the Patient-centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease Investigating Trajectories (PORTRAIT) registry, a multicenter, international prospective study of patients with new or worsening PAD symptoms consulting specialty care (2011-2015). Clinical and treatment characteristics were abstracted from medical records and health status was collected via patient interviews at presentation using the Peripheral Artery Questionnaire (PAQ). We calculated summary statistics using t-test/chi-square analyses and examined mean differences in the PAQ summary score at baseline between blacks and whites. Results: The final cohort consisted of 760 patients (N=183 blacks; 24%). Compared with whites, blacks were younger (66±9.8 vs 70±9.2; P=< 0.001), more likely to be female (58% vs. 37%, P= Conclusion: Despite excess prevalence of adverse risk factors including diabetes, hypertension, and smoking, black patients presenting with PAD have similar health status outcomes and invasive treatment strategies when compared with whites. Follow-up studies are needed to determine if these observations persist after adjustment for covariates and if there are differences in health status recovery over time.

This essay provides a country case for the interplay in an e-development strategy between top–down policy directions and grassroots, community-level initiatives, and how this interplay and balance can evolve over time, reflecting the nature of a networked economy. The authors suggest that an Internet culture and the building of community-level capacity for e-development can compensate for limited e-leadership at the national level, particularly for countries like Canada, where significant levels of connectivity and e-literacy have been achieved. The coverage of Canadian e-development initiatives in this essay is selective. The aim is to illuminate the political economy and policy reform process, shaping e-development. This country case shows the influence of the political and cultural factors, and the Internet, in particular, on the role of ICT in transforming existing structures and creating collaborative ecologies and innovative commons.

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.

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.

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

The majority of adults do not meet current guideline recommendations for moderate to vigorous physical activity. Recent research has linked a high amount of sedentary behavior with an increased risk of obesity, diabetes, the metabolic syndrome, cardiovascular disease, and death. This correlation with sedentary behavior even extends to individuals who meet recommended physical activity goals during the remainder of their day, which implies that sedentary behavior may represent a distinct cardiovascular risk factor that is independent of the overall amount of physical activity. During the past several years, there has been significant interest in identifying and understanding the mechanisms through which sedentary behavior affects cardiovascular health. In this review, we critically evaluate the literature pertaining to sedentary behavior and cardiovascular risk with an emphasis on studies published over the past year, and we suggest possible interventions that may help reduce sedentary behavior time.

In the United States, different races, ethnicities, and their subgroups experience disparities regarding acute coronary syndrome (ACS) and myocardial infarction (MI). This review highlights these differences across 4 stages that comprise the ACS/MI narrative: (1) patient demographics, (2) patient comorbidities and health risks, (3) treatments and their delays, and (4) outcomes. Overall, black and Hispanic ACS/MI patients are more likely to present with comorbidities, experience longer delays before treatment, and suffer worse outcomes when compared with non‐Hispanic white patients. More specifically, across the studies analyzed, black and Hispanic ACS/MI patients were consistently more likely to be younger or female, or to have hypertension or diabetes, than non‐Hispanic white patients. ACS/MI disparities also exist among Asian populations, and these are briefly outlined. However, black, Hispanic, and non‐Hispanic white ACS/MI patients were the 3 most‐studied racial and ethnic groups, indicating that additional studies of other minority groups, such as Native Americans, Asian populations, and black and Hispanic subgroups, are needed for their utility in reducing disparities. Despite notable improvement in ACS/MI treatment quality measures over recent decades, disparities persist. Causes are complex and extend beyond the healthcare system to culture and patients' personal characteristics; sophisticated solutions will be required. Continued research has the potential to further reduce or eliminate disparities in the comorbidities, delays, and treatments surrounding ACS and MI, extending healthy lifespans of many underserved and minority populations, while reducing healthcare costs.

The practice of medicine is transforming substantially and a pivotal driver of this change has been the accelerating pace of technology innovation. Traditional healthcare innovation has focused on the development of new diagnostics, drugs, and devices for use in hospitals and clinics, with more

Aims Angina relief is a major goal of percutaneous coronary intervention (PCI); however, ∼1 in 5 patients continue to have angina after PCI. Understanding patient factors associated with residual angina would enable providers to more accurately calibrate patients'; expectations of angina relief after PCI, may support different follow-up strategies or approaches to coronary revascularisation, and could potentially serve as a marker of PCI quality. Methods and Results Among 2573 patients who had PCI at 10 US hospitals for stable angina, unstable angina or non-ST-elevation myocardial infarctions (NSTEMI), 24% reported angina 6-months after PCI, as assessed with the Seattle Angina Questionnaire Angina Frequency score (categorised as none vs. any angina; score=100 vs.

Health equity has long been the dominant theme in the work of the Aetna Foundation. Recent data have focused on disparities through another lens, particularly the correlation between where people live (i.e., ZIP code) and their quality-and length-of life. In various cities across America, average life expectancies in certain communities are 20-30 years shorter than those mere miles away. In general, health disparities are founded on a complex interplay of racial, economic, educational, and other social factors. For example, breastfeeding rates in the United States differ significantly depending upon the race and income of the mother. Government policy makers are acutely aware of these disparities, but recent health system reforms have focused predominately on the processes used to administer, finance, and deliver care. What is needed is an approach that considers the health and wellness of all people in a geographic area, beyond established patients, and that measures more than clinical factors-such as genetics, environmental health, social circumstances, and individual behaviors. Solutions also must extend beyond the traditional healthcare arena. In particular, novel technological innovations show promise to bridge gaps between our healthcare capabilities and the needs of underserved populations. Digital tools are poised to revolutionize measurement, diagnostics, treatment, and global aspect of our healthcare system. The Aetna Foundation views technology as a core strategy in reducing health inequities through an approach that addresses both clinical and social factors in populations to dismantle the persistent paradigm of ZIP code as personal health destiny.

Evidence that physical activity can curb smoking urges is limited in scope to acute effects and reliant on retrospective self-reported measures. To explore this in a real-world longitudinal setting, we leveraged mobile health tools to assess the real-time association between objectively measured

The authors reflect on population health and technology. They suggest that a rising interest in the use of technology in health offers a great opportunity for finding innovative ways to improve public health. They argue that focusing on people and engaging the public are both critical to achieving a strategy for using technology to improve public health.