Journal of the American Heart Association

BackgroundPremature coronary artery disease (PCAD) continues to impose a disproportionate burden on younger adults in the United States, yet recent patterns across sex, region, race, and urbanization remain poorly defined. MethodsUsing CDC WONDER data from 1999-2023, we examined PCAD-related age-adjusted mortality rates (AAMR) for males <45 years and females <55 years, stratified by region, race/ethnicity, and urbanization. Temporal trends were assessed using Joinpoint regression to estimate annual percent change (APC) and average annual percent change (AAPC). ResultsThe combined AAMR for PCAD in the U.S. is approximately 8.5 deaths per 100,000 population. Both sexes demonstrated overall declines in PCAD mortality since 1999 (AAPC males -0.84%; females -1.07%), interrupted by a transient rise during 2018-2021 (APC = 7.85%; 95% CI 5.41-9.32), followed by a sharp post-pandemic decline (APC = -7.39%; 95% CI -10.64 to -4.53). Females consistently exhibited higher mean AAMRs than males (8.74 vs. 8.34; p<0.00001). Regional analyses showed that mortality rates were highest in the South (males 9.86; females 10.96) and Midwest (8.97; 9.36), with intermediate rates in the Northeast (males 7.09, females 6.77), and the lowest rates in the West (6.35; 6.16). Non-metropolitan residents carried a 1.5-1.7-fold greater mortality burden than metropolitan populations (males 12.20 vs. 7.74; females 13.31 vs. 8.06). Black/African Americans had the highest rates (males: 12.17, females: 15.98), followed by American Indian/Alaska Natives (8.49, 9.02) and Whites (8.0, 8.0), while Asian/Pacific Islanders had the lowest (about 2.4-4.3). ConclusionsNational PCAD mortality has decreased, but disparities persist and are growing by region, race, sex, and urbanization. Concentration in the Southern and Midwestern states and among certain races highlights the need for further research using modern molecular methods and improved health care resources. Graphical Abstract O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=200 SRC="FIGDIR/small/25342435v1_ufig1.gif" ALT="Figure 1"> View larger version (45K): org.highwire.dtl.DTLVardef@5fa12dorg.highwire.dtl.DTLVardef@4eb887org.highwire.dtl.DTLVardef@34b48forg.highwire.dtl.DTLVardef@3a2be1_HPS_FORMAT_FIGEXP M_FIG C_FIG Clinical PerspectiveO_ST_ABSWhat is New?C_ST_ABSO_LIThe combined AAMR for PCAD in the U.S. is approximately 8.5 deaths per 100,000 population. C_LIO_LIPremature coronary artery disease-related mortality rates are higher in the Southern and Midwestern states, among non-Hispanic Black, Native American, and non-metro populations. C_LI What are the Clinical Implications?O_LIThe geographic and demographic clustering of cases strongly suggest contributions from underlying genetic, environmental, and dietary factors that warrant further investigation. C_LIO_LIEarly identification of at-risk individuals through precision-medicine approaches and the implementation of targeted, evidence-based preventive strategies could mitigate these regional and racial disparities. C_LI

Background: Cardiovascular disease remains the leading cause of death in the United States, and marked geographic disparities in cardiovascular mortality persist. However, the community-level socioeconomic indicators most strongly associated with these disparities remain unclear. Community-level measures capture the social and economic conditions that influence cardiovascular health across populations and may help identify communities at greatest risk. We used the Area Health Resources File (AHRF) to identify socioeconomic measures most strongly associated with county-level cardiovascular mortality. Methods: We performed a national cross-sectional ecological analysis using the 2024-2025 Area Health Resources File (AHRF), including counties in the 50 U.S. states and the District of Columbia. The primary outcome was an AHRF-defined cardiovascular mortality composite derived from 2021-2023 National Center for Health Statistics (NCHS) mortality data. Community-level socioeconomic measures included 2023 overall, pediatric, and family childhood poverty and 2019-2023 overall, female, and White unemployment. County-level associations were evaluated using Spearman rank correlation and regional differences using the Kruskal-Wallis test. Sensitivity analyses used a partial mortality composite and Kendall {tau} correlation. Results: Among 1,982 counties, cardiovascular mortality varied significantly across U.S. Census divisions (P<0.001), with the highest population-weighted rate in the East South Central division (348.5 deaths/100,000) and the lowest in the Mountain division (233.9 deaths/100,000). Pediatric poverty demonstrated the strongest association with cardiovascular mortality ({rho}=0.612), followed by family childhood poverty ({rho}=0.603) and overall poverty ({rho}=0.524, all P<0.001). In contrast, unemployment measures were more weakly associated (overall {rho}=0.209, White {rho}=0.176, female {rho}=0.141, all P<0.001). Results were consistent in sensitivity analyses. Conclusions: County-level poverty, particularly pediatric poverty, was more strongly associated with cardiovascular mortality than unemployment across U.S. counties. These findings suggest pediatric poverty may serve as a useful community-level indicator for identifying populations at increased cardiovascular risk and prioritizing future public health interventions.

Pregnancy-related stroke is a previously overlooked risk factor. Addressing this issue is of crucial importance, not just because pregnancy-related disorder affects women of reproductive age, but also because it is often preventable. However, it is difficult to determine whether these disorders in the brief nine months of pregnancy may lead to later stroke risk, because of the difficulties in the systematic collection of long-time follow-up data and the control for confounding factors and potential bias. To address this issue, this study sought to conduct a Mendelian randomization (MR) study and discovered preeclampsia, HELLP syndrome, gestational hypertension and diabetes as major pregnancy-related disorders that pose increased risks of stroke. This study is meant to provide a comprehensive landscape of stroke risks across different pregnancy complications, most of which are preventable and treatable, thus generating many testable candidates of strong associations. From this perspective, these associations may serve as a pragmatic road map for researchers who aim to investigate pregnancy-related stroke, for clinicians who wish to improve maternal care to prevent stroke, and for patients who need to take appropriate precautionary measures or behavior modifications to reduce stroke risk.

BackgroundFew studies have evaluated the prevalence or severity of mitral valve prolapse (MVP) and other valvular heart disease (VHD) in the rural US South, where strategies for early detection are crucial for risk stratification and prevention. ObjectivesWe assessed the prevalence of MVP and other VHD in a rural US South cohort and examined associations with cardiovascular disease (CVD) risk. We also evaluated relationships between MVP severity, high-sensitivity cardiac troponin T (hsTnT), and N-terminal pro-B-type natriuretic peptide (NTproBNP). MethodsWe conducted a cross-sectional analysis from the Risk Underlying Rural Areas Longitudinal (RURAL) study. Logistic regression assessed associations between participant characteristics and MVP, other VHD, or both. Weighted models assessed odds for MVP and other VHD by 10-year CVD risk categories using the Predicting Risk of CVD Events (PREVENT) score. Among a subset, we evaluated associations between MVP severity and cardiac biomarkers. ResultsAmong 2,621 participants (68.7% women), MVP and other VHD were present in 1.9% and 11.2%, respectively. Compared to the low PREVENT risk group, odds of MVP were lower and odds of VHD were higher among borderline and intermediate/high groups. HsTnT was lower in MVP vs. non-MVP (0.64, 95% CI 0.58-0.71), without difference by severity of MVP. NTproBNP was higher in participants with severe MVP than non-MVP (2.05, 95% CI 1.49-2.83). ConclusionsMVP prevalence aligned with population-based epidemiologic studies. PREVENT risk category may differentiate individuals at higher risk for MVP and for other VHD. Future studies are needed to evaluate relationships between MVP/VHD status and clinical events.

BackgroundRecent studies in selected populations suggest that impaired venous return may affect brain health. We examined associations of right heart structure and function with cognition and MRI markers of brain health in a community-based cohort. MethodsThe Multi-Ethnic Study of Atherosclerosis (MESA) is a longitudinal cohort study of individuals 45 to 84 years of age who were free of clinically apparent cerebrovascular or cardiovascular disease at baseline in 2000-2002. From echocardiograms performed at Exam 6 during 2016-2018, we measured: right atrial pressure and end-systolic area; pulmonary artery systolic pressure; and right ventricular free wall strain, fractional area change, and end-diastolic area. Outcome variables were the Cognitive Assessment Screening Instrument, Digit Span, and Digit Symbol Coding tests and MRI-determined volumes of total white matter, total gray matter, and white matter hyperintensity -- as well as fractional anisotropy. Cognitive measures were obtained at Exam 6, and MRI measures, within a median of 18 months of echocardiograms. Covariates were demographics, APOE-{varepsilon}4 allele status, vascular risk factors, and echocardiographic markers of left heart function. We used general linear models to examine associations between each exposure and outcome variable. ResultsIn 1,913 participants with cognitive testing and echocardiography data, we found no associations between any of the echocardiographic exposure variables and worse scores on any of the cognitive tests. Similarly, in 1,035 participants with echocardiography and MRI data, we found no associations between any of the echocardiographic exposure variables and any of the MRI variables. DiscussionWe found no associations in this cohort of right heart structure and function with cognition or brain MRI measures. These findings do not support the hypothesis that right heart dysfunction impedes venous return sufficiently to adversely affect brain health among people without clinically apparent heart failure.

Background: The manifestations of cardiovascular disease (CVD) among people with HIV (PWH) differ by region globally. While HIV disease is associated with increased atherosclerotic CVD risk in the global North, non-ischemic heart failure (HF) is more common in sub-Saharan Africa, the global HIV epicenter. We estimated the effect of treated HIV on the frequency and phenotype of HF and its cardiac precursors in South Africa (SA). Methods: In an observational study, we recruited PWH on antiretroviral therapy (ART), age [&ge;]40 years and people without HIV (PWoH) with similar distributions of age, sex, ethnicity, and hypertension, from a community clinic in Khayelitsha (Cape Town, SA). Procedures included a clinical assessment, echocardiography (Echo), and b-type natriuretic peptide (BNP) measure. Echo parameters defined structural abnormalities, left ventricle (LV) filling pressure, and LV systolic and diastolic dysfunction (DD). HF was defined by symptoms and/or BNP [&ge;]35pg/mL and LV dysfunction, subcategorized as reduced, mildly reduced, or preserved ejection fraction (HFrEF, HFmrEF, and HFpEF). Comparisons by HIV status were adjusted for age, sex, hypertension, smoking, obesity, diabetes, elevated LDL-cholesterol, and hazardous alcohol use. Results: Between September 2022 and August 2025, we enrolled 1008 PWH and 500 controls [median (Q1-Q3) age 48 years (43-53), 77% female]. Among PWH and controls respectively, 37% and 39% had hypertension, 21% and 25% were current smokers, 40% and 45% were obese, and 9% and 17% had diabetes. LV systolic dysfunction (1%) and HFrEF (1%) were rare, and undiagnosed HFpEF (8%) was the predominant HF phenotype. Compared to controls, PWH had higher odds of elevated LV mass index (LVMI) (OR 2.1; 95%CI 1.5-3.0) and DD (OR 1.4; 95%CI 1.0-2.0). Risk for elevated LVMI and DD was greatest among women with HIV, who also had an increased risk for undiagnosed HFpEF (OR 1.9; 95%CI 1.2-3.2), compared to women without HIV; effects which were not seen among men (p=0.051 for HIV*Sex interaction). Conclusions: In a peri-urban SA community with a high burden of cardiometabolic risk factors, the frequency of abnormal structural and functional cardiac precursors of HFpEF was greater amongst ART-treated PWH. This was most pronounced amongst women with HIV, who also had increased risk of undiagnosed HFpEF.

BackgroundExtracellular volume (ECV) and native T1 time (nT1) are markers of interstitial-myocardial-fibrosis (IMF) by cardiac MRI (CMR) and are associated with CV events, heart failure and death. However, the association between smoking and IMF at the population level has not been explored. ObjectivesThis study investigated the relationship between smoking and IMF by CMR, as well as the sex differences of this association in the MESA cohort. MethodsA total of 2118 participants (53% women) had data on smoking between 2000 and 2012 and ECV(%) and nT1 (ms) at exam-5 (2010-2012). We constructed participant-specific trajectories of average cigarettes per day (ACPD) based on linear interpolation to estimate ACPD between exams 1 through 5 (ACPD1-5). We explored the associations of smoking status at Exam-5, ACPD at Exam-5, ACPD1-5 and temporal change in smoking status, with ECV and nT1 using multivariable analysis. ResultsCurrent smoking status was associated with increased markers of IMF in women but not in men, ECV% ({square} =2% p=<0.001 vs. 0.5%; p=0.2) and nT1 ({square} =28ms; p=<0.001 vs. 3ms; p=0.5) in women vs. men, respectively. A higher ACPD1-5 was associated with increased ECV% ({square} =0.1%; p<0.001) and nT1 ({square} =1ms; p=0.003) in women but not in men. Similarly, higher ACPD at Exam-5 was associated with higher ECV% in women vs. men. Sex interaction ascertained prior to stratification was statistically significant. ConclusionIn this population study, cigarette smoking was associated with a higher prevalence of IMF in females but not in males, indicating differences in the pathophysiology of CVD by sex.

BackgroundHeart failure (HF) is associated with frequent hospitalization and worse prognosis. Prognosis factors and survival in very long-term follow-up have not been reported in HF. HF disease management programs(DMP) results are contradictory. DMP efficacy in very long-term follow-up is unknown. We studied the very long-term follow-up of up to 23.6 years and prognostic factors of HF in 412 patients under GDMT included in the REMADHE trial. MethodsThe REMADHE trial was a prospective, single-center, randomized trial comparing DMP versus usual care(C). The first patient was randomized on October 5, 1999. The primary outcome of this extended REMADHE was all-cause mortality. ResultsThe all-cause mortality rate was 88.3%. HF was the first cause of death followed by death at home. Mortality was higher in the first 6-year follow-up. The predictive variables in multivariate analysis associated with mortality were age [&ge;]52 years (P=0.015), Chagas etiology (P=0.010), LVEF <45% (P=0.008), use of digoxin (P=0.002), functional class IV (P=0.01), increase in urea (P=0.03), and reduction of lymphocytes (P=0.005). In very long-term follow-up, DMP did not affect mortality in patients under GDMT. HF as a cause of death was more frequent in the C group. Chagas disease, LVEF <45%, and renal function were associated with different modes of death. ConclusionDMP was not effective in reducing very-long term mortality; however, the causes of death had changed. Our findings that age, LVEF, Chagas disease, functional class, renal function, lymphocytes, and digoxin use were associated with poor prognosis could influence future strategies to improve HF management.

IntroductionBlack Americans have greater coronary heart disease (CHD) burden than White Americans, disparities that are largely socially determined. Discriminatory societal practices that systematically disadvantage Black Americans are forms of structural racism but few studies have examined structural racism and incident CHD. We sought to determine associations between three validated measures of structural racism and incident CHD, hypothesizing that greater state-level structural racism is associated with incident CHD for Black but not White individuals. MethodsWe used data from the national REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort, which enrolled 30,239 Black and White community dwelling adults between 2003-7 who were contacted every 6 months with retrieval of medical records and expert adjudication of myocardial infarction and cause of death. Incident CHD was defined as myocardial infarction or death due to CHD. Structural racism variables included Black:White % living below the Federal poverty line, Black:White % uninsured, and the Dissimilarity Index (DI), a measure of residential racial segregation. Structural racism variables were dichotomized at the median. Separate race-stratified Cox proportional hazards models examined associations between each measure of structural racism and incident CHD. ResultsThe 24,099 participants free of CHD at baseline included 10,286 Black and 13,813 White participants. Mean age at baseline was 64 years, 58% were women, and 47% had annual household income <$35,000. Greater structural racism was significantly associated with incident CHD for Black but not White participants. For high Black:White poverty, Black HR=1.17 (95% CI 1.01-1.35), White HR=0.93 (0.83-1.06); for high Black:White uninsurance, Black=HR 1.34 (1.06-1.70), White HR=1.20 (0.98-1.47); for high DI, Black HR=1.17 (1.01-1.35), White HR=0.99 (0.88-1.12). Findings suggest that structural racism variables indirectly influence CHD via individual-level income and education. Results were similar for men and women and for older and younger individuals. Significant associations were observed for fatal but not nonfatal CHD events. ConclusionsStructural racism was associated with higher incidence of CHD for Black but not White individuals. If these associations are causal, changing state level laws to combat poverty in Black communities, expand Medicaid, and reduce segregation could potentially lessen Black:White disparities in CHD.

BackgroundElevated resting heart rate is associated with increased mortality, but the underlying mechanisms remain incompletely understood. Subclinical myocardial injury (SCMI), defined by a Cardiac Infarction/Injury Score (CIIS) [&ge;]10, represents silent cardiac damage that predicts poor cardiovascular (CV) outcomes and may partially explain this association. MethodsWe analyzed 7,152 participants from NHANES III who underwent ECG recording and were free of cardiovascular disease. Heart rate was categorized as bradycardia ([&le;]50 bpm), normal (>50-<100 bpm), or tachycardia ([&ge;]100 bpm). Mortality was assessed through National Death Index linkage. Logistic and Cox regression models evaluated associations with SCMI and mortality, respectively, and attenuation was assessed by change in hazard ratios after adjusting for SCMI. ResultsSCMI was present in 1,744 (24.3%) participants. Tachycardia was associated with increased odds of SCMI (adjusted OR 2.34, 95% CI 1.42-3.88). Over 13.9 years median follow-up, 2,311 (32.3%) died from all causes and 933 (13.1%) from CV causes. Tachycardia was associated with increased all-cause mortality (HR 3.58, 95% CI 2.63-4.88) and CV mortality (HR 2.05, 95% CI 1.06-3.79). Adjustment for SCMI attenuated the tachycardia-CV mortality association by 8.6% and all-cause mortality by 5%. Bradycardia was not associated with SCMI or mortality. ConclusionThese findings suggest that SCMI partially mediates the heart rate-mortality relationship and that ECG-based assessment of SCMI may enhance risk stratification in individuals with elevated resting heart rate.

BackgroundPericardiectomy is definitive treatment for constrictive pericarditis. However, extent of resection (radical versus partial) and use of cardiopulmonary bypass (CPB) are debated. ObjectivesTo determine the association of extent of pericardial resection and use of CPB with outcomes. MethodsFrom January 2000 to January 2022, 565 patients with constrictive pericarditis underwent radical (n=445, 314 [71%] on CPB) or partial (n=120, 67 [56%] on CPB) pericardiectomy at Cleveland Clinic. Outcomes stratified by extent of pericardial resection and use of CPB were compared after propensity-score matching. ResultsBoth radical pericardiectomy and CPB use (67% [381/565]) increased over time. Among 88 propensity-matched pairs (73% of possible matches), immediate postoperative cardiac index increased (P<0.001) in both groups by a median of 1.0 L*min-1*m-2. There were no significant differences between radical versus partial resection groups in occurrence of reoperation for bleeding (2.3%, [2/88] vs. 0, P=.50). Median postoperative hospital length of stay was 10 versus 8.5 days (P=.02). Operative mortality was 9.1% (8/88) versus 6.8% (6/88) (P=.58). 10-year survival was 54% versus 41%, with a higher propensity-adjusted hazard ratio after partial resection (1.9, 95% CI 1.2-3.1). ConclusionsWhen surgical intervention is deemed necessary, radical -- rather than partial -- resection for constrictive pericarditis can be performed with low surgical mortality and morbidity. Radical pericardiectomy can be accomplished on CPB and results in better long-term survival. CLINICAL PERSPECTIVESO_LIPatients with constrictive pericarditis require a multidisciplinary approach involving primarily a cardiologist and cardiac surgeon, and other disciplines like gastroenterology since liver cirrhosis from increased central venous pressure and congestion is common, or immunology for evaluation of possible autoimmune etiology. C_LIO_LICommunication is critical in managing patient expectations after pericardiectomy, especially linking etiology to short- and long-term outcomes in this complex patient population. C_LIO_LIRadical pericardiectomy should be the gold standard for treating patients with constrictive pericarditis. C_LIO_LIRoutine use of cardiopulmonary bypass is safe and enables the radical pericardiectomy surgery and should be recommended in the guidelines. C_LI

BackgroundNeighborhood social vulnerability may shape cardiovascular health (CVH), but its association with Lifes Essential 8 (LE8), and whether changes in vulnerability track with changes in CVH during midlife, are unclear. We examined cross-sectional and longitudinal associations of the Social Vulnerability Index (SVI) with LE8 and assessed differences by SVI domain, LE8 component, race, and sex. MethodsWe analyzed CARDIA participants at Year 15 (Y15; 2000-2001; n = 3,168; mean age 40 years) and Year 30 (Y30; 2015-2016; n = 2,267; mean age 55 years). Residential addresses were geocoded and linked to 2000 and 2016 SVI. Participants were stratified by SVI quartiles. CVH scores were calculated from LE8 metrics (range 0-100; higher is better CVH), excluding sleep. Using multivariable linear regression adjusted for age, sex, race, and educational attainment, we estimated LE8 differences across SVI quartiles and associations of 15-year SVI change/residential mobility with change in LE8. Cox models estimated incident CVD associations. ResultsHigher SVI was associated with lower LE8 at both exams. Adjusted Q4 vs Q1 differences in overall LE8 were -5.34 points (95% CI, -6.90 to -3.78) at Y15 and -4.60 points (95% CI, -6.51 to -2.69) at Y30. Among the four SVI domains, SES and household characteristics drove most of the disparity in LE8 scores (Y30 Q4 vs. Q1: SES {Delta} = -6.98; household {Delta} = -6.56 points). Component-level differences across quartiles of SVI were largest for nicotine exposure at Y15 (-13.09 points) and physical activity at Y30 (-13.09 points). Changes in SVI and residential mobility were not significantly associated with change in LE8. ConclusionHigher social vulnerability was associated with significantly lower CVH. Socioeconomic and household factors, along with behavioral gaps in nicotine exposure and physical activity, may be key targets for community-level interventions to improve cardiovascular health equity.

Background Hypertension is a major modifiable risk factor for atrial fibrillation (AF), yet blood pressure (BP) control remains suboptimal in older U.S. adults. Objectives This study evaluated how improve systolic BP (SBP) control could affect incident AF, downstream AF ablation demand, Medicare savings, and hospital revenue. Methods A population-based modelling framework was developed to estimate mortality and incident AF hazards across SBP strata: <120, 120-139, 140-159, and ?160 mm/Hg. AF incidence in the SBP <120 mmHg group was set at 2.2 per 1,000 person-year, with hazard ratios of 1.17, 1.42 and 1.64 applied to higher SBP strata. We assumed 25% of incident AF patients would undergo ablation, with a 7.2% complication rate. AF prevalence was projected to increase by 4.6% annually over 10 years. Medicare savings and hospital revenue foregone were estimated under varying procedure cost and contribution-margin assumptions. Results Higher SBP was associated with greater hazards of death and incident AF. Improved SBP control reduced projected AF incidence and ablation demand. Over 10 years, cumulative Medicare savings were projected at $8.7B-$10.9B across the full modelled population. However, reduced ablation volume translated into hospital revenue foregone, ranging from $75M to $377M in the first year, and approximately $1.03B-$5.2B cumulatively over 10 years. Conclusions Improved SBP control may reduce AF incidence, prevent avoidable invasive ablation procedures, relieve pressure on surgical waitlists, and generate substantial Medicare savings. However, these benefits may reduce hospital procedural revenue, highlighting a misalignment between prevention-oriented care and fee-for-service reimbursement incentives.

ObjectivesWe assessed stroke incidence in hypertensive patients according to cardiorespiratory fitness (CRF) and changes in CRF. MethodsA prospective cohort study of 483,379 US Veterans. Participants completed a maximal standardized Exercise Treadmill test (ETT) performed within the Veterans Affairs medical centers across the United States between 1999 and 2020. None exhibited evidence of unstable cardiovascular disease during the ETT. Participants were stratified into 5 age-and-gender specific CRF categories based on the peak metabolic equivalents (METs) achieved. A subgroup of participants with two ETT evaluations (n=110, 576) were also assigned to 4 categories based on MET changes from the initial ETT to the final ETT. Multivariable Cox models, adjusted for age, and co-morbidities were used to estimate HRs and 95% CIs for stroke risk. ResultsThe mean age {+/-} standard deviation (SD) was 59.4{+/-}9.0 years. During the median follow-up time of 10.6 years (5,182,179 person-years), there were 15,925 stroke events with an average annual rate of 3.1 events per 1,000 person-years. In a final adjusted model, relatively poor CRF was the strongest predictor of stroke risk than any other comorbidity (HR: 2.24; 95% CI: 2.10-2.40; P< 0.001). For each 1-MET higher exercise capacity, the risk was 10% lower (0.90, 95% CI 0.90-0.91, p<0.001). Compared to the Least-fit, stroke risk was 23% lower for Low-fit individuals (HR 0.77; 95% CI, 0.73-0.80; p<0.001); and declined progressively to 55% for those in the highest CRF category (HR 0.45; 95% CI 0.42-0.48; p<0.001). We also assessed stroke incidence according to change in CRF. Compared to fit individuals during both evaluations, the risk was 27% higher for those who became unfit (HR 1.27, 95% CI 1.15-1.41, p<0.001), and not significantly different for unfit who became fit (HR 1.10, 95% CI 0.97-1.25, p=0.13). ConclusionsPoor CRF was the strongest predictor of stroke incidence in hypertensive patients, regardless of age race, or gender. The association was independent, inverse, and graded for all stroke types. Changes in CRF over time reflected inverse changes in stroke risk, suggesting that risk of stroke can be modulated by improved CRF.

BACKGROUNDSocioeconomic factors may lead to a disproportionate impact on healthcare utilization and mortality among individuals with congenital heart defects (CHD) by race, ethnicity, and socio-economic factors. How neighborhood poverty affects racial and ethnic disparities in healthcare utilization and mortality among individuals with CHD across the lifespan is not well described. METHODSIndividuals, 1-64 years, with at least one CHD-related ICD-9-CM code were identified from healthcare encounters between 01/01/2011-12/31/2013 from four U.S. sites. Residence was classified into lower or higher poverty neighborhoods based on ZCTA from the 2014 American Community Survey 5-Year Estimates. Multivariable logistic regression models, adjusting for site, sex, CHD anatomic severity, and insurance evaluated associations between race and ethnicity, and healthcare utilization and mortality, stratified by neighborhood poverty. RESULTSOf 31,542 individuals, 22.2% were non-Hispanic Black (nHB) and 17.0% Hispanic. In high poverty neighborhoods, nHB (44.4%) and Hispanic (47.7%) individuals, respectively, were more likely to be hospitalized (aOR)=1.2 [95%CI=1.0-1.3] and aOR=1.3 [95%CI=1.2-1.5]) and have ED visits (aOR=1.3 [95%CI=1.2-1.5] and aOR=1.7 [95%CI=1.5-2.0]) compared to non-Hispanic White (nHW) individuals. In high poverty neighborhoods, nHB individuals with CHD had 1.7 times the odds of mortality compared to nHW individuals in high poverty neighborhoods (95%CI=1.1-2.7). Racial and ethnic disparities in healthcare utilization were similar in low poverty neighborhoods, but disparities in mortality were attenuated (aOR for nHB=1.2 [95%CI=0.9-1.7]). CONCLUSIONSRacial and ethnic disparities in healthcare utilization were found among individuals with CHD in low and high poverty neighborhoods, but mortality disparities were larger in high poverty neighborhoods. Understanding individual- and community-level social determinants of health, including access to healthcare, may help address racial and ethnic inequities in healthcare utilization and mortality among individuals with CHD.

BackgroundGranular regional stroke incidence data in the US is lacking. We sought to identify factors associated with county-level hospitalization rates and counties with hospitalization rates above or below expectation using publicly available data. MethodsThis cross-sectional study is based on the analysis of county-level three-year average stroke hospitalization rates (principal ICD-10 I63, I65-I66) per 100,000 population among Medicare fee-for-service (FFS) beneficiaries from 2018-2020 using data from the CDCs Interactive Atlas of Heart Disease and Stroke (ATLAS) and other sources. ATLAS provided reliable data on 3,198 (98.6%) counties and county-equivalents. Linear mixed models were fitted to investigate six sets of factors (Total of 61) associated with hospitalization rates in a serial additive stepwise fashion (i.e., demographics, overall population vascular risk factors, risk factor treatment, health delivery and access, environmental features, and socioeconomic status). We reported on the predicted hospitalization rates, marginal R2 of the fixed effects, the most impactful factors using average marginal effects, and characterized proportional difference between crude and predicted hospitalization rates. ResultsThe cohort of 3,198 counties and county-equivalents had a mean stroke hospitalization rate of 11.2 per 100,000 (SD= 2.6). Mean characteristics of included counties: 19.4% age [&ge;]65 years, 73% white, 7.6% coronary heart disease (CHD) prevalence, 38% hyperlipidemia prevalence, and 5.7 primary care physicians per 10,000. In the fully adjusted model, between-county unexplained variation remained moderately high (R2= 0.57). The most impactful factors associated with stroke hospitalization rates were prevalence of CHD, hypertension, smoking, nonadherence to antihypertensive medication, and the elevation of the county above sea level. Counties in the northwest United States generally had lower than expected hospitalization rates. ConclusionsConsiderable unexplained county-level variance in stroke hospitalization rates exists after accounting for a wide variety of known and potential predictors. Future work to clarify the mechanism of known predictors and explain variance may inform stroke mechanisms and interventions to improve systems of care.

BackgroundThe Centers for Medicare and Medicaid Services (CMS) New Technology Add-on Payment (NTAP) program supports adoption of new, costly medical technologies demonstrating substantial clinical improvement. In 2021, CMS waived the "substantial clinical improvement" criterion for devices designated under the FDA Breakthrough Devices Program (BDP). This study characterized risk-standardized payments associated with hospitalizations in which Medicare beneficiaries received calcium modification during PCI for acute myocardial infarction (AMI) following the adoption of the Shockwave C2 Coronary Intravascular Lithotripsy (IVL) Catheter (Shockwave Medical) with BDP designation. MethodsWe analyzed Medicare beneficiaries hospitalized for AMI who underwent PCI between January 2021 and December 2022, stratifying them into four groups: no calcium modification, rotational atherectomy (RA), orbital atherectomy (OA), and coronary IVL. Risk-standardized Medicare payments at 30 days, including index facility, physician, and post-acute care costs, were assessed using non-parametric median and chi-square tests. ResultsAmong 87,238 patients, 76,462 (87.6%) received no calcium modification, 8,316 (9.5%) underwent RA, 793 (0.9%) underwent OA, and 1,668 (1.9%) underwent IVL. IVL use increased from 1.6% in October 2021 to 4.4% in December 2022. Median total risk-standardized Medicare payments were significantly higher for patients receiving calcium modification technologies ($27,579 for IVL, $27,353 for OA, $23,240 for RA) compared to those without ($19,115; p<0.001). Payment differences were largest for index facility payments. ConclusionCoronary IVL during PCI for Medicare patients hospitalized for AMI was associated with significantly increased Medicare payments. Further studies must determine whether IVL, and calcium modification technologies in general, improve outcomes for patients hospitalized for AMI undergoing PCI and thus warrant higher payments via NTAP.

Mortality from diseases of the heart claimed the lives of 186,074 New Jerseyans from 2010 to 2019. This study aims to establish correlations between each of health-related risk factors and death from heart disease in each of the six New Jersey counties. Each of the counties ranked by age-adjusted mortality per 100,000 from diseases of the heart. The six counties were divided by the least (Hunterdon, Somerset, Bergen) and greatest (Cape May, Salem, and Cumberland) mortality rates from heart disease. Additionally, this data was broken down into three main categories that include comorbidities, socioeconomic status, and behavior patterns. Each main category is further broken down into subcategories that provide further evidence of how mortality from heart disease impacts the garden state. The main outcome of death in adults over 25 from heart disease from 2010 to 2019 was correlated to 28 health factors including comorbidities, behaviors, and socioeconomic factors. An R squared value was calculated to evaluate the strength of the correlation between each factor and the outcome of mortality from disease of the heart.

ImportanceExtracranial internal carotid artery stenosis (50-99% arterial narrowing) is an important risk factor for ischemic stroke. Yet, the benefits and harms of targeted screening for asymptomatic carotid artery stenosis (ACAS) have not been assessed in population-based studies. ObjectiveTo estimate the cost-effectiveness of one-time, targeted ACAS screening stratified by atherosclerotic cardiovascular disease (ASCVD) risk using the American Heart Associations Pooled Cohort Equations. Design, Setting, and ParticipantsWe developed a lifetime microsimulation model of ACAS and stroke for a hypothetical cohort representative of US adults aged 50-80 years without stroke history. We used the Cardiovascular Health Study to estimate the probability and severity of ACAS based on individual characteristics (e.g., age, sex, smoking status, blood pressure, and cholesterol). Stroke risks were functions of these characteristics and ACAS severity. In the model, individuals testing positive for >70% stenosis with Duplex ultrasound and a confirmatory diagnostic test undergo revascularization, which may reduce the risk of stroke but also introduces complication risks. Diagnostic performance parameters, revascularization benefits and risks, utility weights, and costs were estimated from published sources. Cost-effectiveness was assessed from the health care sector perspective using a $100,000/quality-adjusted life year (QALY) threshold. Main Outcomes and MeasuresEstimated stroke events prevented, lifetime costs, QALYs, and incremental cost-effectiveness ratios (ICERs) associated with ACAS screening. Costs (2023 USD) and QALYs were discounted at 3% annually. ResultsWe found that screening individuals with a 10-year ASCVD risk >30% was the most cost-effective strategy, with an ICER of $89,000/QALY. This strategy would make approximately 11.9% of the population eligible for screening, averting an estimated 24,084 strokes. Results were sensitive to variations in the efficacy and complication risk of revascularization. In probabilistic sensitivity analysis, screening those in lower ASCVD risk groups (0-20%) only had a 0.6% chance of being cost-effective. Conclusion and RelevanceA one-time screening may only be cost-effective for adults at a relatively high ASCVD risk. Our findings provide a framework that can be adapted as future clinical trial data continue to improve our understanding of the role of revascularization and intensive medical therapy in contemporary stroke prevention secondary to carotid disease.

ObjectiveTo examine whether the association between smoking status and cardiovascular (CV) mortality differs by arterial stiffness, assessed by pulse pressure index (PPI), among U.S. adults without baseline cardiovascular disease (CVD). MethodsUsing data from the National Health and Nutrition Examination Survey (NHANES) 2005-2016, we analyzed 16,605 adults aged 40-79 years without baseline CVD, with mortality follow-up through December 31, 2019. PPI was calculated as (systolic blood pressure [SBP] - diastolic blood pressure [DBP])/SBP and split at the cohort median (0.415) as low versus high. Smoking status was classified as never, former, or current, yielding six joint PPI-smoking groups. Cox models estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for CV mortality, adjusting for demographics and cardiometabolic risk factors. ResultsOver a median follow-up of 8.4 years, 518 CV deaths (3.1%) occurred. Among individuals with low PPI, former smokers had CV mortality comparable to never smokers (HR 0.86, 95% CI 0.56-1.33), whereas current smokers remained at elevated risk (HR 2.51, 95% CI 1.65-3.81). This pattern was not observed in the high PPI stratum, where both former and current smokers had significantly higher CV mortality than never smokers. ConclusionFormer smokers with low PPI had CV mortality similar to never smokers, whereas former smokers with high PPI remained at elevated risk. These findings suggest that the CV benefit of smoking cessation may be greatest when arterial stiffness is minimal, supporting early cessation before substantial vascular aging occurs.