2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association.

BACKGROUND: The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS: The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS: Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS: The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Knowledge Gaps, Challenges, and Opportunities in Health and Prevention Research for Asian Americans, Native Hawaiians, and Pacific Islanders: A Report From the 2021 National Institutes of Health Workshop.

Asian Americans (AsA), Native Hawaiians, and Pacific Islanders (NHPI) comprise 7.7% of the U.S. population, and AsA have had the fastest growth rate since 2010. Yet the National Institutes of Health (NIH) has invested only 0.17% of its budget on AsA and NHPI research between 1992 and 2018. More than 40 ethnic subgroups are included within AsA and NHPI (with no majority subpopulation), which are highly diverse culturally, demographically, linguistically, and socioeconomically. However, data for these groups are often aggregated, masking critical health disparities and their drivers. To address these issues, in March 2021, the National Heart, Lung, and Blood Institute, in partnership with 8 other NIH institutes, convened a multidisciplinary workshop to review current research, knowledge gaps, opportunities, barriers, and approaches for prevention research for AsA and NHPI populations. The workshop covered 5 domains: 1) sociocultural, environmental, psychological health, and lifestyle dimensions; 2) metabolic disorders; 3) cardiovascular and lung diseases; 4) cancer; and 5) cognitive function and healthy aging. Two recurring themes emerged: Very limited data on the epidemiology, risk factors, and outcomes for most conditions are available, and most existing data are not disaggregated by subgroup, masking variation in risk factors, disease occurrence, and trajectories. Leveraging the vast phenotypic differences among AsA and NHPI groups was identified as a key opportunity to yield novel clues into etiologic and prognostic factors to inform prevention efforts and intervention strategies. Promising approaches for future research include developing collaborations with community partners, investing in infrastructure support for cohort studies, enhancing existing data sources to enable data disaggregation, and incorporating novel technology for objective measurement. Research on AsA and NHPI subgroups is urgently needed to eliminate disparities and promote health equity in these populations.

Inadequate Use of Newer Treatments and Glycemic Control by Cardiovascular Risk and Sociodemographic Groups in US Adults with Diabetes in the NIH Precision Medicine Initiative All of Us Research Program.

PURPOSE: Data are limited on sodium glucose co-transport 2 inhibitors (SGLT2-is) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) among real-world cohorts of underrepresented patients. We examined these therapies and glycemic control in US adults with diabetes mellitus (DM) by atherosclerotic cardiovascular disease (ASCVD) risk and sociodemographic factors. METHODS: In the NIH Precision Medicine Initiative All of Us Research Program, we categorized DM as (1) moderate risk, (2) high risk, and (3) with ASCVD. We examined proportions on DM therapies, including SGLT2-i or GLP-1 RA, and at glycemic control by sociodemographic factors and CVD risk groups. RESULTS: Our 81,332 adults aged ≥ 18 years with DM across 340 US sites included 22.3% non-Hispanic Black, 17.2% Hispanic, and 1.8% Asian participants; 31.1%, 30.3%, and 38.6% were at moderate risk, high risk, or with ASCVD, respectively. Those with DM and ASCVD were most likely on SGLT2-i (8.6%) or GLP-1 RA (11.9%). SGLT2-i use was < 10% in those with heart failure or chronic kidney disease. The odds (95% CI) of SGLT2-i use were greater among men (1.35 [1.20, 1.53]) and Asian persons (2.31 [1.78, 2.96]), with GLP-1 RA being less common (0.78 [0.70, 0.86]) in men. GLP-1 RA use was greater among those with health insurance, and both GLP-1 RA and SGLT2-i greater within lower income groups. 72.0% of participants had HbA1c < 7%; Hispanic persons were least likely at glycemic control. CONCLUSIONS: Treatment with SGLT2-is and GLP-1 RAs remains low, even among higher ASCVD risk persons with DM and use is even lower among underserved groups.

Cardiodiabetology: newer pharmacologic strategies for reducing cardiovascular disease risks.

Globally, nearly 500 million adults currently have diabetes, which is expected to increase to approximately 700 million by 2040. Cardiovascular diseases (CVD), including coronary heart disease, stroke, heart failure, and peripheral arterial disease, are the principal causes of death in persons with diabetes. Key to the prevention of CVD is optimization of associated risk factors. However, few persons with diabetes are at recommended targets for key CVD risk factors including low-density lipoprotein-cholesterol (LDL-C), blood pressure, glycated hemoglobin, nonsmoking status, and body mass index. While lifestyle management forms the basis for the prevention and control of these risk factors, newer and existing pharmacologic approaches are available to optimize the potential for CVD risk reduction, particularly for the management of lipids, blood pressure, and blood glucose. For higher-risk patients, antiplatelet therapy is recommended. Medication for blood pressure, statins, and most recently, icosapent ethyl, have evidence for reducing CVD events in persons with diabetes. Newer medications for diabetes, including sodium glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists, also reduce CVD and SGLT2 inhibitors in particular also reduce progression of kidney disease and reduce heart failure hospitalizations (HFHs). Most importantly, a multidisciplinary team is required to address the polypharmaceutical options to best reduce CVD risks persons with diabetes.

The costs outweigh the benefits: seeing side-effects online may decrease adherence to statins.

BACKGROUND: The prevalence of medical misinformation on the Internet has received much attention among researchers concerned that exposure to such information may inhibit patient adherence to prescriptions. Yet, little is known about information people see when they search for medical information and the extent to which exposure is directly related to their decisions to follow physician recommendations. These issues were examined using statin prescriptions as a case study. METHODS: We developed and used a tool to rank the quality of statin-related web pages based on the presence of information about side effects, clinical benefits, management of side effects, and misinformation. We then conducted an experiment in which students were presented with a hypothetical scenario in which an older relative was prescribed a statin but was unsure whether to take the medication. Participants were asked to search the web for information about statins and make a recommendation to this relative. Their search activity was logged using a web-browser add-on. Websites each participant visited were scored for quality using our tool, quality scores were aggregated for each participant and were subsequently used to predict their recommendation. RESULTS: Exposure to statin-related benefits and management of side effects during the search was significantly associated with a higher probability of recommending that an older relative adhere to their physician's recommendation. Exposure to misinformation and side effects were not associated, nor were any other participant characteristics. Bigram analyses of the top reasons participants gave for their recommendation mirrored the statistical findings, except that among participants who did not recommend following the prescription order, myriad side effects were mentioned. CONCLUSIONS: Our findings suggest that units of information people see on health-related websites are not treated equally. Our methods offer new understanding at a granular level about the impact of Internet searches on health decisions regarding evidence-based recommended medications. Our findings may be useful to physicians considering ways to address non-adherence. Preventive care should include actively engaging patients in discussions about health information they may find on the web. The effectiveness of this strategy should be examined in future studies.

The complexity of masked hypertension: diagnostic and management challenges.

Masked hypertension, defined as discordant in-office normotension versus out-of-office hypertension, is present in approximately 10 % to 40 % of patients not receiving antihypertensive treatment. Not only are persons with prehypertension more likely to have masked hypertension, but they also frequently develop target organ damage before transitioning to established sustained hypertension. Moreover, the percentage of persons with masked hypertension increases in the presence of cardiovascular disease, diabetes, or chronic renal failure. The gold standard for diagnosing masked hypertension is the 24-hour ambulatory BP monitor (ABPM), but home BP monitoring (HBPM) has also been a useful alternative procedure. Importantly, initiating antihypertensive treatment exclusively with the use of in-office BP monitoring may result in almost one-third of patients remaining with high-risk masked uncontrolled hypertension, which underscores the importance of HBPM and ABPM as supplements to in-office BP monitoring for the effective treatment of hypertension.

World Heart Federation Cholesterol Roadmap 2022.

Background: Atherosclerotic cardiovascular diseases (ASCVD) including myocardial infarction, stroke and peripheral arterial disease continue to be major causes of premature death, disability and healthcare expenditure globally. Preventing the accumulation of cholesterol-containing atherogenic lipoproteins in the vessel wall is central to any healthcare strategy to prevent ASCVD. Advances in current concepts about reducing cumulative exposure to apolipoprotein B (apo B) cholesterol-containing lipoproteins and the emergence of novel therapies provide new opportunities to better prevent ASCVD. The present update of the World Heart Federation Cholesterol Roadmap provides a conceptual framework for the development of national policies and health systems approaches, so that potential roadblocks to cholesterol management and thus ASCVD prevention can be overcome. Methods: Through a review of published guidelines and research papers since 2017, and consultation with a committee composed of experts in clinical management of dyslipidaemias and health systems research in low-and-middle income countries (LMICs), this Roadmap identifies (1) key principles to effective ASCVD prevention (2) gaps in implementation of these interventions (knowledge-practice gaps); (3) health system roadblocks to treatment of elevated cholesterol in LMICs; and (4) potential strategies for overcoming these. Results: Reducing the future burden of ASCVD will require diverse approaches throughout the life-course. These include: a greater focus on primordial prevention; availability of affordable cholesterol testing; availability of universal cholesterol screening for inherited dyslipidaemias; risk stratification moving beyond 10-year risk to look at lifetime risk with adequate risk estimators; wider availability of affordable cholesterol-lowering therapies which should include statins as essential medications globally; use of adequate doses of potent statin regimens; and combination therapies with ezetimibe or other therapies in order to attain and maintain robust reductions in LDL-C in those at highest risk. Continuing efforts are needed on health literacy for both the public and healthcare providers, utilising multi-disciplinary teams in healthcare and applications that quantify both ASCVD risk and benefits of treatment as well as increased adherence to therapies. Conclusions: The adverse effects of LDL-cholesterol and apo B containing lipoprotein exposure are cumulative and result in ASCVD. These are preventable by implementation of different strategies, aimed at efficiently tackling atherosclerosis at different stages throughout the human life-course. Preventive strategies should therefore be updated to implement health policy, lifestyle changes and when needed pharmacotherapies earlier with investment in, and a shift in focus towards, early preventive strategies that preserve cardiovascular health rather than treat the consequences of ASCVD.

Cascade Screening and Treatment Initiation in Young Adults with Heterozygous Familial Hypercholesterolemia.

Heterozygous familial hypercholesterolemia (HeFH) creates elevated low-density lipoprotein cholesterol (LDL-C), causing premature atherosclerotic cardiovascular disease (ASCVD). Guidelines recommend cascade screening relatives and starting statin therapy at 8-10 years old, but adherence to these recommendations is low. Our purpose was to measure self-reported physician practices for cascade screening and treatment initiation for HeFH using a survey of 500 primary care physicians and 500 cardiologists: 54% "always" cascade screen relatives of an individual with FH, but 68% would screen individuals with "strong family history of high cholesterol or premature ASCVD", and 74% would screen a child of a patient with HeFH. The most likely age respondents would start statins was 18-29 years, with few willing to prescribe to a pediatric male (17%) or female (14%). Physicians who reported previously diagnosing a patient with HeFH were more likely to prescribe to a pediatric patient with HeFH, either male (OR = 1.34, 95% CI = 0.99-1.81) or female (OR = 1.31, 95% CI = 0.99-1.72). Many physicians do not cascade screen and are less likely to screen individuals with family history of known HeFH compared to "high cholesterol or premature ASCVD". Most expressed willingness to screen pediatric patients, but few would start treatment at recommended ages. Further education is needed to improve diagnosis and treatment of HeFH.

Impact of nutraceuticals on markers of systemic inflammation: Potential relevance to cardiovascular diseases - A position paper from the International Lipid Expert Panel (ILEP).

Inflammation is a marker of arterial disease stemming from cholesterol-dependent to -independent molecular mechanisms. In recent years, the role of inflammation in atherogenesis has been underpinned by pharmacological approaches targeting systemic inflammation that have led to a significant reduction in cardiovascular disease (CVD) risk. Although the use of nutraceuticals to prevent CVD has largely focused on lipid-lowering (e.g, red-yeast rice and omega-3 fatty acids), there is growing interest and need, especially now in the time of coronavirus pandemic, in the use of nutraceuticals to reduce inflammatory markers, and potentially the inflammatory CVD burden, however, there is still not enough evidence to confirm this. Indeed, diet is an important lifestyle determinant of health and can influence both systemic and vascular inflammation, to varying extents, according to the individual nutraceutical constituents. Thus, the aim of this Position Paper is to provide the first attempt at recommendations on the use of nutraceuticals with effective anti-inflammatory properties.

Continuity of care and outpatient management for patients with and at high risk for cardiovascular disease during the COVID-19 pandemic: A scientific statement from the American Society for Preventive Cardiology.

The coronavirus disease 2019 (COVID-19) pandemic has consumed our healthcare system, with immediate resource focus on the management of high numbers of critically ill patients. Those that fare poorly with COVID-19 infection more commonly have cardiovascular disease (CVD), hypertension and diabetes. There are also several other conditions that raise concern for the welfare of patients with and at high risk for CVD during this pandemic. Traditional ambulatory care is disrupted and many patients are delaying or deferring necessary care, including preventive care. New impediments to medication access and adherence have arisen. Social distancing measures can increase social isolation and alter physical activity and nutrition patterns. Virtually all facility based cardiac rehabilitation programs have temporarily closed. If not promptly addressed, these changes may result in delayed waves of vulnerable patients presenting for urgent and preventable CVD events. Here, we provide several recommendations to mitigate the adverse effects of these disruptions in outpatient care. Angiotensin converting enzyme inhibitors and angiotensin receptor blockers should be continued in patients already taking these medications. Where possible, it is strongly preferred to continue visits via telehealth, and patients should be counselled about promptly reporting new symptoms. Barriers to medication access should be reviewed with patients at every contact, with implementation of strategies to ensure ongoing provision of medications. Team-based care should be leveraged to enhance the continuity of care and adherence to lifestyle recommendations. Patient encounters should include discussion of safe physical activity options and access to healthy food choices. Implementation of adaptive strategies for cardiac rehabilitation is recommended, including home based cardiac rehab, to ensure continuity of this essential service. While the practical implementation of these strategies will vary by local situation, there are a broad range of strategies available to ensure ongoing continuity of care and health preservation for those at higher risk of CVD during the COVID-19 pandemic.

Baseline achievement of lipid goals and usage of lipid medications in patients with diabetes mellitus (from the Veterans Affairs Diabetes Trial).

The American Diabetes Association has established lipid goals for patients with diabetes. Although diabetic populations historically have poor low-density lipoprotein (LDL) cholesterol goal adherence, little is known about adherence to triglyceride and high-density lipoprotein (HDL) cholesterol goals. To determine the degree of lipid goal attainment among patients with diabetes, and to characterize the patterns of lipid medication use, we evaluated the baseline data from 1,742 enrollees of the national Veterans Affairs Diabetes Trial. Using current American Diabetes Association lipid guidelines, we calculated the proportion of participants achieving a LDL cholesterol level <100 mg/dl, triglyceride level <150 mg/dl, and HDL cholesterol level >40 mg/dl in men (>50 mg/dl in women). We also performed a descriptive analysis of the use of lipid medications in this population. The baseline LDL cholesterol level was 111 +/- 63 mg/dl, triglyceride level was 213 +/- 277 mg/dl, and HDL cholesterol was 36 +/- 10 mg/dl. At enrollment, 44% of veterans met the LDL cholesterol goal, 58% met the triglyceride goal, and 16% met the HDL cholesterol goal, but only 6% met all 3 goals. Of the 1,742 enrollees, 2/3 were receiving lipid therapy, with statins (58%) the most commonly used drug. Combination lipid therapy was used by 11% of enrollees. Although the enrollees of the Veterans Affairs Diabetes Trial demonstrated better adherence to the American Diabetes Association's LDL cholesterol goal than other diabetic populations recently studied, more aggressive and directed lipid medication use is needed to treat the overall lipid profile better.

Statin intolerance - an attempt at a unified definition. Position paper from an International Lipid Expert Panel.

Statins are one of the most commonly prescribed drugs in clinical practice. They are usually well tolerated and effectively prevent cardiovascular events. Most adverse effects associated with statin therapy are muscle-related. The recent statement of the European Atherosclerosis Society (EAS) has focused on statin-associated muscle symptoms (SAMS), and avoided the use of the term 'statin intolerance'. Although muscle syndromes are the most common adverse effects observed after statin therapy, excluding other side effects might underestimate the number of patients with statin intolerance, which might be observed in 10 - 15% of patients. In clinical practice, statin intolerance limits effective treatment of patients at risk of, or with, cardiovascular disease. Knowledge of the most common adverse effects of statin therapy that might cause statin intolerance and the clear definition of this phenomenon is crucial to effectively treat patients with lipid disorders. Therefore, the aim of this position paper was to suggest a unified definition of statin intolerance, and to complement the recent EAS statement on SAMS, where the pathophysiology, diagnosis and the management were comprehensively presented.