Social Determinants of Health and Cardiovascular Disease: Current State and Future Directions Towards Healthcare Equity.

PURPOSE OF REVIEW: We sought to examine the role of social and environmental conditions that determine an individual's behaviors and risk of disease-collectively known as social determinants of health (SDOH)-in shaping cardiovascular (CV) health of the population and giving rise to disparities in risk factors, outcomes, and clinical care for cardiovascular disease (CVD), the leading cause of death in the United States (US). RECENT FINDINGS: Traditional CV risk factors have been extensively targeted in existing CVD prevention and management paradigms, often with little attention to SDOH. Limited evidence suggests an association between individual SDOH (e.g., income, education) and CVD. However, inequities in CVD care, risk factors, and outcomes have not been studied using a broad SDOH framework. We examined existing evidence of the association between SDOH-organized into 6 domains, including economic stability, education, food, neighborhood and physical environment, healthcare system, and community and social context-and CVD. Greater social adversity, defined by adverse SDOH, was linked to higher burden of CVD risk factors and poor outcomes, such as stroke, myocardial infarction (MI), coronary heart disease, heart failure, and mortality. Conversely, favorable social conditions had protective effects on CVD. Upstream SDOH interact across domains to produce cumulative downstream effects on CV health, via multiple physiologic and behavioral pathways. SDOH are major drivers of sociodemographic disparities in CVD, with a disproportionate impact on socially disadvantaged populations. Efforts to achieve health equity should take into account the structural, institutional, and environmental barriers to optimum CV health in marginalized populations. In this review, we highlight major knowledge gaps for each SDOH domain and propose a set of actionable recommendations to inform CVD care, ensure equitable distribution of healthcare resources, and reduce observed disparities.

The Impact of Non-Adherence to Antihypertensive Drug Therapy.

Medication non-adherence is a major healthcare barrier, especially among diseases that are largely asymptomatic, such as hypertension. The impact of poor medication adherence ranges from patient-specific adverse health outcomes to broader strains on health care system resources. The Centers for Disease Control (CDC) Wide-ranging Online Data for Epidemiologic Research (WONDER) database was used to retrieve Centers for Medicare and Medicaid Services' data pertaining to blood pressure (BP) medication adherence, socio-economic variables, and cardiovascular (CV) outcomes across the United States. Multivariable linear regression models were used to estimate the change in total CV deaths as a function of non-adherence to BP medications. For every percent increase in the non-adherence rate, the total number of CV deaths increased by 7.13 deaths per 100,000 adults (95% CI: 6.34-7.92), even after controlling for the percentage of residents with access to insurance, the percentage of residents who were eligible for Medicaid, the percentage of residents without a college education, median home value, income inequality, and the poverty rate (p < 0.001). There is a significant association between non-adherence to BP medications and total CV deaths. Even a one percent increase in the adherence rate in the United States could result in tens of thousands of preventable CV deaths. Based on recently published CDC data, this could also have a tremendous impact on health care costs. This provides compelling evidence for increased efforts to improve adherence.

Coronary Artery Fistula and Pectus Excavatum Paradox.

Pectus excavatum is the most common congenital chest wall deformity. Its effects on cardiopulmonary function, exercise capacity, and body image are variable across affected patients. Management practices for pectus deformity vary considerably, but most authors agree on the need for surgical correction if pectus index is >3.0 and there is evidence of cardiac compression on imaging. We encountered a case of a middle-aged man with severe pectus deformity and a coincidental large coronary artery to right atrium fistula. Despite a pectus index of 4.8 and severe right heart compression on thoracic imaging, he had not developed any symptoms or hemodynamic complication from this pectus deformity. Additionally, hemodynamic studies revealed normal left and right heart function, normal pulmonary artery pressures, and absence of any evidence of myocardial ischemia or significant left-to-right shunt. These abnormalities would have been expected with a coronary fistula of this size. His pectus deformity and coronary fistula had opposing hemodynamic effects, thus protecting him from severe complications of either. Presently, an association between congenital coronary fistulae and pectus excavatum is not known, and this is one of the very first reported cases of these two congenital abnormalities coexisting in a patient. Additionally, concurrence of these two conditions poses a unique therapeutic challenge due to their opposing hemodynamic effects.

Associations between particulate matter air pollution, presence and progression of subclinical coronary and carotid atherosclerosis: A systematic review.

BACKGROUND AND AIMS: Long-term exposure to particulate matter (PM) air pollution has been linked with increased cardiovascular events and mortality, however, studies had shown inconsistent associations between PM exposure and subclinical atherosclerosis. METHODS: We performed an updated systematic literature review to identify studies evaluating the associations between PM and subclinical atherosclerosis, measured using presence/progression of coronary artery calcium (CAC) or carotid intima-media thickness (CIMT) in adult populations. Quality was assessed using the Newcastle-Ottawa scale. RESULTS: Eighteen studies were included: 5 cohorts and 13 cross-sectional. Amongst 7 studies that evaluated the associations between PM and prevalence of CAC, 4 reported significantly higher odds of detectable CAC>0 or CAC>400 with increased PM exposure. Nine studies evaluated the association between exposure to at least one of the particulates and CIMT; of these, 6 reported significant independent associations. Two studies evaluated PM2.5 and CAC progression, with 1 reporting a greater progression of CAC with increased exposure to PM, while 3 out of 4 studies evaluating CIMT progression showed no significant difference in CIMT progression with a higher PM2.5 exposure. Additionally, 3 studies found significant associations between proximity to major roadways and measures of subclinical atherosclerosis. Among null studies, most displayed non-significant trends towards higher atherosclerosis burden with higher PM exposure. CONCLUSIONS: Overall, available observational studies support a positive association between PM exposure and subclinical atherosclerosis. Further longitudinal studies are needed to better establish this relationship and assess the efficacy of previously identified interventions on mitigation of clinical cardiovascular disease.

Stroke in young adults: Current trends, opportunities for prevention and pathways forward.

Cardiovascular disease remains a major contributor to morbidity and mortality in the US and elsewhere, and stroke is a leading cause of disability worldwide. Despite recent success in diminishing stroke incidence in the general US population, in parallel there is now a concerning propensity for strokes to happen at younger ages. Specifically, the incidence of stroke for US adults 20-44 years of age increased from 17 per 100,000 US adults in 1993 to 28 per 100,000 in 2015. Occurrence of strokes in young adults is particularly problematic as these patients are often affected by physical disability, depression, cognitive impairment and loss of productivity, all of which have vast personal, social and economic implications. These concerning trends among young adults are likely due to increasing trends in the prevalence of modifiable risk factors amongst this population including hypertension, hyperlipidemia, obesity and diabetes, highlighting the importance of early detection and aggressive prevention strategies in the general population at early ages. In parallel and compounding to the issue, troublesome trends are evident regarding increasing rates of substance abuse among young adults. Higher rates of strokes have been noted particularly among young African Americans, indicating the need for tailored prevention and social efforts targeting this and other vulnerable groups, including the primordial prevention of risk factors in the first place, reducing stroke rates in the presence of prevalent risk factors such as hypertension, and improving outcomes through enhanced healthcare access. In this narrative review we aim to emphasize the importance of stroke in young adults as a growing public health issue and increase awareness among clinicians and the public health sector. For this purpose, we summarize the available data on stroke in young adults and discuss the underlying epidemiology, etiology, risk factors, prognosis and opportunities for timely prevention of stroke specifically at young ages. Furthermore, this review highlights the gaps in knowledge and proposes future directions moving forward.

Lambl's Excrescences: An Enigma of Modern Diagnostic Cardiology.

Lambl's excrescences were first described in 1856 by a Bohemian physician, Vilém Dusan Lambl, and since then have gained widespread attention and controversy within the medical literature. Despite numerous case reports and observational studies, consensus on the significance and management of Lambl's excrescences remains sparse. We describe the case of a 48-year-old male who presented with recurrent embolic strokes. No underlying paroxysmal arrhythmia or inter-atrial shunt was identified, and the only pathological finding was a 1-mm aortic valve strand. We managed this patient successfully using a novel oral anticoagulant.