Association between social vulnerability index and admission urgency for transcatheter aortic valve replacement.

Background: Transcatheter aortic valve replacement (TAVR) are not offered equitably to vulnerable population groups. Adequate levels of insurance may narrow gaps among patients with higher social vulnerability index (SVI). Among a national population of individuals with commercial or Medicare insurance, we sought to determine whether SVI was associated with urgency of receipt of TAVR for aortic stenosis. Methods and results: Using Optum's de-identified Clinformatics Data Mart Database (CDM), we identified admissions for TAVR with aortic stenosis between January 2018 and March 2022. Admission urgency was identified by CDM claims codes. SVI was cross-referenced to patient zip codes and grouped into quintiles. Generalized linear mixed effects models were used to predict the probability of a TAVR admission being urgent based on SVI quintiles, adjusting for patient and hospital-level covariates. Results: Among 6680 admissions for TAVR [median age 80 years (interquartile range 75-85), 43.9 % female], 8.5 % (n = 567) were classified as urgent. After adjusting for patient and hospital-level variables, there were no significant differences in the odds of urgent admission for TAVR according to SVI quintiles [OR 5th (greatest social vulnerability) vs 1st quintile (least social vulnerability): 1.29 (95 % CI: 0.90-1.85)]. Conclusions: Among commercial or Medicare beneficiaries with aortic stenosis, SVI was not associated with admission urgency for TAVR. To clarify whether cardiovascular care delivery is improved across SVI with higher paying beneficiaries, future investigation should identify whether relationships between SVI and TAVR urgency vary for Medicaid beneficiaries compared to commercial beneficiaries.

Neighborhoods and Cardiovascular Health: A Scientific Statement From the American Heart Association.

The neighborhoods where individuals reside shape environmental exposures, access to resources, and opportunities. The inequitable distribution of resources and opportunities across neighborhoods perpetuates and exacerbates cardiovascular health inequities. Thus, interventions that address the neighborhood environment could reduce the inequitable burden of cardiovascular disease in disenfranchised populations. The objective of this scientific statement is to provide a roadmap illustrating how current knowledge regarding the effects of neighborhoods on cardiovascular disease can be used to develop and implement effective interventions to improve cardiovascular health at the population, health system, community, and individual levels. PubMed/Medline, CINAHL, Cochrane Library reviews, and ClinicalTrials.gov were used to identify observational studies and interventions examining or targeting neighborhood conditions in relation to cardiovascular health. The scientific statement summarizes how neighborhoods have been incorporated into the actions of health care systems, interventions in community settings, and policies and interventions that involve modifying the neighborhood environment. This scientific statement presents promising findings that can be expanded and implemented more broadly and identifies methodological challenges in designing studies to evaluate important neighborhood-related policies and interventions. Last, this scientific statement offers recommendations for areas that merit further research to promote a deeper understanding of the contributions of neighborhoods to cardiovascular health and health inequities and to stimulate the development of more effective interventions.

Rurality and Atrial Fibrillation: Patient Perceptions of Barriers and Facilitators to Care.

Background Patients experience atrial fibrillation (AF) as a complex disease given its adversity, chronicity, and necessity for long-term treatments. Few studies have examined the experience of rural individuals with AF. We conducted qualitative assessments of patients with AF residing in rural, western Pennsylvania to identify barriers and facilitators to care. Methods and Results We conducted 8 semistructured virtual focus groups with 42 individuals living in rural western Pennsylvania using contextually tailored questions to assess participant perspectives. We inductively analyzed focus group transcripts using paragraph-by-paragraph and focused coding to identify themes with the qualitative description approach. We used Krippendorff α scoring to determine interreviewer reliability. We harnessed investigator triangulation to augment the reliability of our findings. We reached thematic saturation after coding 8 focus groups. Participants were 52.4% women, with a median age of 70.9 years (range, 54.5-82.0 years), and most were White race (92.9%). Participants identified medication costliness, invisibility of AF to others, and lack of emergent transportation as barriers to care. Participants described interpersonal support and use of technology as important for AF self-care, and expressed ambivalence about how relationships with health care providers affected AF care. Conclusions Focus group participants described multiple social and structural barriers to care for AF. Our findings highlight the complexity of the experience of individuals with AF residing in rural western Pennsylvania. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04076020.

Association Between Race, Cardiology Care, and the Receipt of Guideline-Directed Medical Therapy in Peripartum Cardiomyopathy.

BACKGROUND: Black patients with peripartum cardiomyopathy (PPCM) have disproportionately worse outcomes than White patients, possibly related to variable involvement of cardiovascular specialists in their clinical care. We sought to determine whether race was associated with cardiology involvement in clinical care during inpatient admission and whether cardiology involvement in care was associated with higher claims of guideline-directed medical therapy (GDMT) a week after hospital discharge. METHODS: Using Optum's de-identified Clinformatics® Data Mart (CDM), we included Black and White patients' first hospital admission for PPCM from 2008 to 2021. Cardiology involvement in clinical care was defined as the receipt of attending care from a cardiovascular specialist during admission. GDMT included beta-blockers (BB) for all patients and triple therapy (BB, angiotensin-responsive medications, and mineralocorticoid receptor antagonists) for non-pregnant patients. Logistic regression was used to determine the associations between cardiology involvement in clinical care during admission and (1) patient race and (2) GDMT prescription, adjusting for age and comorbidities. RESULTS: Among 668 patients (32.6% Black, 67.4% White, 93.3% commercially insured), there was no significant difference in the odds of cardiology involvement in clinical care by race (aOR: 1.41; 95%CI: 0.87-2.33, P=0.17). Inpatient cardiology care was associated with 2.75 times increased odds of having a prescription claim for GDMT (BB) for White patients (aOR: 2.75; 95%CI 1.50-5.06, P=0.001), and the estimated effect size was similar but not statistically significant for Black patients (aOR: 2.20, 95% CI, 0.84-5.71, P=0.11). The interaction between race and cardiology involvement in clinical care was not statistically significant for the receipt of BB prescription. Among 274 non-pregnant patients with PPCM (37.2% Black, 62.8% White), 5.8% received triple GDMT. Of these, none of the Black patients lacking cardiology care had triple GDMT. However, cardiology involvement in care was not significantly associated with triple GDMT for either race. CONCLUSIONS: Among a commercially insured population within PPCM, race was not associated with cardiology involvement in clinical care during hospitalization. However, cardiology involvement in care was associated with significantly higher odds of prescription claims for BB for only White patients. Additional strategies are needed to support equitable GDMT prescription.

Disparities in Guideline-Recommended Statin Use for Prevention of Atherosclerotic Cardiovascular Disease by Race, Ethnicity, and Gender : A Nationally Representative Cross-Sectional Analysis of Adults in the United States.

BACKGROUND: Although statins are a class I recommendation for prevention of atherosclerotic cardiovascular disease and its complications, their use is suboptimal. Differential underuse may mediate disparities in cardiovascular health for systematically marginalized persons. OBJECTIVE: To estimate disparities in statin use by race-ethnicity-gender and to determine whether these potential disparities are explained by medical appropriateness of therapy and structural factors. DESIGN: Cross-sectional analysis. SETTING: National Health and Nutrition Examination Survey from 2015 to 2020. PARTICIPANTS: Persons eligible for statin therapy based on 2013 and 2018 American College of Cardiology/American Heart Association blood cholesterol guidelines. MEASUREMENTS: The independent variable was race-ethnicity-gender. The outcome of interest was use of a statin. Using the Institute of Medicine framework for examining unequal treatment, we calculated adjusted prevalence ratios (aPRs) to estimate disparities in statin use adjusted for age, disease severity, access to health care, and socioeconomic status relative to non-Hispanic White men. RESULTS: For primary prevention, we identified a lower prevalence of statin use that was not explained by measurable differences in disease severity or structural factors among non-Hispanic Black men (aPR, 0.73 [95% CI, 0.59 to 0.88]) and non-Mexican Hispanic women (aPR, 0.74 [CI, 0.53 to 0.95]). For secondary prevention, we identified a lower prevalence of statin use that was not explained by measurable differences in disease severity or structural factors for non-Hispanic Black men (aPR, 0.81 [CI, 0.64 to 0.97]), other/multiracial men (aPR, 0.58 [CI, 0.20 to 0.97]), Mexican American women (aPR, 0.36 [CI, 0.10 to 0.61]), non-Mexican Hispanic women (aPR, 0.57 [CI, 0.33 to 0.82), non-Hispanic White women (aPR, 0.69 [CI, 0.56 to 0.83]), and non-Hispanic Black women (aPR, 0.75 [CI, 0.57 to 0.92]). LIMITATION: Cross-sectional data; lack of geographic, language, or statin-dose data. CONCLUSION: Statin use disparities for several race-ethnicity-gender groups are not explained by measurable differences in medical appropriateness of therapy, access to health care, and socioeconomic status. These residual disparities may be partially mediated by unobserved processes that contribute to health inequity, including bias, stereotyping, and mistrust. PRIMARY FUNDING SOURCE: National Institutes of Health.

Association of Prescription Co-payment With Adherence to Glucagon-Like Peptide-1 Receptor Agonist and Sodium-Glucose Cotransporter-2 Inhibitor Therapies in Patients With Heart Failure and Diabetes.

Importance: Type 2 diabetes (T2D) and heart failure (HF) prevalence are rising in the US. Although glucagon-like peptide-1 receptor agonists (GLP1-RA) and sodium-glucose cotransporter 2 inhibitors (SGLT2i) improve outcomes for these conditions, high out-of-pocket costs may be associated with reduced medication adherence. Objective: To compare 1-year adherence to GLP1-RA and SGLT2i therapies by prescription co-payment level in individuals with T2D and/or HF. Design, Setting, and Participants: This retrospective cohort study used deidentified data from Optum Insight's Clinformatics Data Mart Database of enrollees with commercial and Medicare health insurance plans. Individuals aged 18 years or older with T2D and/or HF who had a prescription claim for a GLP1-RA or SLGT2i from January 1, 2014, to September 30, 2020, were included. Exposures: Prescription co-payment, categorized as low (<$10), medium ($10 to<$50), and high (≥$50). Main Outcomes and Measures: The primary outcome was medication adherence, defined as a proportion of days covered (PDC) of 80% or greater at 1 year. Logistic regression models were used to examine the association between co-payment and adherence, adjusting for patient demographics, medical comorbidities, and socioeconomic factors. Results: A total of 94 610 individuals (mean [SD] age, 61.8 [11.4] years; 51 226 [54.1%] male) were prescribed GLP1-RA or SGLT2i therapy. Overall, 39 149 individuals had a claim for a GLP1-RA, of whom 25 557 (65.3%) had a PDC of 80% or greater at 1 year. In fully adjusted models, individuals with a medium (adjusted odds ratio [AOR], 0.62; 95% CI, 0.58-0.67) or high (AOR, 0.47; 95% CI, 0.44-0.51) co-payment were less likely to have a PDC of 80% or greater with a GLP1-RA compared with those with a low co-payment. Overall, 51 072 individuals had a claim for an SGLT2i, of whom 37 339 (73.1%) had a PDC of 80% or greater at 1 year. Individuals with a medium (AOR, 0.67; 95% CI, 0.63-0.72) or high (AOR, 0.68; 95% CI, 0.63-0.72) co-payment were less likely to have a PDC of 80% or greater with an SGLT2i compared with those with a low co-payment. Conclusions and Relevance: In this cohort study of individuals with T2D and/or HF, 1-year adherence to GLP1-RA or SGLT2i therapies was highest among individuals with a low co-payment. Improving adherence to guideline-based therapies may require interventions that reduce out-of-pocket prescription costs.

A qualitative crossroads of rhythm and race: Black patients' experiences living with atrial fibrillation.

Importance: Race-based disparities in atrial fibrillation (AF) outcomes are well-documented, but few studies have investigated individuals' experiences of living with the condition, particularly among Black individuals. Objective: We aimed to identify common themes and challenges experienced by individuals of Black race with AF. Design: A tailored, qualitative script was developed to assess the perspectives of participants in focus groups. Setting: Virtual focus groups. Participants: Three focus groups of 4-6 participants (16 participants total) were recruited from the racial/ethnic minority participants in the Mobile Relational Agent to Enhance Atrial Fibrillation Self-care Trial. Main outcomes and measures: Focus group transcripts were inductively coded to identify common themes. Results: Nearly all participants self-identified as Black race (n = 15, 93.8 %). Participants were mostly male (62.5 %) with mean age of 67 (range 40-78) years. Three themes were identified. First, participants described physical and mental burdens associated with having AF. Second, participants described AF as being a condition that is difficult to manage. Lastly, participants identified key tenets to support self-management of AF (self-education, community support, and patient-provider relationships). Conclusions and relevance: Participants reported AF is unpredictable and challenging to manage, and that social and community supports are essential. The social and behavioral themes identified in this qualitative research highlight the need for tailored clinical strategies for AF self-management which incorporate individuals' social contexts. Trial registration: National Clinical Trial number 04075994.

Health Literacy is Essential to ASCVD Prevention in Youth.

PURPOSE OF REVIEW: Health literacy is fundamental to primary and primordial prevention of atherosclerotic vascular disease (ASCVD) in children and adolescents. Here we summarize essential components of interventions which address health literacy challenges to reduce ASCVD risk in youth. RECENT FINDINGS: There is a global pandemic of suboptimal health behaviors among youth that may contribute to the increasing rates of ASCVD worldwide. Deficiencies in youth cardiovascular health have promoted increased attention to health education that incorporates health literacy. Studies conducted in both the child (0 to 9 years) and adolescent (10 to 17 years) population have shown improvement in health knowledge, health behaviors such as physical activity and eating habits, and objective measures such as body mass index (BMI), blood pressure, and serum lipid levels. The available literature affirms that the involvement of family and community members in young people's surroundings-including parents, teachers, and peers-can influence educational interventions' protective effects. Educational interventions which incorporate health literacy have demonstrated potential to address ASCVD risk factors in youth and may be augmented by caregiver and community involvement.

Coronary perfusion pressure is associated with adverse outcomes in advanced heart failure.

BACKGROUND: Myocardial perfusion is an important determinant of cardiac function. We hypothesized that low coronary perfusion pressure (CPP) would be associated with adverse outcomes in heart failure. Myocardial perfusion impacts the contractile efficiency thus a low CPP would signal low myocardial perfusion in the face of increased cardiac demand as a result of volume overload. METHODS: We analyzed patients with complete hemodynamic data in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness trial using Cox Proportional Hazards regression for the primary outcome of the composite risk of death, heart transplantation, or left ventricular assist device [(LVAD). DT × LVAD] and the secondary outcome of the composite risk of DT × LVAD and heart failure hospitalization (DT × LVADHF). CPP was calculated as the difference between diastolic blood pressure and pulmonary artery wedge pressure. Heart failure categories (ischemic vs non-ischemic) were also stratified based on CPP strata. RESULTS: The 158 patients (56.7 ± 13.6 years, 28.5% female) studied had a median CPP of 40 mmHg (IQR 35-52 mmHg). During 6 months of follow-up, 35 (22.2%) had the composite primary outcome and 109 (69.0%) had the composite secondary outcome. When these outcomes were then stratified based on the median, CPP was associated with these outcomes. Increasing CPP was associated with lower risk of both the primary outcome of DT × LVAD (HR 0.96, 95% CI 0.94-0.99 p = .002) and as well as the secondary outcome of DT × LVADHF (p = .0008) There was significant interaction between CPP and ischemic etiology (p = .04). CONCLUSION: A low coronary artery perfusion pressure below (median) 40mmHg in patients with advanced heart failure undergoing invasive hemodynamic monitoring with a pulmonary artery catheter was associated with adverse outcomes. CPP could useful in guiding risk stratification of advanced heart failure patients and timely evaluation of advanced heart failure therapies.

The impact of COVID-19 on clinical outcomes among acute myocardial infarction patients undergoing early invasive treatment strategy.

BACKGROUND: The implications of coronavirus disease 2019 (COVID-19) infection on outcomes after invasive therapeutic strategies among patients presenting with acute myocardial infarction (AMI) are not well studied. HYPOTHESIS: To assess the outcomes of COVID-19 patients presenting with AMI undergoing an early invasive treatment strategy. METHODS: This study was a cross-sectional, retrospective analysis of the National COVID Cohort Collaborative database including all patients presenting with a recorded diagnosis of AMI (ST-elevation myocardial infarction (MI) and non-ST elevation MI). COVID-19 positive patients with AMI were stratified into one of four groups: (1a) patients who had a coronary angiogram with percutaneous coronary intervention (PCI) within 3 days of their AMI; (1b) PCI within 3 days of AMI with coronary artery bypass graft (CABG) within 30 days; (2a) coronary angiogram without PCI and without CABG within 30 days; and (2b) coronary angiogram with CABG within 30 days. The main outcomes were respiratory failure, cardiogenic shock, prolonged length of stay, rehospitalization, and death. RESULTS: There were 10 506 COVID-19 positive patients with a diagnosis of AMI. COVID-19 positive patients with PCI had 8.2 times higher odds of respiratory failure than COVID-19 negative patients (p = .001). The odds of prolonged length of stay were 1.7 times higher in COVID-19 patients who underwent PCI (p = .024) and 1.9 times higher in patients who underwent coronary angiogram followed by CABG (p = .001). CONCLUSION: These data demonstrate that COVID-19 positive patients with AMI undergoing early invasive coronary angiography had worse outcomes than COVID-19 negative patients.

Relation of Household Income to Access and Adherence to Combination Sacubitril/Valsartan in Heart Failure: A Retrospective Analysis of Commercially Insured Patients.

BACKGROUND: Outcomes in heart failure with reduced ejection fraction (HFrEF) are influenced by access and adherence to guideline-directed medical therapy. Our objective was to study the association between annual household income and: (1) the odds of having a claim for sacubitril/valsartan among insured patients with HFrEF and (2) medication adherence (measured as the proportion of days covered). We hypothesized that lower annual household income is associated with decreased odds of having a claim for and adhering to sacubitril/valsartan. METHODS: Using the Optum de-identified Clinformatics Data Mart, patients with HFrEF and ≥6 months of enrollment for follow-up (2016-2020) were included. Covariates included age, sex, race, ethnicity, educational attainment, US region, number of prescribed medications, and Elixhauser Comorbidity Index. Prescription for sacubitril/valsartan was defined by the presence of a claim within 6 months of HFrEF diagnosis. Adherence was defined as proportion of days covered ≥80%. We fit multivariable-adjusted logistic regression models and hierarchical logistic regression accounting for covariates. RESULTS: Among 322 007 individuals with incident HFrEF, 135 282 had complete data for analysis. Of the patients eligible for sacubitril/valsartan, 4.7% (6372) had a claim within 6 months of HFrEF diagnosis. Following multivariable adjustment, individuals in the lowest annual income category (<$40 000) were significantly less likely (odds ratio, 0.83 [95% CI, 0.76-0.90]) to have a sacubitril/valsartan claim within 6 months of HFrEF diagnosis than those in the highest annual income category (≥$100 000). Annual income <$40 000 was associated with lower odds of proportion of days covered ≥80% compared with income ≥$100 000 (odds ratio, 0.70 [95% CI, 0.59-0.83]). CONCLUSIONS: Lower household income is associated with decreased likelihood of a sacubitril/valsartan claim and medication adherence within 6 months of HFrEF diagnosis, even after adjusting for sociodemographic and clinical factors. Future analyses are needed to identify additional social factors associated with delays in sacubitril/valsartan initiation and long-term adherence.

Utilizing Artificial Intelligence to Enhance Health Equity Among Patients with Heart Failure.

Patients with heart failure (HF) are heterogeneous with various intrapersonal and interpersonal characteristics contributing to clinical outcomes. Bias, structural racism, and social determinants of health have been implicated in unequal treatment of patients with HF. Through several methodologies, artificial intelligence (AI) can provide models in HF prediction, prognostication, and provision of care, which may help prevent unequal outcomes. This review highlights AI as a strategy to address racial inequalities in HF; discusses key AI definitions within a health equity context; describes the current uses of AI in HF, strengths and harms in using AI; and offers recommendations for future directions.

Developing and Implementing an mHealth Heart Failure Self-care Program to Reduce Readmissions: Randomized Controlled Trial.

BACKGROUND: Patients admitted with decompensated heart failure (HF) are at risk for hospital readmission and poor quality of life during the discharge period. Lifestyle behavior modifications that promote the self-management of chronic cardiac diseases have been associated with an improved quality of life. However, whether a mobile health (mHealth) program can assist patients in the self-management of HF during the acute posthospital discharge period is unknown. OBJECTIVE: We aimed to develop an mHealth program designed to enhance patients' self-management of HF by increasing knowledge, self-efficacy, and symptom detection. We hypothesized that patients hospitalized with HF would be willing to use a feasibly deployed mHealth program after their hospital discharge. METHODS: We employed a patient-centered outcomes research methodology to design a stakeholder-informed mHealth program. Adult patients with HF admitted to a large academic hospital were enrolled and randomized to receive the mHealth intervention versus usual care. Our feasibility outcomes included ease of program deployment, use of the clinical escalation process, duration of participant recruitment, and participant attrition. Surveys assessing the demographics and clinical characteristics of HF were measured at baseline and at 30 and 90 days after discharge. RESULTS: The study period was between July 1, 2019, and April 7, 2020. The mean cohort (N=31) age was 60.4 (range 22-85) years. Over half of the participants were men (n=18, 58%) and 77% (n=24) were White. There were no significant differences in baseline measures. We determined that an educational mHealth program tailored for patients with HF is feasibly deployed and acceptable by patients. Though not significant, we found notable trends including a higher mean quality of life at 30 days posthospitalization among program users and a longer duration before rehospitalization, which are suggestive of better HF prognosis. CONCLUSIONS: Our mHealth tool should be further assessed in a larger comparative effectiveness trial. Our pilot intervention offers promise as an innovative means to help HF patients lead healthy, independent lives. These preliminary data suggest that patient-centered mHealth tools can enable high-risk patients to play a role in the management of their HF after discharge. TRIAL REGISTRATION: ClinicalTrials.gov NCT03982017; https://clinicaltrials.gov/ct2/show/NCT03982017.

Association between neighborhood deprivation and presenting with a ruptured abdominal aortic aneurysm before screening age.

OBJECTIVE: Recent data indicate social determinants of health (SDOH) have a great impact on prevention and treatment outcomes across a broad variety of disease states, especially cardiovascular diseases. The area deprivation index (ADI) is a validated measure of neighborhood level disadvantage capturing key social determinate factors. Abdominal aortic aneurysm rupture (rAAA) is highly morbid, but also preventable through evidence-based screening. However, the association between rAAA and SDOH is poorly characterized. Our objective is to study the association of SDOH with rAAA and screening age. METHODS: This retrospective study included patients who underwent operative repair of a rAAA at a multihospital healthcare system (2003-2019). Deprivation was measured by the ADI (scale 1-100), grouped into quintiles for simplicity, with higher quintiles indicating greater deprivation. Patients with the highest quintile ADI (89-100) were categorized as the most deprived. We investigated the association between neighborhood deprivation with the odds of (i) undergoing repair for rAAA before screening age 65 and (ii) undergoing endovascular aortic repair (EVAR) using logistic regression, sequentially modeling nonmodifiable then both nonmodifiable and modifiable confounding variables. RESULTS: There were 632 patients who met the inclusion criteria (aged 74.2 ± 9.4 years; 174 women [27.6%]; 564 White [89.2%]; ADI 66.8 ± 22.3). Those from the most deprived neighborhoods (n = 118) were younger (71.7 ± 10.0 years vs 74.8 ± 9.2 years; P = .002), more likely to be female (36% vs 26%; P = .031), more likely to be Black (5.9% vs 0.4%; P = .007), and fewer underwent EVAR (28% vs 39.5%; P = .020) compared with those from other neighborhoods. On sequential modeling, residing in the most deprived neighborhoods was associated with undergoing rAAA repair before age 65 after adjusting for nonmodifiable factors (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.39-2.95; P < .001), and nonmodifiable as well as modifiable factors (OR, 2.22; 95% CI, 1.56-3.16; P < .001). Those in the most deprived neighborhoods had a lower odds of undergoing EVAR compared with open repair after adjusting for nonmodifiable factors (OR, 0.64; 95% CI, 0.41-0.98; P = .042), and nonmodifiable as well as modifiable factors (OR, 0.61; 95% CI, 0.37-0.99; P = .047). CONCLUSIONS: Among patients who underwent rAAA, residing in the most deprived neighborhoods was associated with greater adjusted odds of presenting under age 65 and undergoing an open repair. These neighborhoods represent tangible geographic targets that may benefit from a younger screening age, enhanced education, and access to care. These findings stress the importance of developing strategies for early prevention and diagnosis of cardiovascular diseases among patients with disadvantageous SDOH.

Educational Attainment, Race, and Ethnicity as Predictors for Ideal Cardiovascular Health: From the National Health and Nutrition Examination Survey.

Background Educational attainment is protective for cardiovascular health (CVH), but the benefits of education may not persist across racial and ethnic groups. Our objective was to determine whether the association between educational attainment and ideal CVH differs by race and ethnicity in a nationally representative sample. Methods and Results Using the National Health and Nutrition Examination Survey, we determined the distribution of ideal CVH, measured by Life's Simple 7, across levels of educational attainment. We used multivariable ordinal logistic regression to assess the association between educational attainment (less than high school, high school graduate, some college, college graduate) and Life's Simple 7 category (ideal, intermediate, poor), by race and ethnicity (Asian, Black, Hispanic, White). Covariates were age, sex, history of cardiovascular disease, health insurance, access to health care, and income-poverty ratio. Of 7771 National Health and Nutrition Examination Survey participants with complete data, as level of educational attainment increased, the criteria for ideal health were more often met for most metrics. After adjustment for covariates, effect of education was attenuated but remained significant (P<0.01). Those with at least a college degree had 4.12 times the odds of having an ideal Life's Simple 7 compared with less than high school (95% CI, 2.70-5.08). Among all racial and ethnic groups, as level of educational attainment increased, so did Life's Simple 7. The magnitude of the association between education and CVH varied by race and ethnicity (interaction P<0.01). Conclusions Our findings demonstrate that educational attainment has distinct associations with ideal CVH that differs by race and ethnicity. This work demonstrates the need to elucidate barriers preventing individuals from racial and ethnic minority groups from achieving equitable CVH.

Internet access and cardiovascular death in the United States.

As high-speed internet becomes increasingly important as a resource for cardiovascular disease (CVD) prevention and management services, gaps in digital infrastructure may have detrimental impact on health outcomes. Using national census and CDC data from 2018 we evaluated state-level rates of household internet access and age-adjusted cardiac mortality. After adjusting for state level demographic variables, and rates of education, income, and health insurance, internet access rates were inversely associated with age adjusted CVD mortality, showing that the potential for internet access to affect CVD management deserves further study.

Disparities in Reporting a History of Cardiovascular Disease Among Adults With Limited English Proficiency and Angina.

Importance: Individuals with limited English proficiency (LEP) may be unaware of underlying cardiovascular disease (CVD) owing to a lack of diagnostic testing or poor communication with health care practitioners. Objective: To evaluate whether participants with anginal symptoms and LEP would be less likely to report a history of CVD compared with those without LEP. Design, Study, and Participants: This population-based cross-sectional study combined data from 5 National Health and Nutrition Examination Survey (NHANES) cycles conducted from 2007 to 2016. Each cycle includes an interview that collects demographic, dietary, and health-related data as well as a medical examination component in which physiological measurements are taken. All NHANES participants aged 40 years or older who took the Rose questionnaire were included. Data were analyzed from September 2020 to April 2021. Exposures: LEP was defined as a participant receiving the survey in a non-English language or by interpreter. Main Outcomes and Measures: The 7-item Rose questionnaire assessed the presence of anginal symptoms. Self-reported CVD was defined as history of heart failure, coronary heart disease, angina pectoris, or myocardial infarction. The association between LEP status and self-reported CVD among those with anginal symptoms was determined in multivariable-adjusted models. All analyses were weighted per NHANES analytic protocols. Results: Among 19 320 participants (mean [SD] age, 57.8 [11.8] years; 9344 [47.2%] male; 4145 [10.6%] Black; 2743 [6.3%] Mexican American; 2111 [4.6%] other Hispanic; 8386 [71.6%] White; and 1935 [6.9%] other race), 583 (3.0%) reported anginal symptoms. Of these, most were non-LEP (484 [96.1%]), women (344 [62.1%]), White (251 [66.8%]), and did not report having CVD (347 [62.8%]). Among those with angina, 73 of 99 respondents with LEP (79.0%) reported not having a history of CVD, compared with 274 of 484 without LEP (61.4%; P = .002). Participants with LEP had 2.8-fold higher odds of not reporting a history of CVD compared with participants without LEP (odds ratio, 2.77; 95% CI, 1.38-5.55; P = .005). Conclusions and Relevance: Among NHANES participants reporting anginal symptoms, participants with LEP were more likely not to report having CVD. This discrepancy may be because of higher rates of undiagnosed CVD or lower awareness of such diagnoses among individuals with LEP. Our findings highlight the relevance of communication strategies for individuals with LEP to provide effective intervention and treatment for CVD prevention.

Area Deprivation Index and Cardiac Readmissions: Evaluating Risk-Prediction in an Electronic Health Record.

Background Assessment of the social determinants of post-hospital cardiac care is needed. We examined the association and predictive ability of neighborhood-level determinants (area deprivation index, ADI), readmission risk, and mortality for heart failure, myocardial ischemia, and atrial fibrillation. Methods and Results Using a retrospective (January 1, 2011-December 31, 2018) analysis of a large healthcare system, we assess the predictive ability of ADI on 30-day and 1-year readmission and mortality following hospitalization. Cox proportional hazards models analyzed time-to-event. Log rank analyses determined survival. C-statistic and net reclassification index determined the model's discriminative power. Covariates included age, sex, race, comorbidity, number of medications, length of stay, and insurance. The cohort (n=27 694) had a median follow-up of 46.5 months. There were 14 469 (52.2%) men and 25 219 White (91.1%) patients. Patients in the highest ADI quintile (versus lowest) were more likely to be admitted within 1 year of index heart failure admission (hazard ratio [HR], 1.25; 95% CI, 1.03‒1.51). Patients with myocardial ischemia in the highest ADI quintile were twice as likely to be readmitted at 1 year (HR, 2.04; 95% CI, 1.44‒2.91]). Patients with atrial fibrillation living in areas with highest ADI were less likely to be admitted within 1 year (HR, 0.79; 95% CI, 0.65‒0.95). As ADI increased, risk of readmission increased, and risk reclassification was improved with ADI in the models. Patients in the highest ADI quintile were 25% more likely to die within a year (HR, 1.25 1.08‒1.44). Conclusions Residence in socioeconomically disadvantaged communities predicts rehospitalization and mortality. Measuring neighborhood deprivation can identify individuals at risk following cardiac hospitalization.

Training Underrepresented Early-Career Faculty in Cardiovascular Health Research during COVID-19: Structural Inequities and Health Disparity.

The COVID-19 pandemic has highlighted race-based health disparities and structural racism in the United States. Enhancing the training of early-career academic and health scientists from underrepresented minority groups (URM) is critical to reduce disparities affecting underserved population groups. A dedicated training program that has been proven to support URM can facilitate career development for junior faculty during the pandemic. This critical support ensures the retention of talented, racially diverse junior faculty who are poised to mitigate structural racism, rather than perpetuate it. We describe how the Cardiovascular Disease Programs to Increase Diversity Among Individuals Engaged in Health-Related Research (PRIDE-CVD) summer institute successfully transitioned from a face-to-face format to a virtual format during the COVID-19 pandemic. As a result, early-career faculty continued to receive the PRIDE-CVD training on research methodology, grantsmanship, career development, and CVD health disparities, especially as related to the pandemic. In addition, the virtual format facilitated networking, promoted mental wellness, and allowed continual mentorship. Collectively, the program provided timely and relevant career development in the COVID-19 era and helped participants navigate the psychosocial challenges of being a URM in cardiovascular health research.