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1.
JAMA Cardiol ; 2022 Jan 05.
Artigo em Inglês | MEDLINE | ID: mdl-34985497

RESUMO

Importance: There are limited data regarding sex-based differences in physical and mental health domains and health care access in adults with premature atherosclerotic cardiovascular disease (ASCVD). Objective: To study the association of sex with physical and mental health domains as well as health care access-related factors among adults with self-reported premature ASCVD. Design, Setting, and Participants: Retrospective cohort analysis of 748 090 adults aged 18 to 55 years in the Behavioral Risk Factor Surveillance System 2016 to 2019 in the US. Data were analyzed from June to July 2021. Exposures: Self-reported ASCVD, defined as having a history of coronary artery disease, myocardial infarction, or stroke. Main Outcomes and Measures: Self-reported physical and mental health and measures of health care access, including self-reported cost-related medication nonadherence and inability to see a physician due to cost. Results: Between 2016 and 2019, 748 090 adults aged 18-55 years were identified, of whom 28 522 (3.3%) had self-reported premature ASCVD. Of these, 14 358 (47.0%) were women. Compared with men, women with premature ASCVD were more likely to report being clinically depressed (odds ratio [OR], 1.73; 95% CI, 1.41-2.14; P < .001), have cost-related medication nonadherence (OR, 1.42; 95% CI, 1.11-1.82; P = .005), have not seen a physician due to cost-related issues (OR, 4.52; 95% CI, 2.24-9.13; P < .001), and were more likely to report overall poor physical health (OR, 1.39; 95% CI, 1.09-1.78; P = .008) despite being more likely to have health care coverage (85.3% vs 80.8%; P = .04) and a primary care physician (84.2% vs 75.7%; P < .001). Conclusions and Relevance: Results from this study indicate that women with premature ASCVD were more likely to report worse overall physical and mental health, inability to see a physician due to cost, and cost-related medical nonadherence. Interventions addressing mental health and out-of-pocket costs are needed in adults with premature ASCVD.

2.
Diabetes Care ; 2022 Jan 06.
Artigo em Inglês | MEDLINE | ID: mdl-35015080

RESUMO

OBJECTIVE: There is mounting evidence regarding the cardiovascular benefits of sodium-glucose cotransporter 2 inhibitors (SGLT2-Is) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) among patients with atherosclerotic cardiovascular disease (ASCVD) and type 2 diabetes mellitus (T2DM). There is paucity of data assessing real-world practice patterns for these drug classes. We aimed to assess utilization rates of these drug classes and facility-level variation in their use. RESEARCH DESIGN AND METHODS: We used the nationwide Veterans Affairs (VA) health care system data set from 1 January 2020 to 31 December 2020 and included patients with established ASCVD and T2DM. Among these patients, we assessed the use of SGLT2-I and GLP-1 RA and the facility-level variation in their use. Facility-level variation was computed using median rate ratios (MRR), a measure of likelihood that two random facilities differ in use of SGLT2i and GLP-1 RA in patients with ASCVD and T2DM. RESULTS: Among 537,980 patients with ASCVD and T2DM across 130 VA facilities, 11.2% of patients received an SGLT2i while 8.0% of patients received a GLP-1 RA. Patients receiving these cardioprotective glucose-lowering drug classes were on average younger and had a higher proportion of non-Hispanic Whites. Overall, median (10th-90th percentile) facility-level rates were 14.92% (9.31-22.50) for SGLT2i and 10.88% (4.44-17.07) for GLP-1 RA. There was significant facility-level variation among SGLT2-Is use-MRRunadjusted: 1.41 (95% CI 1.35-1.47) and MRRadjusted: 1.55 (95% CI 1.46 -1.63). Similar facility-level variation was observed for use of GLP-1 RA-MRRunadjusted: 1.34 (95% CI 1.29-1.38) and MRRadjusted: 1.78 (95% CI1.65-1.90). CONCLUSIONS: Overall utilization rates of SGLT2i and GLP-1 RA among eligible patients are low, with significantly higher residual facility-level variation in the use of these drug classes. Our results suggest opportunities to optimize their use to prevent future adverse cardiovascular events among these patients.

3.
Circulation ; 2021 Dec 08.
Artigo em Inglês | MEDLINE | ID: mdl-34879218

RESUMO

Background: The 2018 American Heart Association/ American College of Cardiology Multisociety (AHA/ACC/MS) cholesterol guideline states that statin therapy may be withheld or delayed among intermediate risk individuals in the absence of coronary artery calcium (CAC=0). We evaluated whether traditional cardiovascular risk factors are associated with incident atherosclerotic cardiovascular disease (ASCVD) events among individuals with CAC=0 over long-term follow-up. Methods: We included participants with CAC=0 at baseline from the Multi-Ethnic Study of Atherosclerosis (MESA), a prospective cohort study of individuals free of clinical ASCVD at baseline. We used multivariable-adjusted Cox proportional hazards models to study the association between cardiovascular risk factors [cigarette smoking, diabetes mellitus, hypertension, preventive medication use (aspirin and statin), family history of premature ASCVD, chronic kidney disease, waist circumference, lipid and inflammatory markers] and adjudicated incident ASCVD outcomes. Results: We studied 3,416 individuals (mean (SD) age 58 (9) years; 63% were female, 33% White, 31% Black, 12% Chinese-American, and 24% Hispanic. Over a median follow-up of 16 years, there were 189 ASCVD events (composite of CHD and stroke) of which 91 were CHD, 88 were stroke, and 10 were both CHD and stroke events. The unadjusted event rates of ASCVD were ≤5 per 1000-person-years among individuals with CAC=0 for most risk factors with the exception of current cigarette smoking (7.3), diabetes mellitus (8.9), hypertension (5.4), and chronic kidney disease (6.8). After multivariable-adjustment, risk factors that were significantly associated with ASCVD: hazard ratio (HR) 95% confidence interval (CI) included current cigarette smoking: 2.12 (1.32,3.42), diabetes mellitus: 1.68 (1.01,2.80), and hypertension: 1.57 (1.06,2.33). Conclusions: Current cigarette smoking, diabetes mellitus, and hypertension are independently associated with incident ASCVD over 16-year follow-up among those with CAC=0. Family history of premature ASCVD may be associated with ASCVD risk among women only.

4.
JAMA Netw Open ; 4(12): e2140212, 2021 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-34962564
5.
Artigo em Inglês | MEDLINE | ID: mdl-34656489

RESUMO

OBJECTIVES: The aim of this study was to compare the incremental prognostic value of coronary computed tomography (CT) angiography (CCTA)-derived machine learning fractional flow reserve CT (ML-FFRct) versus that of ischemia detected on single-photon emission-computed tomography (SPECT) myocardial perfusion imaging (MPI) on incident cardiovascular outcomes. BACKGROUND: SPECT MPI and ML-FFRct are noninvasive tools that can assess the hemodynamic significance of coronary atherosclerotic disease. METHODS: We studied a retrospective cohort of consecutive patients who underwent clinically indicated CCTA and SPECT MPI. ML-FFRct was computed using a ML prototype. The primary outcome was all-cause mortality and nonfatal myocardial infarction (D/MI), and the secondary outcome was D/MI and unplanned revascularization, percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) occurring more than 90 days postimaging. Multiple nested multivariate cox regression was used to model a scenario wherein an initial anatomical assessment was followed by a functional assessment. RESULTS: A total of 471 patients (mean age: 64 ± 13 year; 53% males) were included. Comorbidities were prevalent (78% hypertension, 66% diabetes, 81% dyslipidemia). ML-FFRct was <0.8 in at least 1 proximal/midsegment was present in 41.6% of patients, and ischemia on MPI was present in 13.8%. After a median follow-up of 18 months, 7% of patients (n = 33) experienced D/MI. On multivariate Cox proportional analysis, the presence of ischemia on MPI but not ML-FFRct significantly predicted D/MI (HR: 2.3; 95% CI: 1.0-5.0; P = 0.047; or HR: 0.7; 95% CI: 0.3-1.4; P = 0.306 respectively) when added to CCTA obstructive stenosis. Furthermore, the model with SPECT ischemia had higher global chi-square result and significantly improved reclassification. Results were similar using the secondary outcome and on several sensitivity analyses. CONCLUSIONS: In a high-risk patient cohort, SPECT MPI but not ML-FFRct adds independent and incremental prognostic information to CCTA-based anatomical assessment and clinical risk factors in predicting incident outcomes.

6.
Curr Atheroscler Rep ; 23(12): 76, 2021 10 14.
Artigo em Inglês | MEDLINE | ID: mdl-34648072

RESUMO

PURPOSE OF REVIEW: This review highlights select studies presented at the virtual 2021 European Society of Cardiology (ESC) Congress. RECENT FINDINGS: Reviewed studies assess single photon emission computed tomography, positron emission tomography, magnetic resonance imaging in coronary artery disease (PACIFIC-II); empagliflozin in heart failure with preserved ejection fraction (EMPEROR-Preserved); dapagliflozin in chronic heart failure (DAPA-HF); proprotein convertase subtilisin/kexin type 9 inhibitor and its lipid lowering effects (NATURE-PCSK9); fixed-dose combination therapies with or without aspirin in primary prevention; overview of contrasting results between REDUCE-IT versus STRENGTH trials; Quadruple UltrA-low-dose tReaTment for hypertension (QUARTET); evolocumab and changes in plaque composition on optical coherence tomography (HUYGENS); and low-dose rivaroxaban during the acute phase of acute coronary syndrome (H-REPLACE). Research presented at the 2021 ESC Congress shows promise in reducing burden of cardiovascular disease and reinforces the value of cardiovascular disease prevention.


Assuntos
Síndrome Coronariana Aguda , Cardiologia , Doenças Cardiovasculares , Doenças Cardiovasculares/tratamento farmacológico , Doenças Cardiovasculares/prevenção & controle , Humanos , Pró-Proteína Convertase 9
7.
JAMA Cardiol ; 2021 Sep 08.
Artigo em Inglês | MEDLINE | ID: mdl-34495296

RESUMO

Importance: Women cardiologists receive lower salaries than men; however, it is unknown whether US Centers for Medicare & Medicaid Services (CMS) reimbursement also differs by gender and contributes to the lower salaries. Objective: To determine whether gender differences exist in the reimbursements, charges, and reimbursement per charge from CMS. Design, Setting, and Participants: This cross-sectional analysis used the CMS database to obtain 2016 reimbursement data for US cardiologists. These included reimbursements to cardiologists, charges submitted, and unique billing codes. Gender differences in reimbursement for evaluation and management and procedural charges from both inpatient and outpatient settings were also assessed. Analysis took place between April 2019 and December 2020. Main Outcomes and Measures: Outcomes included median CMS payments received and median charges submitted in the inpatient and outpatient settings in 2016. Results: In 2016, 17 524 cardiologists (2312 women [13%] and 15 212 men [87%]) received CMS payments in the inpatient setting, and 16 929 cardiologists (2151 women [13%] and 14 778 men [87%]) received CMS payments in the outpatient setting. Men received higher median payments in the inpatient (median [interquartile range], $62 897 [$30 904-$104 267] vs $45 288 [$21 371-$73 191]; P < .001) and outpatient (median [interquartile range], $91 053 [$34 820-$196 165] vs $51 975 [$15 622-$120 175]; P < .001) practice settings. Men submitted more median charges in the inpatient (median [interquartile range], 1190 [569-2093] charges vs 959 [569-2093] charges; P < .001) and outpatient settings (median [interquartile range], 1685 [644-3328] charges vs 870 [273-1988] charges; P < .001). In a multivariable-adjusted linear regression analysis, women received less CMS payments compared with men (log-scale ß = -0.06; 95% CI, -0.11 to -0.02) after adjustment for number of charges, number of unique billing codes, complexity of patient panel, years since graduation of physicians, and physician subspecialty. Payment by billing codes, both inpatient and outpatient, did not differ by gender. Conclusions and Relevance: There may be potential differences in CMS payments between men and women cardiologists, which appear to stem from gender differences in the number and types of charges submitted. The mechanisms behind these differences merit further research, both to understand why such gender differences exist and also to facilitate reductions in pay disparities.

8.
Am J Med ; 2021 Sep 09.
Artigo em Inglês | MEDLINE | ID: mdl-34509447

RESUMO

PURPOSE: We conducted this study to investigate the association of cardiorespiratory fitness and all-cause mortality among patients with chronic kidney disease. METHODS: We studied a retrospective cohort of patients from the Henry Ford Health System who underwent clinically indicated exercise stress testing with baseline cardiorespiratory fitness and estimated glomerular filtration rate measurement. Cardiorespiratory fitness was expressed as metabolic equivalents of task, and kidney function was categorized into stages according to estimated glomerular filtration rate. Multivariable-adjusted Cox proportional hazard models were used to examine the association between metabolic equivalents of task and all-cause mortality among patients with chronic kidney disease stages 3-5. Discrimination of mortality was assessed using receiver operating characteristic curves, while reclassification was evaluated using net reclassification index (NRI). RESULTS: Among 50,121 participants, the mean age was 55 ± 12.6 years; 47.5% were women, 64.5% were white, and 6877 (13.7%) participants had chronic kidney disease stage 3-5. Over a median follow-up of 6.7 years, 6308 participants died (12.6%). Each 1-unit higher metabolic equivalents of task was associated with a significant 15% reduction in all-cause mortality (hazard ratio 0.85; 95% confidence interval [CI], 0.84-0.87). Metabolic equivalents of task improved discriminatory ability of mortality prediction when added to traditional risk factors and estimated glomerular filtration rate (area under the curve 0.7996; 95% CI, 0.789-0.810 vs 0.759; 95% CI, 0.748-0.770, respectively; P < .001). The addition of metabolic equivalents of task to traditional risk factors resulted in significant reclassification (6% for events, 5% for non-events: NRI = 0.13, P < .001). CONCLUSIONS: Cardiorespiratory fitness improves mortality risk prediction among patients with chronic kidney disease. Cardiorespiratory fitness provides incremental prognostic information when added to traditional risk factors and may help guide treatment options among patients with renal dysfunction.

10.
Prev Med ; 153: 106779, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-34487748

RESUMO

Ensuring healthcare access is critical to maintain health and prevent illness. Studies demonstrate gender disparities in healthcare access. Less is known about how these vary with age, race/ethnicity, and atherosclerotic cardiovascular disease. We utilized cross-sectional data from 2016 to 2019 CDC Behavioral Risk Factor Surveillance System (BRFSS), a U.S. telephone-based survey of adults (≥18 years). Measures of difficulty accessing healthcare included absence of healthcare coverage, delay in healthcare access, absence of primary care physician, >1-year since last checkup, inability to see doctor due to cost, and cost-related medication non-adherence. We studied the association between gender and these variables using multivariable-adjusted logistic regression models, stratifying by age, race/ethnicity, and atherosclerotic cardiovascular disease status. Our population consisted of 1,737,397 individuals; 54% were older (≥45 years), 51% women, 63% non-Hispanic White, 12% non-Hispanic Black,17% Hispanic, 9% reported atherosclerotic cardiovascular disease. In multivariable-adjusted models, women were more likely to report delay in healthcare access: odds ratio (OR) and (95% confidence interval): 1.26 (1.11, 1.43) [p < 0.001], inability to see doctor due to cost: 1.29 (1.22, 1.36) [p < 0.001], cost-related medication non-adherence: 1.24 (1.01, 1.50) [p = 0.04]. Women were less likely to report lack of healthcare coverage: 0.71 (0.66, 0.75) [p < 0.001] and not having a primary care physician: 0.50 (0.48, 0.52) [p < 0.001]. Disparities were pronounced in younger (<45 years) and Black women. Identifying these barriers, particularly among younger women and Black women, is crucial to ensure equitable healthcare access to all individuals.

11.
Atherosclerosis ; 334: 48-56, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34481175

RESUMO

BACKGROUND AND AIMS: South Asian (SA) ethnicity is associated with an increased risk of atherosclerotic cardiovascular disease (ASCVD). However, the implications of considering SA ethnicity as a "risk-enhancing factor" per recent American College of Cardiology/American Heart Association guidelines are not fully understood. METHODS: We used data from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study, a community-based cohort study of individuals of SA ancestry living in the US. The Pooled Cohort Equations were used to estimate 10-year ASCVD risk. Metabolic risk factors and coronary artery calcium (CAC) scores were assessed. RESULTS: Among 1114 MASALA participants included (median age 56 years, 48% women), 28% were already using a statin at baseline, 25% had prevalent diabetes, and 59% qualified for 10-year ASCVD risk assessment for statin allocation purposes. The prevalence of low, borderline, intermediate, and high estimated ASCVD risk was 65%, 11%, 20% and 5%, respectively. Among participants at intermediate risk, 30% had CAC = 0 and 37% had CAC>100, while among participants at borderline risk, 54% had CAC = 0 and 13% had CAC>100. Systematic consideration of intermediate and, particularly, of borderline risk individuals as statin candidates would enrich the statin-consideration group with CAC = 0 participants up to 35%. Prediabetes and abdominal obesity were highly prevalent across all estimated risk strata, including among those with CAC = 0. CONCLUSIONS: Our findings suggest that systematic consideration of borderline risk SAs as statin candidates might result in considerable overtreatment, and further risk assessment with CAC may help better personalize statin allocation in these individuals. Early, aggressive lifestyle interventions aimed at reducing the risk of incident diabetes should be strongly recommended in US SAs, particularly among those considered candidates for statin therapy for primary prevention. Longitudinal studies are needed to confirm the favorable prognosis of CAC = 0 in SAs.


Assuntos
Aterosclerose , Cardiologia , Doença da Artéria Coronariana , Inibidores de Hidroximetilglutaril-CoA Redutases , American Heart Association , Cálcio , Estudos de Coortes , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/epidemiologia , Feminino , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Masculino , Pessoa de Meia-Idade , Prevenção Primária , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Estados Unidos/epidemiologia
12.
Vasa ; 50(6): 439-445, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34346252

RESUMO

Background: Galectin-3 (gal-3) is a ß-galactoside-binding lectin associated tissue fibrosis and inflammation. There is limited understanding of the relationship between gal-3 and vascular health. Our aim was to assess the association between gal-3 and arterial stiffness in older adults. Methods: We conducted a cross-sectional study of 4275 participants (mean age of 75 years) from the Atherosclerosis Risk in Communities (ARIC) Study. Central arterial stiffness was measured by carotid-femoral pulse wave velocity (cfPWV). We evaluated the association of gal-3 with cfPWV using multivariable linear regression. Results: The median (interquartile range) gal-3 concentration was 16.5 (13.8, 19.8) ng/mL and mean cfPWV was 1163±303 cm/s. Higher gal-3 concentration was associated with greater central arterial stiffness after adjustment for age, sex, race-center, heart rate, systolic blood pressure, anti-hypertensive medication use, and current smoking status (ß=36.4 cm/s change in cfPWV per log unit change in gal-3; 95% CI: 7.2, 65.5, p=0.015). The association was attenuated after adjusting for additional cardiovascular risk factors (ß=17.3, 95% CI: -14.4, 49.0). Conclusions: In community-dwelling older adults, gal-3 concentration was associated with central arterial stiffness, likely sharing common pathways with traditional cardiovascular risk factors.


Assuntos
Galectina 3/sangue , Rigidez Vascular , Idoso , Pressão Sanguínea , Estudos Transversais , Humanos , Análise de Onda de Pulso , Fatores de Risco
14.
Prog Cardiovasc Dis ; 68: 2-6, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34371083

RESUMO

Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of morbidity and mortality in the United States (U.S.) and incurs significant cost to the healthcare system. Management of cholesterol remains central for ASCVD prevention and has been the focus of multiple national guidelines. In this review, we compare the American Heart Association (AHA)/American College of Cardiology (ACC) and the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) Cholesterol guidelines. We review the evidence base that was used to generate recommendations focusing on 4 distinct themes: 1) the threshold of absolute 10-year ASCVD risk to start a clinician-patient discussion for the initiation of statin therapy in primary prevention patients; 2) the utility of coronary artery calcium score to guide clinician-patient risk discussion pertaining to the initiation of statin therapy for primary ASCVD prevention; 3) the use of moderate versus high-intensity statin therapy in patients with established ASCVD; and 4) the utility of ordering lipid panels after initiation or intensification of lipid lowering therapy to document efficacy and monitor adherence to lipid lowering therapy. We discuss why the VA/DoD and AHA/ACC may have reached different conclusions on these key issues.

15.
Atherosclerosis ; 334: 9-16, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34450557

RESUMO

BACKGROUND AND AIMS: Cardiac computed tomographic angiography (CCTA) - derived measures of coronary artery disease (CAD) burden have been shown to independently predict incident cardiovascular events. We aimed to compare the added prognostic value of plaque burden to CCTA anatomic assessment and single photon emission computed tomography (SPECT) physiologic assessment in a cohort with high prevalence of risk factors undergoing both tests. METHODS: Consecutive patients who underwent clinically indicated CCTA and SPECT myocardial imaging for suspected CAD were included. Stenosis severity and segment involvement score (SIS - number of segments with plaque irrespective of stenosis) were determined from CCTA, and presence of ischemia was determined from SPECT. Patients were followed for major adverse cardiovascular events (MACE, inclusive of all-cause death, non-fatal myocardial infarction, and percutaneous coronary intervention or coronary artery bypass grafting 90-days after imaging test.) RESULTS: A total of 956 patients were included (mean age 61.1 ± 14.2 years, 54% men, 89% hypertension, 81% diabetes, 84% dyslipidemia). Obstructive stenosis (left main ≥50%, all other coronary segments ≥70%) and ischemia were observed in a similar number of patients (14%). In multivariable Cox regression models, SIS significantly predicted outcomes and improved risk discrimination in models with CCTA obstructive stenosis (HR 1.15, p ≤ 0.001; Harrel's C 0.74, p = 0.008) and SPECT ischemia (HR 1.14, p < 0.001; Harrel's C 0.76, p = 0.019). CONCLUSIONS: Our results suggest that in patients with suspected CAD and a high prevalence of risk-factors, plaque burden adds incremental prognostic value over established CCTA and SPECT measures to predict incident cardiovascular outcomes.


Assuntos
Doença da Artéria Coronariana , Imagem de Perfusão do Miocárdio , Idoso , Angiografia por Tomografia Computadorizada , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico
16.
Prev Med ; 153: 106715, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-34242664

RESUMO

Medication nonadherence is highly prevalent among patients with chronic cardiovascular disease. Poor adherence has been associated with increased morbidity and mortality. Medication cost is a major driver for medication nonadherence. Utilizing data from the 2016 to 2018 Behavioral Risk Factor Surveillance System (BRFSS) survey, we estimated the prevalence of cost-related medication nonadherence (CRMNA) among the overall population and among individuals who reported a history of diabetes, atherosclerotic cardiovascular disease (ASCVD), or hypertension. We then performed multivariable logistic regression to analyze sociodemographic factors associated with CRMNA. Our study population consisted of 142,577 individuals of whom 24% were older than 65 years, 47% were men, 66% were White, 17% Black, 35% had hypertension, 13% had diabetes mellitus, and 10% had ASCVD. CRMNA was reported in 10% of the overall population, 12% among those with hypertension, 17% among those with diabetes, and 17% among those with ASCVD. Age below 65 years, female gender, unemployment, lower income, lower educational attainment, having at least 1 comorbidity, and living in a state that did not expand Medicaid were independently associated with CRMNA. The prevalence of CRMNA increased with greater number of these high-risk sociodemographic factors. We conclude that the prevalence of CRMNA is 10% among U.S. adults overall and is higher among those with common chronic diseases. Risk factors associated with CRMNA should be addressed in order to improve adherence rates and health outcomes among high-risk individuals.

17.
JAMA Cardiol ; 6(10): 1161-1170, 2021 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-34259820

RESUMO

Importance: The 2018 American Heart Association/American College of Cardiology Guideline on the Management of Blood Cholesterol recommends the use of risk-enhancing factor assessment and the selective use of coronary artery calcium (CAC) scoring to guide the allocation of statin therapy among individuals with an intermediate risk of atherosclerotic cardiovascular disease (ASCVD). Objective: To examine the association between risk-enhancing factors and incident ASCVD by CAC burden among those at intermediate risk of ASCVD. Design, Setting, and Participants: The Multi-Ethnic Study of Atherosclerosis is a multicenter population-based prospective cross-sectional study conducted in the US. Baseline data for the present study were collected between July 15, 2000, and July 14, 2002, and follow-up for incident ASCVD events was ascertained through August 20, 2015. Participants were aged 45 to 75 years with no clinical ASCVD or diabetes at baseline, were at intermediate risk of ASCVD (≥7.5% to <20.0%), and had a low-density lipoprotein cholesterol level of 70 to 189 mg/dL. Exposures: Family history of premature ASCVD, premature menopause, metabolic syndrome, chronic kidney disease, lipid and inflammatory biomarkers, and low ankle-brachial index. Main Outcomes and Measures: Incident ASCVD over a median follow-up of 12.0 years. Results: A total of 1688 participants (mean [SD] age, 65 [6] years; 976 men [57.8%]). Of those, 648 individuals (38.4%) were White, 562 (33.3%) were Black, 305 (18.1%) were Hispanic, and 173 (10.2%) were Chinese American. A total of 722 participants (42.8%) had a CAC score of 0. Among those with 1 to 2 risk-enhancing factors vs those with 3 or more risk-enhancing factors, the prevalence of a CAC score of 0 was 45.7% vs 40.3%, respectively. Over a median follow-up of 12.0 years (interquartile range [IQR], 11.5-12.6 years), the unadjusted incidence rate of ASCVD among those with a CAC score of 0 was less than 7.5 events per 1000 person-years for all individual risk-enhancing factors (with the exception of ankle-brachial index, for which the incidence rate was 10.4 events per 1000 person-years [95% CI, 1.5-73.5]) and combinations of risk-enhancing factors, including participants with 3 or more risk-enhancing factors. Although the individual and composite addition of risk-enhancing factors to the traditional risk factors was associated with improvement in the area under the receiver operating curve, the use of CAC scoring was associated with the greatest improvement in the C statistic (0.633 vs 0.678) for ASCVD events. For incident ASCVD, the net reclassification improvement for CAC was 0.067. Conclusions and Relevance: In this cross-sectional study, among participants with CAC scores of 0, the presence of risk-enhancing factors was generally not associated with an overall ASCVD risk that was higher than the recommended treatment threshold for the initiation of statin therapy. The use of CAC scoring was associated with significant improvements in the reclassification and discrimination of incident ASCVD. The results of this study support the utility of CAC scoring as an adjunct to risk-enhancing factor assessment to more accurately classify individuals with an intermediate risk of ASCVD who might benefit from statin therapy.

18.
Am J Prev Med ; 61(4): 492-500, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34229931

RESUMO

INTRODUCTION: Ensuring adequate access to health care is essential for timely delivery of preventive services. It is important to evaluate the prevalence and determinants of difficulty in accessing medical care in the overall U.S. population and among those with high-risk chronic conditions. METHODS: The study utilized cross-sectional data from the 2016-2019 Behavioral Risk Factor Surveillance System, a nationally representative telephone-based survey of adults aged ≥18 years. The prevalence and sociodemographic characteristics associated with difficulty in receiving medical care were assessed, including regional variations across U.S. states. RESULTS: The prevalence of difficulty in accessing medical care was 14% overall, 15% among those with hypertension, 15% among those with diabetes mellitus, and 17% among those with atherosclerotic cardiovascular disease. Age 18-34 years, having less than high school education, having annual household income <$75,000, unemployment, and living in a state without Medicaid expansion were all associated with a higher risk of not accessing medical care. The prevalence of difficulty in accessing medical care was 27% among individuals with ≥3 of these sociodemographic characteristics. There was regional variation across the U.S. states in the distribution of difficulty in accessing medical care with a median of 13.6% (IQR=11.3%-15.9%) for the overall population: 16.3% (IQR=14.1%-19.0%) among those living in states without Medicaid expansion versus 12.7% (IQR=10.9%-15.6%) among those living in states with Medicaid expansion (p=0.01). CONCLUSIONS: In total, 1 in 7 adults report difficulty in accessing medical care. This prevalence is nearly 1 in 4 adults with ≥3 sociodemographic characteristics related to difficulty in accessing medical care. There are regional variations in the distribution of the difficulty in accessing medical care, especially among individuals living in states that have not undergone Medicaid expansion.


Assuntos
Prevalência , Adolescente , Adulto , Estudos Transversais , Humanos , Adulto Jovem
19.
Curr Atheroscler Rep ; 23(9): 50, 2021 07 06.
Artigo em Inglês | MEDLINE | ID: mdl-34226979

RESUMO

PURPOSE OF REVIEW: This review highlights late-breaking science presented at the Virtual American College of Cardiology Scientific Sessions 2021 that demonstrated advancements in preventative cardiology and introduced novel therapeutic modalities for the management of chronic kidney disease, heart failure, and COVID-19. RECENT FINDINGS: The studies reviewed include clinical trials that assessed the use of dapagliflozin in patients with respiratory failure due to COVID-19 (DARE-19 trial); evinacumab for patients with severe hypertriglyceridemia and pancreatitis; effect of genotype-guided oral P2y12 inhibitors vs conventional clopidogrel on long-term ischemic outcomes after percutaneous coronary intervention (TAILOR-PCI trial); anticoagulation in patients hospitalized with COVID-19 (ACTION trial); atorvastatin vs placebo in patients with COVID-19 admitted to the ICU (INSPIRATION-S trial); rehabilitation therapy in older acute heart failure patients (REHAB-HF trial); and aspirin dosing: a patient-centric trial assessing benefits and long-term effectiveness (ADAPTABLE trial). In addition, we review the results of the American College of Cardiology Global Heart Attack Initiative (GHATI). Finally, we discuss the secondary analysis of the STRENGTH trial assessing the association of achieved levels of omega-3 fatty acid levels and major cardiovascular outcomes. The studies presented at the virtual American College of Cardiology Scientific Session 2021 represent remarkable contributions in the field of cardiovascular disease and prevention.

20.
Popul Health Manag ; 2021 Jun 14.
Artigo em Inglês | MEDLINE | ID: mdl-34129402

RESUMO

Individuals with atherosclerotic cardiovascular disease (ASCVD) often have a high burden of comorbidities. Social determinants of health (SDOH) may complicate adherence to treatment in these patients. This study assessed the association of comorbidities and SDOH among individuals with ASCVD. Cross-sectional data from the 2016 to 2019 Behavioral Risk Factor Surveillance System, a nationally representative US telephone-based survey of adults ages ≥18 years, were used. Cardiovascular comorbidities included hypertension, hyperlipidemia, diabetes mellitus, current cigarette smoking, and chronic kidney disease. Non-cardiovascular comorbidities included chronic obstructive pulmonary disease, asthma, arthritis, cancer, and depression. SDOH associated with being at or above the 75th percentile of comorbidity burden were analyzed using multivariable adjusted logistic regression models. The study population included 387,044 individuals, 9% of whom had ASCVD. The mean (SD) numbers of total, cardiovascular, and non-cardiovascular comorbidities were 1.97 (1.27), 1.28 (0.74), 0.69 (0.91) among those without ASCVD and 3.28 (1.62), 1.73 (0.91), and 1.54 (1.22) among those with ASCVD, respectively (P < 0.001 for all comparisons). Female gender, household income ≤$75,000, being unemployed, and difficulty accessing health care were significantly associated with a higher burden of comorbidities among those with ASCVD. The mean (SD) numbers of comorbidities for those with 0, 1, 2, and ≥3 of the aforementioned SDOH were 2.89 (1.45), 2.86 (1.47), 3.39 (1.58), and 4.01 (1.73), respectively (P < 0.001). Among persons with ASCVD, the burden of cardiovascular and non-cardiovascular comorbidities is directly proportional to SDOH in any given individual. Clinicians should address SDOH when managing high-risk individuals.

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