Transgender Cardiovascular Health: Practical Management for the Clinician.

PURPOSE OF REVIEW: Transgender individuals represent a growing part of our population with current trends indicating that clinicians will be treating more transgender patients in both the inpatient and outpatient setting. Current cardiovascular guidelines lack recommendations for transgender care secondary to limited data in this population. As we await future guideline recommendations, we provide a comprehensive review of the literature and practical management strategies related to transgender cardiovascular health. RECENT FINDINGS: Transgender individuals are at higher risk for some cardiovascular diseases compared to their cisgender counterparts. Gender-affirming hormone therapy, concomitant health conditions, lifestyle habits, access to services, and quality of care all contribute to this finding. While it is likely both safe and appropriate to apply current CVD guidelines to the care of transgender men and women, clinicians should consider additional factors in risk assessment and address unique aspects of care at every visit.

Challenges in Optimizing Lipid Management in Women.

While there are physiologic differences in lipid metabolism in men and women, pharmacologic therapy is very effective in both with similar management strategies recommended in the current guidelines for the management of dyslipidemia. Despite similar guidelines for treatment, studies have shown that women have worse control of dyslipidemia than their male counterparts. This may stem from multiple contributing factors including underestimation of cardiovascular disease risk in women, decreased prescription and utilization of lipid-lowering therapies, decreased medication adherence, and higher risk of statin intolerance, all of which may contribute to lower attainment of lipid targets. Furthermore, heart disease is the leading cause of mortality in women, with heart disease noted an average of 7-10 years later than in men. This has historically led to the misperception that women are protected from heart disease and can be treated less aggressively. In fact, traditional risk factors for atherosclerotic cardiovascular disease often impact risk in women to a greater extent than they do in men. Unique risk factors such as pregnancy-related disorders also contribute to the level of risk and therefore warrant consideration in risk stratification. This review summarizes the efficacy of contemporary lipid-lowering therapies in women versus men and discusses the challenges that arise with lipid management in women along with potential ways to tackle these obstacles.

Incidence of Venous Thromboembolism and Mortality in Patients with Initial Presentation of COVID-19.

Venous thromboembolism (VTE) has emerged as an important issue in patients with COVID-19. The purpose of this study is to identify the incidence of VTE and mortality in COVID-19 patients initially presenting to a large health system. Our retrospective study included adult patients (excluding patients presenting with obstetric/gynecologic conditions) across a multihospital health system in the New York Metropolitan Region from March 1-April 27, 2020. VTE and mortality rates within 8 h of assessment were described. In 10,871 adults with COVID-19, 118 patients (1.09%) were diagnosed with symptomatic VTE (101 pulmonary embolism, 17 deep vein thrombosis events) and 28 patients (0.26%) died during initial assessment. Among these 146 patients, 64.4% were males, 56.8% were 60 years or older, 15.1% had a BMI > 35, and 11.6% were admitted to the intensive care unit. Comorbidities included hypertension (46.6%), diabetes (24.7%), hyperlipidemia (14.4%), chronic lung disease (12.3%), coronary artery disease (11.0%), and prior VTE (7.5%). Key medications included corticosteroids (22.6%), statins (21.2%), antiplatelets (20.6%), and anticoagulants (20.6%). Highest D-Dimer was greater than six times the upper limit of normal in 51.4%. Statin and antiplatelet use were associated with decreased VTE or mortality (each p < 0.01). In COVID-19 patients who initially presented to a large multihospital health system, the overall symptomatic VTE and mortality rate was over 1.0%. Statin and antiplatelet use were associated with decreased VTE or mortality. The potential benefits of antithrombotics in high risk COVID-19 patients during the pre-hospitalization period deserves study.

External validation of the IMPROVE-DD risk assessment model for venous thromboembolism among inpatients with COVID-19.

There is a need to discriminate which COVID-19 inpatients are at higher risk for venous thromboembolism (VTE) to inform prophylaxis strategies. The IMPROVE-DD VTE risk assessment model (RAM) has previously demonstrated good discrimination in non-COVID populations. We aimed to externally validate the IMPROVE-DD VTE RAM in medical patients hospitalized with COVID-19. This retrospective cohort study evaluated the IMPROVE-DD VTE RAM in adult patients with COVID-19 admitted to one of thirteen Northwell Health hospitals in the New York metropolitan area between March 1, 2020 and April 27, 2020. VTE was defined as new-onset symptomatic deep venous thrombosis or pulmonary embolism. To assess the predictive value of the RAM, the receiver operating characteristic (ROC) curve was plotted and the area under the curve (AUC) was calculated. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Of 9407 patients who met study criteria, 274 patients developed VTE with a prevalence of 2.91%. The VTE rate was 0.41% for IMPROVE-DD score 0-1 (low risk), 1.21% for score 2-3 (moderate risk), and 5.30% for score ≥ 4 (high risk). Approximately 45.7% of patients were classified as high VTE risk, 33.3% moderate risk, and 21.0% low risk. Discrimination of low versus moderate-high VTE risk demonstrated sensitivity 0.971, specificity 0.215, PPV 0.036, and NPV 0.996. ROC AUC was 0.703. In this external validation study, the IMPROVE-DD VTE RAM demonstrated very good discrimination to identify hospitalized COVID-19 patients at low, moderate, and high VTE risk.

Novel Nutritional and Dietary Approaches to Weight Loss for the Prevention of Cardiovascular Disease: Ketogenic Diet, Intermittent Fasting, and Bariatric Surgery.

PURPOSE OF REVIEW: Cardiovascular disease (CVD) is highly associated with obesity and cardiometabolic dysfunction. This review will focus on three novel therapies that have been identified for potential treatment of obesity and its associated CVD risk factors. RECENT FINDINGS: Intermittent fasting (IF) studies in animal models have shown improvements in cardiometabolic factors, including improved glucose metabolism, reduced inflammation, and reduced blood pressure. However, there is still a lack of prospective human trials to support results from animal-based studies and observational data. Studies of ketogenic diets in humans have produced mixed effects in CVD risk factors. It has been shown that the ketogenic diet (KD) increases low-density lipoprotein cholesterol (LDL-C) but decreases triglycerides. Additionally, implementation of KD in rodent studies have demonstrated increased insulin resistance and glucose intolerance. Bariatric surgery is a useful tool to help patients with obesity lose significant amounts of weight while alleviating CVD risk factors such as hypertension, LDL-C levels, triglyceride levels, and diabetes. The type of procedure influences degree of improvement in weight and CVD risk factors, yet complications remain possible. IF and bariatric surgery offer potential for weight loss and treatment of CVD risk factors. Negative cardiovascular effects of KD have been noted and should be considered before recommending this diet to patients, particularly those with established cardiovascular disease.

Strategies to Fill the Gaps in Nutrition Education for Health Professionals through Continuing Medical Education.

PURPOSE OF REVIEW: Recent studies have documented that diet quality in the US is poor and linked to higher rates of cardiovascular disease (CVD), other non-communicable diseases, and total mortality. As a result, nutrition counseling in clinical practice is an evidence-based strategy endorsed by numerous stakeholders. However, medical nutrition education (MNE) in the US has been inadequate, and physician knowledge, competencies, and practices related to diet counseling have been documented to be insufficient. National scientific meetings and conferences offer opportunities to translate new scientific evidence, guidelines, and competencies to clinicians in attendance and to publicize this evidence widely. This review assessed the adequacy of, and trends in, nutrition education provided at recent major US scientific meetings that offer continuing medical education (CME), with a focus on CVD-related conferences. RECENT FINDINGS: The authors found no reviews that have assessed the scope and type of nutrition-related educational programming at major conferences. We therefore investigated nutrition-related programming at CVD-related CME conferences in the US from 2013 to 2018. National scientific CVD-related conferences in the USA have offered variable amounts of programming related to practical applications of nutrition science. We did not observe an increase in nutrition-related offerings, despite the increase in diet-related diseases and the growing evidence base for the role of nutrition in the prevention and management of chronic disease. Increasing nutrition-related CME programming at national scientific meetings can lead to greater translation of nutrition evidence to patients by healthcare providers and improved health outcomes in the population.

Cardiovascular Risk Factor Control and Lifestyle Factors in Young to Middle-Aged Adults with Newly Diagnosed Obstructive Coronary Artery Disease.

BACKGROUND: While progress in the prevention of cardiovascular disease (CVD) has been noted over the past several decades, there are still those who develop CVD earlier in life than others. OBJECTIVE: We investigated traditional and lifestyle CVD risk factors in young to middle-aged patients compared to older ones with obstructive coronary artery disease (CAD). METHODS: A retrospective analysis of patients with a new diagnosis of obstructive CAD undergoing coronary intervention was performed. Young to middle-aged patients were defined as those in the youngest quartile (n = 281, mean age 50 ± 6 years, 81% male) compared to the other three older quartiles combined (n = 799, mean age 69 ± 7.5 years, 71% male). Obstructive CAD was determined by angiography. RESULTS: Young to middle-aged patients compared to older ones were more likely to be male (p < 0.01), smokers (21 vs. 9%, p < 0.001), and have a higher body mass index (31 ± 6 vs. 29 ± 6 kg/m2, p < 0.001). Younger patients were less likely to eat fruits, vegetables, and fish and had fewer controlled CVD risk factors (2.7 ± 1.2 vs. 3.0 ± 1.0, p < 0.001). Compared to older patients, higher levels of psychological stress (aOR 1.6, 95% CI 1.1-2.4), financial stress (aOR 1.8, 95% CI 1.3-2.5), and low functional capacity (aOR 3.3, 95% CI 2.4-4.5) were noted in the young to middle-aged population as well. CONCLUSION: Lifestyle in addition to traditional CVD risk factors should be taken into account when evaluating risk for development of CVD in a younger population.

Investigation of Motivational Interviewing and Prevention Consults to Achieve Cardiovascular Targets (IMPACT) trial.

BACKGROUND: Patients undergoing cardiovascular (CV) procedures often have suboptimal CV risk factor control and may benefit from strategies targeting healthy lifestyle behaviors and education. Implementation of prevention strategies may be particularly effective at this point of heightened motivation. METHODS: A prospective, randomized, pilot study was conducted in 400 patients undergoing a nonurgent CV procedure (cardiac catheterization ± revascularization) to evaluate the impact of different prevention strategies. Patients were randomized in a 1:1:1 fashion to usual care (UC; group A, n = 134), in-hospital CV prevention consult (PC; group B, n = 130), or PC plus behavioral intervention program (telephone-based motivational interviewing and optional tailored text messages) (group C, n = 133). The primary end point was the Δ change in non-high-density lipoprotein cholesterol (non-HDL-C) from baseline to 6 month. RESULTS: The mean age was 64.6 ± 10.8 years, 23.7% were female, and 31.5% were nonwhite. After 6 months, the absolute difference in non-HDL-C for all participants was -19.8 mg/dL (95% CI -24.1 to -15.6, P < .001). There were no between-group differences in the primary end point for the combined PC groups (B and C) versus UC, with a Δ adjusted between group difference of -5.5 mg/dL (95% CI -13.1 to 2.1, P = .16). Patients in the PC groups were more likely to be on high-intensity statins at 6 months (52.9% vs 38.1%, P = .01). After excluding participants with baseline non-HDL-C <100 mg/dL (initial exclusion criterion), Δ non-HDL-C and Δ low-density lipoprotein cholesterol were improved in the PC groups compared to UC (non-HDL-C -8.13 mg/dL [-16.00 to -0.27], P = .04; low-density lipoprotein cholesterol -7.87mg/dL [-15.10 to -0.64], P = .03). CONCLUSIONS: Although non-HDL-C reduction at 6 months following a nonurgent CV procedure was not significant in the overall cohort, an increased uptake in high-potency statins may translate into improved long-term health outcomes and cost reductions.

Greater Frequency of Fruit and Vegetable Consumption Is Associated With Lower Prevalence of Peripheral Artery Disease.

OBJECTIVE: Although fruit and vegetable (F&V) consumption is associated with lower risk of coronary heart disease and stroke, its association with peripheral artery disease (PAD) is less certain. We, thus, sought to characterize F&V intake and investigate the association between F&V consumption and presence of PAD in a large community sample. APPROACH AND RESULTS: Self-referred participants at >20 000 US sites who completed medical and lifestyle questionnaires were evaluated by screening ankle brachial indices for PAD (ankle brachial index ≤0.9). Among 3 696 778 individuals, mean age was 64.1±10.2 years and 64.1% were female. Daily consumption of ≥3 servings of F&V was reported by 29.2%. Increasing age, female sex, white race, never smoking, being currently married, physical activity, increasing income, and frequent consumption of fish, nuts, and red meat were positively associated with daily consumption of F&V. After multivariable adjustment, there was a stepwise inverse association between F&V intake and PAD. Participants reporting daily intake of ≥3 servings of F&V had 18% lower odds of PAD than those reporting less than monthly consumption. In unadjusted and multivariable-adjusted models, the inverse association with F&V became stronger as ankle brachial index decreased. When stratified by smoking status, the association was present only among those subjects who currently or formerly smoked tobacco. CONCLUSIONS: Our study demonstrates an inverse association of F&V consumption with prevalent PAD and overall low F&V consumption. These observations suggest the need to further efforts to increase F&V consumption and for more rigorous evaluation of the role of F&V in PAD prevention.

Rationale and design of the Investigation of Motivational Interviewing and Prevention Consults to Achieve Cardiovascular Targets (IMPACT) trial.

BACKGROUND: Patients undergoing cardiovascular procedures remain at increased risk for myocardial infarction, stroke, and cardiovascular death. Risk factor control in this patient population remains suboptimal and would likely benefit from strategies targeting education, lifestyle, and healthy behaviors. DESIGN: The IMPACT trial is a 400-subject prospective randomized trial designed to compare different cardiovascular prevention strategies in subjects following a cardiovascular intervention. The trial began enrollment in the Spring of 2012 and is randomizing subjects in a 1:1:1 manner to usual care, a one-time cardiovascular prevention consult, or a one-time cardiovascular prevention consult plus behavioral intervention program (telephone-based motivational interviewing and tailored text messages) over a 6-month period. The primary end point is non-high-density lipoprotein cholesterol. Secondary end points include other plasma lipid values, metabolic risk, smoking cessation, physical activity, dietary intake, medication use and adherence, and quality of life. CONCLUSIONS: The IMPACT trial provides data on different management strategies for risk factor optimization in subjects following cardiovascular procedures. The results will provide a platform for the continued development of novel multidisciplinary interventions in this high-risk population.

Prevalence of unrecognized diabetes, prediabetes and metabolic syndrome in patients undergoing elective percutaneous coronary intervention.

BACKGROUND: Diabetes mellitus (DM) and metabolic syndrome are important targets for secondary prevention in cardiovascular disease. However, the prevalence in patients undergoing elective percutaneous coronary intervention is not well defined. We aimed to analyse the prevalence and characteristics of patients undergoing percutaneous coronary intervention with previously unrecognized prediabetes, diabetes and metabolic syndrome. METHODS: Data were collected from 740 patients undergoing elective percutaneous coronary intervention between November 2010 and March 2013 at a tertiary referral center. Prevalence of DM and prediabetes was evaluated using Haemoglobin A1c (A1c ≥ 6.5% for DM, A1c 5.7-6.4% for prediabetes). A modified definition was used for metabolic syndrome [three or more of the following criteria: body mass index ≥30 kg/m2; triglycerides ≥ 150 mg/dL; high density lipoprotein <40 mg/dL in men and <50 mg/dL in women; systolic blood pressure ≥ 130 mmHg and/or diastolic ≥ 85 mmHg; and A1c ≥ 5.7% or on therapy]. RESULTS: Mean age was 67 years, median body mass index was 28.2 kg/m(2) and 39% had known DM. Of those without known DM, 8.3% and 58.5% met A1c criteria for DM and for prediabetes at time of percutaneous coronary intervention. Overall, 54.9% met criteria for metabolic syndrome (69.2% of patients with DM and 45.8% of patients without DM). CONCLUSION: Among patients undergoing elective percutaneous coronary intervention, a substantial number were identified with a new DM, prediabetes, and/or metabolic syndrome. Routine screening for an abnormal glucometabolic state at the time of revascularization may be useful for identifying patients who may benefit from additional targeting of modifiable risk factors.

The recent national lipid association recommendations: how do they compare to other established dyslipidemia guidelines?

The National Lipid Association (NLA) recently released recommendations for the treatment of dyslipidemias. These recommendations have commonalities and differences with those of other major societies with respect to risk assessment, lifestyle therapy, targets of therapy, and the use of non-statin agents. In this review, we compare the basic elements of the guidelines from each major society to provide clinicians with a comprehensive document reviewing the key principles of each.

Greater frequency of nut consumption is associated with lower prevalence of peripheral arterial disease.

UNLABELLED: Nut consumption has been associated with lower risk of coronary heart disease and all-cause mortality. The association between nut intake and peripheral arterial disease (PAD) is uncertain. OBJECTIVE: We sought to investigate the association between nut consumption and presence of prevalent PAD in a large cross-sectional sample. METHODS: Self-referred participants at >20,000 US sites who completed a medical and lifestyle questionnaire were evaluated by screening ankle brachial indices for PAD. Multivariable logistic regression analysis was used to estimate odds of PAD in different nut consumption categories. RESULTS: Among 3,312,403 individuals, mean age was 63.6 ± 10.6 years and 62.8% were female. There were 219,527 cases of PAD. After multivariable adjustment there was an inverse association of nut intake with PAD. Compared to subjects with consumption of nuts

Temporal trends in clinical characteristics of patients without known cardiovascular disease with a first episode of myocardial infarction.

BACKGROUND: Recent initiatives have focused on primary prevention to delay time to first myocardial infarction (MI). The aim of this study was to evaluate the change in risk factor profile over time in patients without known cardiovascular disease presenting with first MI. METHODS: In the American Heart Association's Get With The Guidelines-Coronary Artery Disease national registry, 100,884 patients without known cardiovascular disease presenting with acute MI from 408 hospitals were evaluated between 2002 and 2008. The time trends of the proportion of patients with cardiovascular risk factors (nonmodifiable: age >45 years for men or >55 years for women, male sex, modifiable: diabetes mellitus, hypertension, hyperlipidemia, tobacco use) were analyzed. Analyses were stratified by non-ST-segment elevation MI (NSTEMI) versus ST-segment elevation MI (STEMI). RESULTS: The proportion of patients with ≥3 of 6 traditional risk factors slightly decreased over time in the NSTEMI (69.5%-66.8%, P < .0001) and STEMI (68.9%-66.4%, P < .0001) cohorts. The proportion of patients with ≥2 of 4 modifiable risk factors increased from 52% to 59% and then declined to 52.1% (P < .0001) in the NSTEMI cohort but declined slightly in the STEMI cohort (50.9%-47.3%, P < .0001). After adjusting for age and gender, the time trend of proportion with diabetes mellitus, hypertension, and tobacco use declined in both cohorts. However, the proportion of patients with hyperlipidemia remained similar. CONCLUSIONS: Although risk factor profiles in patients presenting with first MI have shown improvements over time, the changes are modest.

Suboptimal risk factor control in patients undergoing elective coronary or peripheral percutaneous intervention.

BACKGROUND: The American Heart Association recommends targeting 7 cardiovascular (CV) health metrics to reduce morbidity and mortality. Control of these targets in patients undergoing CV intervention is uncertain. METHODS: We prospectively studied patients undergoing elective percutaneous coronary or peripheral intervention from November 2010 to May 2012. We recorded data on patient demographics, clinical characteristics, and social history. Risk factor control was categorized as ideal, intermediate, or poor according to the 7 American Heart Association-defined CV health metrics (smoking status, body mass index, physical activity, diet, cholesterol, blood pressure, and metabolic control). Linear regression model was used to evaluate the association between baseline characteristics and poor CV health. RESULTS: Among 830 consecutive patients enrolled, mean age is 67.3 ± 10.8 years, 74.2% are male, and 62.1% are white. The adequacy of achievement of ideal CV health is suboptimal in our cohort; the mean number of ideal CV metrics is 2.15 ± 1.06. Less than 1 in 10 (9.7%) met ≥4 ideal CV health metrics. After multivariate analysis, male sex (P = .04), nonwhite race (P = .01), prior coronary artery disease (P < .01), prior peripheral arterial disease (P < .01), and history of depression (P = .01) were significantly associated with poor CV health. CONCLUSIONS: Among patients referred for elective CV intervention, achievement of ideal CV health is poor. Elective interventions represent an opportunity to identify and target CV health for risk factor control and secondary prevention.

Patterns of Statin Therapy Use and Associated Outcomes in Older Veterans Across Kidney Function.

BACKGROUND: Despite significant morbidity and mortality related to atherosclerotic cardiovascular disease, to date, most major clinical trials studying the effects of statin therapy have excluded older adults. The objective of this analysis was to evaluate the effect of initiating statin therapy on incident dementia and mortality among individuals 75 years of age or older across the complete spectrum of kidney function. METHODS: We conducted a retrospective cohort study of 640,191 VA health system patients who turned 75 years of age between 2000 and 2018. Patients on statin therapy received the medication for an average of 6.3 years (standard deviation 4.6 years). The primary outcome of interest included incident dementia diagnosis during the study period. The secondary outcome was all-cause mortality. Cox proportional hazard analysis was used to evaluate the adjusted association of statin initiation with these outcomes. RESULTS: There was a higher rate of incident dementia in the No Statin group (4.7%) vs the Statin group (3.2%). Additionally, we observed a 22% all-cause mortality benefit associated with statin therapy. We did not observe a treatment effect with respect to primary or secondary outcomes across varying levels of kidney function. CONCLUSION: This large cohort study did not reveal an association between the initiation of statin therapy and incident dementia. A survival benefit was seen in statin users compared with nonusers. Prospective studies in more diverse populations including older adults will be needed to verify these findings.

Clinical, Sociodemographic, and Neighborhood Characteristics Associated with Adverse Pregnancy Outcomes.

Background: Cardiovascular risk is increased by a history of adverse pregnancy outcomes (APOs). Efforts to understand and prevent these adverse outcomes may improve both fetal and birthing persons' outcomes in the peripartum period, and over the patient's lifetime. This study aims to assess the association of clinical, sociodemographic, and economic neighbor-hood factors with preterm birth (PTB) and APOs (the composite of stillbirth, small for gestation age, and low birthweight). Materials and Methods: This is a cross-sectional study using the electronic medical records of deliveries from seven Northwell Health hospitals between January 1, 2018 and July 31, 2020. There were 62,787 deliveries reviewed in this study. Deliveries that were not the first for the patient during the study period and multiple gestational pregnancies were excluded. Patients with incomplete data on outcome were also excluded. Main outcomes were PTB and composite APOs. Measures included history of PTB, hypertension, diabetes, body mass index, race/ethnicity, age, preferred language, marital status, parity, health insurance, and median income, percent unemployment, and mean household size by zip code. Results: Of the 62,787 deliveries, 43.3% were from white, Non-Hispanic, and Non-Latino patients. There were 4,552 (7.2%) PTBs and 8,634 (13.8%) APOs. Patients enrolled in public insurance had higher odds of PTB (odds ratio [OR] 1.15, 95% CI 1.06-1.24) and APOs (OR 1.19, 95% CI 1.12-1.25). There was a statistically significant association of both PTB (p = 0.037) and APOs (p = 0.005) when comparing patients that live in a zip code with a median income over 100k to those with an income <100k. In addition, living in a zip code within the second quintile of unemployment was associated with lower odds of APOs (OR 0.92, 95% CI 0.84-0.99). Conclusions: Numerous sociodemographic and clinical factors are associated with both PTB and APOs. Tailored programs addressing these disparities may improve outcomes in pregnant persons.

Clinical Significance of Supraventricular Tachycardia During Pregnancy in Healthy Women.

BACKGROUND: Supraventricular tachycardias (SVT) are the most frequently encountered arrhythmias in pregnancy with unclear clinical significance. OBJECTIVES: This study sought to report the prevalence, describe the management, and explore the association between SVT and adverse obstetric outcomes. METHODS: Cohort study of primiparous and multiparous women without history of Cesarean section (CS), and with structurally normal hearts admitted in labor. The study group consisted of women with at least 1 SVT episode during pregnancy, and the control group was randomly selected in a 4:1 ratio. RESULTS: Of 141,769 women meeting the inclusion criteria, SVT diagnosis was confirmed in 122. A total of 76 (age 33.2 ± 4.8 years) had at least 1 symptomatic and documented episode during pregnancy. In women with a known SVT diagnosis before pregnancy, medical therapy was not associated with a lower risk of SVT recurrence (OR: 1.07; 95% CI: 0.41-2.80). However, catheter ablation before pregnancy was associated with significantly lower risk of SVT recurrence (OR: 0.09; 95% CI: 0.04-0.23). Women with SVT during pregnancy had higher incidence of CS (39.5% vs 27.0%; P = 0.03), and preterm labor (PTL) (30.3% vs 8.6%; P < 0.001). Adjusting for age and parity, SVT during pregnancy was an independent predictor of CS (OR: 1.80; 95% CI: 1.03-3.10), particularly planned CS (OR: 2.89; 95% CI: 1.06-7.89) and PTL (OR: 4.37; 95% CI: 2.30-8.31). CONCLUSIONS: SVT during pregnancy is associated with increased risk for CS and PTL in healthy women. History of SVT should be sought as early as preconception counseling, and a multidisciplinary approach is warranted for both prevention and management of SVT occurrence.

Advances in targeting LDL cholesterol: PCSK9 inhibitors and beyond.

There is a direct relationship between the duration and level of exposure to low density lipoprotein cholesterol (LDL-C) levels over one's lifespan and cardiovascular events. Early treatment to lower elevated LDL-C is crucial for better outcomes with multiple therapies currently available to reduce atherogenic lipoproteins. Statins remain the foundation of LDL-C lowering therapy as one of the most cost-effective drugs to reduce atherosclerotic events (ASCVD) and mortality. Nonetheless, LDL-driven goal attainment remains suboptimal globally, highlighting a considerable need for non-statin therapies to address residual risk related to statin intolerance, non-adherence, and inherited lipoprotein disorders. LDL-C lowering interventions beyond statins include ezetimibe, PCSK9 monoclonal antibodies, inclisiran and bempedoic acid with specific guideline recommendations as to when to consider each. For patients with homozygous familial hypercholesterolemia requiring more advanced therapy, lomitapide and evinacumab are available, providing mechanisms that are not LDL receptor dependent. Lipoprotein apheresis remains an effective option for clinical familial hypercholesterolemia as well as elevated lipoprotein (a). There are investigational therapies being explored to add to our current armamentarium including CETP inhibitors, a third-generation PCSK9 inhibitor (small recombinant fusion protein oral PCSK9 inhibitor) and gene editing which aims to directly restore or disrupt genes of interest at the DNA level. This article is a brief review of the pharmacotherapy options beyond statins for lowering LDL-C and their impact on ASCVD risk reduction. Our primary aim is to guide physicians on the role these therapies play in achieving appropriate LDL-C goals, with an algorithm of when to consider each based on efficacy, safety and outcomes.