Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association.

BACKGROUND: The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS: The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals. RESULTS: Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS: The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Platelet Inhibitors Reduce Rupture in a Mouse Model of Established Abdominal Aortic Aneurysm.

OBJECTIVE: Rupture of abdominal aortic aneurysms causes a high morbidity and mortality in the elderly population. Platelet-rich thrombi form on the surface of aneurysms and may contribute to disease progression. In this study, we used a pharmacological approach to examine a role of platelets in established aneurysms induced by angiotensin II infusion into hypercholesterolemic mice. APPROACH AND RESULTS: Administration of the platelet inhibitors aspirin or clopidogrel bisulfate to established abdominal aortic aneurysms dramatically reduced rupture. These platelet inhibitors reduced abdominal aortic platelet and macrophage recruitment resulting in decreased active matrix metalloproteinase-2 and matrix metalloproteinase-9. Platelet inhibitors also resulted in reduced plasma concentrations of platelet factor 4, cytokines, and components of the plasminogen activation system in mice. To determine the validity of these findings in human subjects, a cohort of aneurysm patients were retrospectively analyzed using developed and validated algorithms in the electronic medical record database at Vanderbilt University. Similar to mice, administration of aspirin or P2Y12 inhibitors was associated with reduced death among patients with abdominal aortic aneurysm. CONCLUSIONS: These results suggest that platelets contribute to abdominal aortic aneurysm progression and rupture.

From Data to Action: Neuroepidemiology Informs Implementation Research for Global Stroke Prevention and Treatment.

As a scientific field of study, neuroepidemiology encompasses more than just the descriptive study of the frequency, distribution, determinants and outcomes of neurologic diseases in populations. It also includes experimental aspects that span the full spectrum of clinical and population science research. As such, neuroepidemiology has a strong potential to inform implementation research for global stroke prevention and treatment. This review begins with an overview of the progress that has been made in descriptive and experimental neuroepidemiology over the past quarter century with emphasis on standards for evidence generation, critical appraisal of that evidence and impact on clinical and public health practice at the national, regional and global levels. Specific advances made in high-income countries as well as in low- and middle-income countries are presented. Gaps in implementation as well as evidence gaps in stroke research, stroke burden, clinical outcomes and disparities between developed and developing countries are then described. The continuing need for high quality neuroepidemiologic data in low- and middle-income countries is highlighted. Additionally, persisting disparities in stroke burden and care by sex, race, ethnicity, income and socioeconomic status are discussed. The crucial role that national stroke registries have played in neuroepidemiologic research is also addressed. Opportunities presented by new directions in comparative effectiveness and implementation research are discussed as avenues for turning neuroepidemiological insights into action to maximize health impact and to guide further biomedical research on neurological diseases.

Carotid adventitial vasa vasorum and intima-media thickness in a primary prevention population.

BACKGROUND: Vasa vasorum (VV) vessels are critical in the genesis of atherosclerosis. Therefore, we assessed measures of carotid VV, intima-media thickness (CIMT), and patient risk factors in a primary prevention population. METHODS: We used multivariable linear models to evaluate the relationship between baseline covariates and a measure of carotid VV (VV ratio) and CIMT among 324 diabetics and 141 nondiabetics. RESULTS: Median CIMT (in mm) and VV ratio among nondiabetics were 0.82 ± 0.22 and 0.80 ± 0.19, respectively, and 1.06 ± 0.19 and 1.21 ± 0.26 among diabetics (P < 0.0001). Diabetes was associated with 36% (95% CI: 24.3-48.0, P < 0.001) higher VV ratio whereas a unit change in BMI was associated with ≈1% (95% CI: 0.5-1.4, P < 0.001) change in VV ratio. A 10-year increase in age was associated with 4% (95% CI: 1-7, P = 0.005) higher CIMT. Each 10 mmHg increase in mean systolic blood pressure was associated with 2% (95% CI: 1-4, P = 0.003) higher CIMT whereas diabetes conferred 31% (95% CI: 19.1-42.1, P < 0.001) higher CIMT. Female sex was associated with a 9% (95% CI: -12.9 to -4.1, P < 0.001) lower CIMT. Low density lipoprotein (LDL) cholesterol, blood pressure, and CIMT were not significantly associated with VV ratio. CONCLUSION: In this cohort of patients with low CIMT, VV ratio, and CIMT were distinctly unrelated, but each independently associated with diabetes. VV ratio and CIMT relationships warrant further investigation in large-scale studies and across a spectrum of atherosclerostic states.

Short-term trends in heart failure-related hospitalizations in a high-risk state.

OBJECTIVES: We sought to determine whether there are signs of improvement in the rates of heart failure (HF) hospitalizations given the recent reports of improvement in national trends. METHODS: HF admissions data from the Tennessee Hospital Discharge Data System were analyzed. RESULTS: Hospitalization for primary diagnosis of HF (HFPD) in adults (aged 20 years old or older) decreased from 4.5% in 2006 to 4.2% in 2008. Similarly, age-adjusted HF hospitalization (per 10,000 population) declined by 19.1% (from 45.5 in 2006 to 36.8 in 2008). The age-adjusted rates remain higher among blacks than whites and higher among men than women. Notably, the rate ratio of black-to-white men ages 20 to 34 years admitted with HFPD increased from 8.5 in 2006 to 11.1 in 2008; similarly, the adjusted odds ratios for HFPD were 4.75 (95% confidence interval 3.29-6.86) and 5.61 (95% confidence interval 3.70-8.49), respectively. There was, however, a significant improvement in odds ratio for HF rates among young black women, as evidenced by a decrease from 4.60 to 3.97 (aged 20-34 years) and 4.21 to 3.12 (aged 35-44 years) between 2006 and 2008, respectively. Among patients aged 20 to 34 and 35 to 44 years, hypertension was the strongest independent predictor for HF. Diabetes and myocardial infarction emerged as predictors for HF among patients aged 35 years and older. CONCLUSIONS: The overall rate of HF hospitalization declined during the period surveyed, but the persistent disproportionate involvement of blacks with evidence of worsening among younger black men, requires close attention.

Benzo[a]pyrene potentiates the pathogenesis of abdominal aortic aneurysms in apolipoprotein E knockout mice.

The objective of this study was to determine the effect of benzo[a]pyrene (BaP), an abundant environmental polycyclic aromatic hydrocarbon compound, on the pathogenesis of abdominal aortic aneurysms (AAA). Earlier studies have shown that BaP promotes vasculopathy, including atherosclerosis, a predisposing factor for AAA development. In two experimental arms, 203 apolipoprotein E knockout (ApoE-/-) mice were evaluated in 4 groups: BaP, angiotensin II (AngII), BaP+AngII and control. Mice in the first arm were exposed to 5mg/kg/week of BaP for 42 days, and in the second arm to 0.71mg/kg daily for 60 days. In arm one, AAA incidence was higher in the BaP+AngII (14/28) versus AngII (8/27) group (p < 0.05), rupture (n=3) was observed only in BaP+AngII treated mice (p < 0.05). In the second arm, AAA incidence did not differ between AngII (17/30) and BaP+AngII (16/29) groups. However, intact AAA diameter was larger in the BaP+AngII (2.3 ± 0.1mm) versus AngII (1.9 ± 0.1mm) group (p < 0.05), but AAA rupture did not differ (p=NS). In both experimental arms, BaP+AngII mice showed increased expression of tumor necrosis factor alpha (TNF-α), cyclophilin A (Cyp A), and matrix metalloproteinase-9 (MMP9) (p < 0.05). No AAA occurred in control or BaP groups. These findings suggest the role of BaP exposure in potentiating AAA pathogenesis, which may have potential public health significance.

Residual cardiovascular risk despite optimal LDL cholesterol reduction with statins: the evidence, etiology, and therapeutic challenges.

This review captures the existence, cause, and treatment challenges of residual cardiovascular risk (CVR) after aggressive low-density lipoprotein cholesterol (LDL-C) reduction. Scientific evidence implicates low high-density lipoprotein cholesterol (HDL-C) and high triglycerides (TG) in the CVR observed after LDL-C lowering. However, the Action to Control Cardiovascular Risk in Diabetes (ACCORD) lipid trial with fenofibrate, the Investigation of Lipid Level Management to Understand its Impact in Atherosclerotic Events (ILLUMINATE) study with torcetrapib, and the recently terminated Atherothrombosis Intervention in Metabolic Syndrome with Low HDL Cholesterol/High Triglyceride and Impact on Global Health Outcomes (AIM-HIGH) study with niacin, do not clearly attribute risk reduction value to HDL-C/TG modulation. The optimum approach to long-term lipid-modifying therapies for CVR reduction remains uncertain. Consequently, absolute risk modulation via lifestyle changes remains the centerpiece of a strategy addressing the physiologic drivers of CVR associated with HDL-C/TG, especially in the context of diabetes/metabolic syndrome.

Assessment of commonly available education materials in heart failure clinics.

BACKGROUND: Health literacy (HL) is an established independent predictor of cardiovascular outcomes. Approximately 90 million Americans have limited HL and read at the fifth grade level or lower. Therefore, we sought to determine the suitability and readability level of common cardiovascular patient education materials (PEM) related to heart failure and heart-healthy lifestyle. METHODS AND RESULTS: The suitability and readability of written PEMs were assessed using the suitability assessment of materials (SAM) and Fry readability formula. The SAM criteria are composed of the following categories: message content, text appearance, visuals, and layout and design. We obtained a convenience sample of 18 English-written cardiovascular PEMs freely available from major health organizations. Two reviewers independently appraised the PEMs. Final suitability scores ranged from 12% to 87%. Readability levels ranged between 3rd and 15th grade level; the average readability level was 8th grade. Ninety-four percent of the PEMs were rated either superior or adequate on text appearance, but 50% or more of the PEMs were rated inadequate on each of the other categories of the SAM criteria. Only 2 (11%) PEMs had the optimum suitability score of 70% or higher and 5th grade or lower readability level suitable for populations with limited HL. CONCLUSIONS: Commonly available cardiovascular PEMs used by some major healthcare institutions are not suitable for the average American patient. The true prevalence of suboptimal PEMs needs to be determined because it potentially negatively impacts optimal healthcare delivery and outcomes.

Are statins diabetogenic?

PURPOSE OF REVIEW: Statins are widely utilized for low-density lipoprotein lowering and for prevention of atherosclerotic cardiovascular disease. Although these drugs have a good safety record, increased risk of developing diabetes during extended use has recently garnered attention. Here we review clinical trial evidence related to statin use and incident diabetes, and the potential mechanisms for this association. RECENT FINDINGS: The increased incidence of diabetes with rosuvastatin treatment in Justification for the Use of Statins in Primary Prevention: an intervention Trial Evaluating Rosuvastatin (JUPITER) reignited attention on the link between statin therapy and diabetes. The JUPITER findings are supported by two recent meta-analyses of large-scale placebo-controlled and standard care-controlled trials, which, respectively, observed a 9% [odds ratio 1.09; 95% confidence interval (CI) 1.02-1.17] and 13% (risk ratio 1.13; 95% CI 1.03-1.23) increased risk for incident diabetes associated with statin therapy. However, the underlying mechanisms for this association remain unclear. Experimental evidence supports a paradigm implicating inhibition of ß-cell glucose transporters, delayed ATP production, pro-inflammatory and oxidative ß-cell effects of plasma-derived cholesterol, inhibition of calcium channel-dependent insulin secretion, and ß-cell apoptosis. SUMMARY: The aggregate of large clinical trials supports the notion that statins modestly increase the risk of incident diabetes. Because diabetes is a risk equivalent condition for coronary and peripheral arterial diseases, these findings create a paradox whereby needed statin therapy may be withheld to avoid excess risk of diabetes while representing the strongest cardiovascular risk reduction tool in diabetics. We simply recommend regular glucose monitoring in patients taking statins.

Quantitative estimates of the variability of in vivo sonographic measurements of the mouse aorta for studies of abdominal aortic aneurysms and related arterial diseases.

OBJECTIVES: Burgeoning interest in reducing the morbidity and mortality associated with abdominal aortic aneurysms (AAAs) has led to experimental strategies to elucidate the disease process and attain pharmacologic regression using the apolipoprotein E(-/-) (ApoE(-/-)) mouse model of angiotensin-induced AAAs and in vivo sonography. However, the variability of in vivo sonographic measurements of the mouse aorta has not been established. Thus, our purpose was to determine quantitative estimates of the variability of in vivo sonographic measurements of the mouse aorta as a guide for the design and assessment of studies focused on regression of AAAs and related arterial diseases. METHODS: We used Bland-Altman, locally weighted scatterplot-smoothing regression, and resampling (bootstrapping) methods for variability analyses of multiple in vivo short- and long-axis sonographic measurements of ApoE(-/-) mouse aortas. We measured distinct aortic sites in vivo at the baseline and after angiotensin-induced AAAs and ex vivo using digital calipers. RESULTS: We analyzed 236 data points from 10 male mice (14 weeks old; mean weight ± SD, 29.7 ± 1.6 g). Overall intramouse differences between short- and long-axis and in vivo and ex vivo measurements were 0.038 (95% confidence interval [CI], 0.031-0.046) and 0.085 (95% CI, 0.062-0.109) mm, respectively. Intermouse differences in short-axis measurements were 0.047 (95% CI, 0.042-0.053), 0.049 (95% CI, 0.044-0.055), and 0.039 (95% CI, 0.036-0.042) mm for infrarenal, suprarenal, and thoracic measurements, respectively; differences in long-axis measurements were 0.054 (95% CI, 0.044-0.064), 0.029 (95% CI, 0.024-0.034), and 0.046 (95% CI, 0.037-0.054) mm. Bland-Altman and locally weighted scatterplot-smoothing analyses showed excellent agreement between measures with no variation in discrepancies vis-à-vis the target measurement. CONCLUSIONS: These data establish previously undefined estimates of measurement variability relevant for in vivo sonographic studies of AAA regression in a commonly studied mouse model.

Advancing the Science of Healthcare Service Delivery: The NHLBI Corporate Healthcare Leaders' Panel.

There is a growing gap between available science and evidence and the ability of service providers to deliver high-quality care in a cost-effective way to the entire population. We believe that the chasm between knowledge and action is due to a lack of concerted effort among all organizations that deliver health care services across the life span of patients. Broad participation is needed and necessitates a far more explicit and concerted public-private partnership focused on large-scale transformation. In this context, the National Heart, Lung, and Blood Institute convened a panel made up of leaders of corporate health care entities, including academic health centers, and government agency representatives to inform contemporary strategic partnerships with health care companies. This article provides insights from the meeting on how to execute a transformative innovation research agenda that will foster improvements in health care service delivery by leveraging the translation of biomedical research evidence in real-world settings.

Implementation Research to Address the United States Health Disadvantage: Report of a National Heart, Lung, and Blood Institute Workshop.

Four decades ago, U.S. life expectancy was within the same range as other high-income peer countries. However, during the past decades, the United States has fared worse in many key health domains resulting in shorter life expectancy and poorer health-a health disadvantage. The National Heart, Lung, and Blood Institute convened a panel of national and international health experts and stakeholders for a Think Tank meeting to explore the U.S. health disadvantage and to seek specific recommendations for implementation research opportunities for heart, lung, blood, and sleep disorders. Recommendations for National Heart, Lung, and Blood Institute consideration were made in several areas including understanding the drivers of the disadvantage, identifying potential solutions, creating strategic partnerships with common goals, and finally enhancing and fostering a research workforce for implementation research. Key recommendations included exploring why the United States is doing better for health indicators in a few areas compared with peer countries; targeting populations across the entire socioeconomic spectrum with interventions at all levels in order to prevent missing a substantial proportion of the disadvantage; assuring partnership have high-level goals that can create systemic change through collective impact; and finally, increasing opportunities for implementation research training to meet the current needs. Connecting with the research community at large and building on ongoing research efforts will be an important strategy. Broad partnerships and collaboration across the social, political, economic, and private sectors and all civil society will be critical-not only for implementation research but also for implementing the findings to have the desired population impact. Developing the relevant knowledge to tackle the U.S. health disadvantage is the necessary first step to improve U.S. health outcomes.

Value of vasodilator left ventricular ejection fraction reserve in evaluating the magnitude of myocardium at risk and the extent of angiographic coronary artery disease: a 82Rb PET/CT study.

UNLABELLED: Our aim was to determine the value of vasodilator left ventricular ejection fraction (LVEF) reserve (stress ejection fraction - rest ejection fraction) in evaluating the magnitude of myocardium at risk and the anatomic extent of underlying severe coronary artery disease (CAD). METHODS: We studied 510 consecutive patients with suspected CAD undergoing gated rest and vasodilator stress (82)Rb PET/CT. Patients were categorized as having no perfusion abnormalities, mild, moderate, or severe reversible perfusion defects. In a subgroup of 68 patients with coronary angiography, patients were categorized as having 0-vessel, 1-vessel, 2-vessel, or left main/3-vessel disease. RESULTS: Patients without coronary risk factors who comprised our control group as well as patients with coronary risk factors and normal perfusion demonstrated a high LVEF reserve (7% +/- 7% and 5% +/- 6%, respectively). The mean LVEF reserve was negative (-0.2% +/- 8%) in patients with severe reversible defects and in patients with 3-vessel (-6% +/- 8%) and left main (-8% +/- 5%) disease. Among the clinical and scintigraphic variables studied, male sex, rest ejection fraction, and increasing magnitude of myocardium at risk predicted a lower LVEF reserve, whereas LVEF reserve was the only independent predictor of left main/3-vessel disease (P = 0.008). An LVEF reserve of more than +5% had a positive predictive value of only 41% but a negative predictive value of 97% for excluding severe left main/3-vessel CAD. CONCLUSION: During (82)Rb PET/CT, LVEF increases with vasodilator stress in patients without significant stress-induced perfusion defects or severe left main/3-vessel CAD. A high LVEF reserve appears to be an excellent tool to exclude left main/3-vessel CAD noninvasively.

CT-based attenuation correction versus prone imaging to decrease equivocal interpretations of rest/stress Tc-99m tetrofosmin SPECT MPI.

BACKGROUND: The purpose of this study was to compare stress supine single photon emission computed tomography (SPECT) imaging with attenuation correction (AC) via computed tomography-based attenuation maps with stress prone SPECT imaging with regard to the rate of equivocal interpretation of rest/stress myocardial perfusion imaging. METHODS AND RESULTS: Interpretations for 324 consecutive patients referred for rest/stress myocardial perfusion imaging were performed by use of the following sets of poststress SPECT images: supine with no AC (NC), supine NC/AC, supine NC/prone, and all images. The number of equivocal studies decreased with additional imaging: supine NC, 40%; supine NC/prone, 18%; supine NC/AC, 11%; and all images, 8%. The supine NC/AC sets of images reduced the number of defects to a greater extent than the supine NC/prone images for all patients (P = .01), men (P = .002), and women (P = .425). For the inferior (but not the anterior) wall, the percent decrease in defects with supine NC/AC images was lower as compared with supine NC/prone images. CONCLUSION: Interpretation with all images resulted in the fewest equivocal studies. The supine NC/AC images reduced the number of equivocal studies to a greater extent than the supine NC/prone images. AC and prone imaging were more helpful in men than women and were more helpful to resolve inferior than anterior wall defects. Adding prone imaging to supine imaging without and with AC does not significantly alter the number of equivocal interpretations.

Peripheral artery disease: epidemiology and global perspectives.

Global populations are undergoing a major epidemiological transition in which the burden of atherosclerotic cardiovascular diseases is shifting rapidly from high-income to low-income and middle-income countries (LMICs). Peripheral artery disease (PAD) is no exception, so that greater focus is now required on the prevention and management of this disease in less-advantaged countries. In this Review, we examine the epidemiology of PAD and, where feasible, take a global perspective. However, the dearth of publications in LMICs means an unavoidable over-reliance on studies in high-income countries. Research to date suggests that PAD might affect a greater proportion of women than men in LMICs. Although factors such as poverty, industrialization, and infection might conceivably influence the development of PAD in such settings, the ageing of the population and increase in traditional cardiovascular risk factors, such as smoking, diabetes mellitus, and hypertension, are likely to be the main driving forces.

Perspectives from NHLBI Global Health Think Tank Meeting for Late Stage (T4) Translation Research.

Almost three-quarters (74%) of all the noncommunicable disease burden is found within low- and middle-income countries. In September 2014, the National Heart, Lung, and Blood Institute held a Global Health Think Tank meeting to obtain expert advice and recommendations for addressing compelling scientific questions for late stage (T4) research-research that studies implementation strategies for proven effective interventions-to inform and guide the National Heart, Lung, and Blood Institute's global health research and training efforts. Major themes emerged in two broad categories: 1) developing research capacity; and 2) efficiently defining compelling scientific questions within the local context. Compelling scientific questions included how to deliver inexpensive, scalable, and sustainable interventions using alternative health delivery models that leverage existing human capital, technologies and therapeutics, and entrepreneurial strategies. These broad themes provide perspectives that inform an overarching strategy needed to reduce the heart, lung, blood, and sleep disorders disease burden and global health disparities.

Tackling NCD in LMIC: Achievements and Lessons Learned From the NHLBI-UnitedHealth Global Health Centers of Excellence Program.

Effectively tackling the growing noncommunicable disease (NCD) burden in low- and middle-income countries (LMIC) is a major challenge. To address research needs in this setting for NCDs, in 2009, National Heart, Lung, and Blood Institute (NHLBI) and UnitedHealth Group (UHG) engaged in a public-private partnership that supported a network of 11 LMIC-based research centers and created the NHLBI-UnitedHealth Global Health Centers of Excellence (COE) Program. The Program's overall goal was to contribute to reducing the cardiovascular and lung disease burdens by catalyzing in-country research institutions to develop a global network of biomedical research centers. Key elements of the Program included team science and collaborative approaches, developing research and training platforms for future investigators, and creating a data commons. This Program embraced a strategic approach for tackling NCDs in LMICs and will provide capacity for locally driven research efforts that can identify and address priority health issues in specific countries' settings.