Improve Cardiovascular Disease Outcomes Research Articles

Gratitude, Self-Efficacy and Self-Care Behaviors among Patients with Cardiovascular Diseases

Cardiovascular disease (CVD) is a complex disease with persistent course of treatment having serious consequences for the patients’ wellbeing. Positive psychological factors can play a significant role in improving CVD outcomes. Objectives: To better understand the intricate relationships among gratitude, self-efficacy, and self-care behaviors in individuals diagnosed with cardiovascular diseases. Methods: A quantitative cross-sectional research design was employed for the study. 160 patients with CVD aged between 40 to 60 years (M=49.79, SD=5.59) were selected for the study through purposive sampling. The Gratitude Questionnaire, Self-Care Behavior Scale-9 and General Self Efficacy Scale were used to measure gratitude, self-care behaviors, and self-efficacy respectively. Results: Results revealed a significant relationship between gratitude, self-care behaviors and self-efficacy. The findings also indicated self-efficacy to be a significant predictor of self-care behaviors. Conclusions: The study advocates for inclusive healthcare interventions that emphasize the role of gratitude and self-efficacy on self-care behaviors for enhancing wellbeing of CVD patients. It contributes to the understanding of the psychological dynamics within CVD patients emphasizing the role of interventions that promote holistic well-being.

Statin use for cardiovascular disease prevention: perceptions among people living with HIV in the United States

BackgroundPeople living with HIV (PLWH) may be at heightened risk for cardiovascular disease (CVD). Statin use and lifestyle changes reduce the risk of CVD but remain under-prescribed among PLWH. The objective of this study was to characterize knowledge of CVD and statin use, current usage, barriers to taking statins, and information desired by PLWH to improve statin uptake among PLWH in Los Angeles, CA.MethodsBetween April 2019 and April 2020, we conducted four focus group discussions (n = 37) with patients across three public community health clinics that serve PLWH in Los Angeles County, California. All clinics participated in a larger study to improve statin prescribing for PLWH. We asked about knowledge of statins, willingness to take a statin, possible barriers to statin usage, preferred information sources for health information, and desired information about statins. We utilized standard qualitative content analysis methods to identify themes.ResultsWe found a range in the awareness of statins, with some participants reporting never having heard of statins while others had a history of statin use. There were concerns about the potential long-term effect of statin use, but participants expressed willingness to use CVD medications generally and statins specifically, especially if recommended by their healthcare provider. Participants also expressed interest in potential alternatives to statin usage such as exercising regularly and nutritious eating.ConclusionsMore interventions are needed to increase statin use among PLWH to improve CVD outcomes, which also has implications for HIV progression. Clinics should aim to increase patient and provider knowledge about CVD risk and statin use for PLWH and provide shared decision-making tools that are easy to use and culturally appropriate.

Cardiovascular Disease in Diabetes and Chronic Kidney Disease.

Chronic kidney disease (CKD) is a common occurrence in patients with diabetes mellitus (DM), occurring in approximately 40% of cases. DM is also an important risk factor for cardiovascular disease (CVD), but CKD is an important mediator of this risk. Multiple CVD outcomes trials have revealed a greater risk for CVD events in patients with diabetes with CKD versus those without. Thus, reducing the risk of CKD in diabetes should result in improved CVD outcomes. To date, of blood pressure (BP) control, glycemic control, and inhibition of the renin-angiotensin system (RASI), glycemic control appears to have the best evidence for preventing CKD development. In established CKD, especially with albuminuria, RASI slows the progression of CKD. More recently, sodium glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide receptor agonists (GLP1RA) have revolutionized the care of patients with diabetes with and without CKD. SGLT2i and GLP1RA have proven to reduce mortality, heart failure (HF) hospitalizations, and worsening CKD in patients with diabetes with and without existing CKD. The future of limiting CVD in diabetes and CKD is promising, and more evidence is forthcoming regarding combinations of evidence-based therapies to further minimize CVD events.

Abstract LB128: Cardiovascular disease mortality among cancer survivors by race and ethnicity in the United States

Abstract Background Cancer survivors have higher cardiovascular disease (CVD) mortality than the general population but comprehensive data by race and ethnicity are limited. Methods Data from 17 Surveillance, Epidemiology, and End Results (SEER) registries were used to identify adults diagnosed with invasive cancer at ages ≥20 years from 2000 to 2018. CVD mortality was calculated for five mutually exclusive race/ethnicity categories (non-Hispanic American Indian/Alaska Native [AIAN], non-Hispanic Asian or Pacific Islander [API], Hispanic, non-Hispanic Black [Black], and non-Hispanic White [White]). Standardized mortality ratios (SMR) were estimated to compare mortality rates in cancer survivors to their counterparts in the general population. Analyses were stratified by demographic factors, CVD subtype, and cancer site. Results During a mean follow up of 5.3 person-years among 5,786,876 survivors (20-64 years, 49.3%; men, 51.2%; White, 71.7%; Black, 10.1%; Hispanic, 10.9%; API, 7%, AIAN, 0.3%), 358,970 CVD deaths (cardiac death, 76.9%; cerebrovascular death, 15.9%) occurred. CVD mortality per 10,000 person-years was highest among survivors who were Black (122.9), followed by White (114.7), AIAN (86.7), API (78.6) and Hispanic (75.3). In contrast, SMRs were greatest among AIAN survivors (SMR=1.42, 95% CI=1.32-1.51), followed by API (SMR=1.39, 1.37-1.41), Hispanic (SMR=1.29, 1.27-1.30), Black (SMR=1.19, 1.17-1.20) and White (SMR=1.08, 1.07-1.08) survivors. Among survivors ages 20-64 years, Black survivors were approximately three times as likely to die from cardiac death as Hispanic or API survivors (46.7 vs. 14.5-17.6 per 10,000). SMR, however, was 1.47 among Hispanic survivors (95% CI=1.42-1.51) and 1.80 among API survivors (95% CI=1.42-1.51), greater than 1.25 among Black survivors (95% CI=1.22-1.27). Across cancer types, the highest SMR was among API survivors of pancreatic cancer (SMR=5.27, 3.83-7.08) and brain cancer (SMR=4.56, 3.10-6.48) in ages 20-64 years and among Hispanic (SMR=3.77, 3.09-4.56) and API survivors of brain cancer (SMR=3.24, 2.40-4.28) in ages ≥65 years. Conclusion Black survivors had the greatest CVD mortality of all groups, demonstrating that CVD health disparities in the general population extend to cancer survivors. Despite the lower absolute mortalities, relative risks compared to their counterparts in the general population were greatest among API and Hispanic survivors, implying a greater impact of cancer diagnosis on the risk of CVD death among survivors of these populations. Targeted primary care and cardio-oncologic intervention strategies are needed to improve CVD outcomes and achieve cardiovascular health equity among cancer survivors. Citation Format: Lauren Nisotel, Rebecca L. Siegel, Eric H. Yang, Ahmedin Jemal, Hyuna Sung. Cardiovascular disease mortality among cancer survivors by race and ethnicity in the United States [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 2 (Clinical Trials and Late-Breaking Research); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(8_Suppl):Abstract nr LB128.

Development of Novel siRNA Therapeutics: A Review with a Focus on Inclisiran for the Treatment of Hypercholesterolemia.

Over the past two decades, it was discovered that introducing synthetic small interfering RNAs (siRNAs) into the cytoplasm facilitates effective gene-targeted silencing. This compromises gene expression and regulation by repressing transcription or stimulating sequence-specific RNA degradation. Substantial investments in developing RNA therapeutics for disease prevention and treatment have been made. We discuss the application to proprotein convertase subtilisin/kexin type 9 (PCSK9), which binds to and degrades the low-density lipoprotein cholesterol (LDL-C) receptor, interrupting the process of LDL-C uptake into hepatocytes. PCSK9 loss-of-function modifications show significant clinical importance by causing dominant hypocholesterolemia and lessening the risk of cardiovascular disease (CVD). Monoclonal antibodies and small interfering RNA (siRNA) drugs targeting PCSK9 are a significant new option for managing lipid disorders and improving CVD outcomes. In general, monoclonal antibodies are restricted to binding with cell surface receptors or circulating proteins. Similarly, overcoming the intracellular and extracellular defenses that prevent exogenous RNA from entering cells must be achieved for the clinical application of siRNAs. N-acetylgalactosamine (GalNAc) conjugates are a simple solution to the siRNA delivery problem that is especially suitable for treating a broad spectrum of diseases involving liver-expressed genes. Inclisiran is a GalNAc-conjugated siRNA molecule that inhibits the translation of PCSK9. The administration is only required every 3 to 6 months, which is a significant improvement over monoclonal antibodies for PCSK9. This review provides an overview of siRNA therapeutics with a focus on detailed profiles of inclisiran, mainly its delivery strategies. We discuss the mechanisms of action, its status in clinical trials, and its prospects.

Improving diabetic patients’ adherence to treatment and prevention of cardiovascular disease (Office Guidelines Applied to Practice—IMPACT Study)—a cluster randomized controlled effectiveness trial

BackgroundDespite nationwide improvements in cardiovascular disease (CVD) mortality and morbidity, CVD deaths in adults with type 2 diabetes (T2DM) are 2–4 times higher than among those without T2DM. A key contributor to these poor health outcomes is medication non-adherence. Twenty-one to 42% of T2DM patients do not take blood sugar, blood pressure (BP), or statin medications as prescribed. Interventions that foster and reinforce patient-centered communication show promise in improving health outcomes. However, they have not been widely implemented, in part due to a lack of compelling evidence for their effectiveness in real-life primary care settings.MethodsThis pragmatic cluster-randomized trial randomizes 17 teams in 12 Federally Qualified Healthcare Centers (FQHCs) to two experimental groups: intervention (group 1): Office-Gap + Texting vs. control (group 2): Texting only. Office-GAP (Office-Guidelines Applied to Practice) is a patient activation intervention to improve communication and patient-provider partnerships through brief patient and provider training in shared decision-making (SDM) and use of a guideline-based checklist. The texting intervention (Way2Health) is a cell phone messaging service that informs and encourages patients to adhere to goals, adhere to medication use and improve communication. After recruitment, patients in groups 1 and 2 will both attend (1) one scheduled group visit, (90–120 min) conducted by trained research assistants, and (2) follow-up visits with their providers after group visit at 0–1, 3, 6, 9, and 12 months. Data will be collected over 12-month intervention period. Our primary outcome is medication adherence measured using eCAP electronic monitoring and self-report. Secondary outcomes are (a) diabetes-specific 5-year CVD risk as measured with the UK Prospective Diabetes Study (UKPDS) Engine score, (b) provider engagement as measured by the CollaboRATE Shared-Decision Making measure, and (c) patient activation measures (PAM).DiscussionThis study will provide a rigorous pragmatic evaluation of the effectiveness of combined mHealth, and patient activation interventions compared to mHealth alone, targeting patients and healthcare providers in safety net health centers, in improving medication adherence and decreasing CVD risk. Given that 20–50% of adults with chronic illness demonstrate medication non-adherence, increasing adherence is essential to improve CVD outcomes as well as healthcare cost savings.Trial registrationThe ClinicalTrials.gov registration number is NCT04874116.

Association of Systemic Inflammation with Lipid Profiles and Management in Patients with Rheumatoid Arthritis

Lead Author's Financial Disclosures Nothing to disclose. Study Funding None. Background/Synopsis Cardiovascular disease (CVD) is a leading cause of premature mortality among patients with rheumatoid arthritis (RA). The use of lipid-lowering therapies in this population has been associated with not only improved CVD outcomes and lipid profiles but also decreased systemic inflammation. Furthermore, increased inflammation has been associated with low total cholesterol, LDL and HDL levels, referred to as the 'lipid paradox,' adding complexity to optimal management and therapeutic interventions. Objective/Purpose This study sought to demonstrate a correlation between systemic inflammation as by erythrocyte sedimentation rate (ESR) and lipid markers in RA patients while characterizing lipid monitoring and management practices in this population. Methods This was a retrospective cross-sectional study of RA patients seen ≥ 2 times in an outpatient rheumatology clinic from October 2015 to October 2020 at a minority-serving metropolitan academic medical center. Patients were excluded if they did not have a reported ESR in the electronic medical record (EMR). Clinical variables for each patient were defined by the first reported value during the study period. Elevated ESR was defined as ≥ 20 mm/hr. Statistical methods included t-test and chi-square test as appropriate. Results Among 756 patients with RA, the mean age was 54.1 years, 80.7% were female and 43.4% were non-Hispanic Black. 200 (26.5%) patients had a lipid panel reported in the EMR. Patients with elevated ESR were not significantly more likely to have been evaluated with a lipid panel than those with normal ESR (29.5% versus 23.5%, P=0.06). Patients with an elevated ESR had a significantly lower LDL than those with a normal ESR (94.6 mg/dl versus 105.4 mg/dL, P=0.03). When comparing patients with elevated and normal ESR, the following lipid components were not significantly different: total cholesterol (P=0.09), HDL cholesterol (P=0.87) or triglycerides (P=0.67). A significant difference in the prescription of lipid-lowering medications between patients with elevated and normal ESR was not detected (9.9% versus 8.1%, P=0.38). Conclusions Among patients with elevated ESR, only 29.5% of patients were evaluated with a lipid profile and 9.9% patients were prescribed a lipid-lowering medication despite evidence that these therapies decrease both CVD risk and inflammation. The study findings contribute to the existing evidence behind the 'lipid paradox,' as LDL is inversely correlated with inflammation among patients with RA. Thus, due to the 'lipid paradox' and RA-associated inflammation, patients with elevated ESR and RA may benefit from specialized risk evaluation and rigorous management of atherosclerotic CVD with a lipid specialist or preventive cardiologist. Nothing to disclose.

A Time to Rest, a Time to Dine: Sleep, Time-Restricted Eating, and Cardiometabolic Health.

Cardiovascular disease (CVD) poses a serious health and economic burden worldwide. Modifiable lifestyle factors are a focus of research into reducing the burden of CVD, with diet as one of the most investigated factors. Specifically, the timing and regularity of food intake is an emerging research area, with approaches such as time-restricted eating (TRE) receiving much attention. TRE involves shortening the time available to eat across the day and is associated with improved CVD outcomes compared with longer eating windows. However, studies that have examined TRE have not considered the impact of sleep on CVD outcomes despite recent evidence showing that sleep duration can influence the timing and amount of food eaten. In this article, we argue that as TRE and sleep influence each other, and influence the same cardiometabolic parameters, experiencing inadequate sleep may attenuate any positive impact TRE has on CVD. We examine the relationship between TRE and CVD, with sleep as a potential mediator in this relationship, and propose a research agenda to investigate this relationship. This will provide necessary evidence to inform future interventions aimed at reducing the burden of CVD.

Blood Pressure Variability: Mechanisms, Measurement, Subtypes, and Clinical Implications

The complex topic of short- and long-term blood pressure (BP) variability confounds the diagnosis, classification, and management of hypertension. True pathophysiologic BP variation (systematic and non-systematic deviations between- and within-individuals) is related to heart rate, respiration, complex responses of the sympathetic nervous system, vascular reactivity, and arterial stiffness. Measurement errors (systematic biases and random error) further compound the analysis. Most studies use serial clinic BP values, 24-hour ambulatory BP recordings, or home BP values with standard statistical indicators (standard deviation, variance, or coefficient of variation) or absolute real variability (mean difference of successive values). Clinical impact in retrospective secondary analyses includes a modest increase in cardiovascular disease (CVD) risk (equivalent to a few mmHg in mean systolic BP) yet questions remain whether adjustment for mean BP is needed. BP variability is reduced to a small degree by calcium antagonists and increased by ACE inhibitors, beta-blockers, and alpha-blockers but no interventional trial has addressed the question of whether reducing BP variability confers CVD risk protection. BP variability is not specifically discussed in practice guidelines but it is tacitly acknowledged by recommendations to repeat BP measurements, standardize technique, and confirm the hypertension diagnosis by home or ambulatory BP measurements to account for the “white coat effect.” There is no formal consensus on how to quantitate or manage BP variability despite a real-world need for better diagnostic and therapeutic guidance. Practitioners should thus focus on control of (mean) BP using combinations of agents that improve CVD outcomes. Future consensus guidance should directly address BP variability and should include educational materials for physicians, patient-contact staff, and patients.

Underrepresentation of women in cardiovascular trials- it is time to shatter this glass ceiling

Cardiovascular disease (CVD) is the leading cause of death in women, with underrepresented minority (URM) women experiencing the highest mortality rate. For decades, there has been an underrepresentation of women in CVD trials. Although more recent studies have increased the number of women enrolled in these trials, systematic reviews have demonstrated that this enrollment is still low. The National Institute of Health along with other agencies have boosted their efforts to increase enrollment of women and URM populations in CVD trials. Despite these efforts, there still remains a gap. This paper reviews the magnitude, implications and causes of the underrepresentation of women in CVD trials. A proposed multifaceted approach to solving this issue is also outlined in this commentary. Hopefully, implementation of these proposed solutions may facilitate the increase of women, including URM women, enrolled in CVD trials. It is anticipated that this will improve CVD outcomes in these patients.

Recommendations from the EGAPP Working Group: Genomic profiling to assess cardiovascular risk to improve cardiovascular health

Summary of RecommendationsThe Evaluation of Genomic Applications in Practice and Prevention Working Group (EWG) found insufficient evidence to recommend testing for the 9p21 genetic variant or 57 other variants in 28 genes (listed in Table 1) to assess risk for cardiovascular disease (CVD) in the general population, specifically heart disease and stroke. The EWG found that the magnitude of net health benefit from use of any of these tests alone or in combination is negligible. The EWG discourages clinical use unless further evidence supports improved clinical outcomes. Based on the available evidence, the overall certainty of net health benefit is deemed “Low.” RationaleIt has been suggested that an improvement in CVD risk classification (adjusting intermediate risk of CVD into high- or low-risk categories) might lead to management changes (e.g., earlier initiation or higher rates of medical interventions, or targeted recommendations for behavioral change) that improve CVD outcomes. In the absence of direct evidence to support this possibility, this review sought indirect evidence aimed at documenting the extent to which genomic profiling alters CVD risk estimation, alone and in combination with traditional risk factors, and the extent to which risk reclassification improves health outcomes. Analytic validityAssay-related evidence on available genomic profiling tests was deemed inadequate. However, based on existing technologies that have been or may be used and on data from two of the companies performing such testing, the analytic sensitivity and specificity of tests for individual gene variants might be at least satisfactory. Clinical validityTwenty-nine gene candidates were evaluated, with 58 different gene variant/disease associations. Evidence on clinical validity was rated inadequate for 34 of these associations (59%) and adequate for 23 (40%). Inadequate grades were based on limited evidence, poor replication, existence of possible biases, or combinations of these factors. For heart disease (25 combined associations) and stroke (13 combined associations), profiling provided areas under the receiver operator characteristics curve of 66% and 57%, respectively. Only the association of 9p21 variants with heart disease had convincing evidence of a per-allele odds ratio of between 1.2 and 1.3; this was the highest effect size for any variant/disease combination with at least adequate evidence. Although the 9p21 association seems to be independent of traditional risk factors, there is adequate evidence that the improvement in risk prediction is, at best, small. Clinical utilityClinical utility was not formally evaluated in any of the studies reported to date, including for 9p21. As a result, no evidence was available on the balance of benefits and harms. Also, there was no direct evidence available to assess the health benefits and harms of adding these markers to traditional risk factors (e.g., Framingham Risk Score). However, the estimated additional benefit from adding genomic markers to traditional risk factors was found to be negligible. Contextual IssuesPrevention of CVD is a public health priority. Improvements in outcomes associated with genomic profiling could have important impacts. Traditional risk factors such as those used in the Framingham Risk Scores have an advantage in clinical screening and risk assessment strategies because they measure the actual targets for therapy (e.g., lipid levels and blood pressure). To add value, genomic testing should lead to better outcomes than those achievable by assessment and treatment of traditional risk factors alone. Some issues important for clinical utility remain unknown, such as the biological mechanism underlying the most convincing marker's (9p21) association with CVD; the level of risk that changes intervention; whether long-term disease outcomes will improve; how individuals ordering direct to consumer tests will understand/respond to test results and interact with the health care system; and whether direct to consumer testing will motivate behavior change or amplify potential harms.

Effects of Nutritional Interventions on Cardiovascular Disease Health Outcomes in Aboriginal and Torres Strait Islander Australians: A Scoping Review

Nutrition interventions can support Aboriginal and Torres Strait Islander peoples to reduce their risk of cardiovascular disease (CVD). This review examines nutritional interventions aiming to improve CVD outcomes and appraises peer-reviewed interventions using an Aboriginal and Torres Strait Islander Quality Appraisal Tool. Five electronic databases and grey literature were searched, applying no time limit. Two reviewers completed the screening, data extraction and quality assessment independently. The study quality was assessed using the South Australian Health and Medical Research Institute and the Centre of Research Excellence in Aboriginal Chronic Disease Knowledge Translation and Exchange Aboriginal and Torres Strait Islander Quality Appraisal Tool (QAT). Twenty-one nutrition programs were included in this review. Twelve reported on anthropometric measurements, ten on biochemical and/or hematological measurements and sixteen on other outcome domains. Most programs reported improvements in measurable CVD risk factors, including reduced body mass index (BMI), waist circumference (WC), weight, blood pressure and improved lipid profiles. Most programs performed well at community engagement and capacity strengthening, but many lacked the inclusion of Indigenous research paradigms, governance and strengths-based approaches. This review highlights the need for contemporary nutrition programs aimed at improving cardiovascular health outcomes to include additional key cultural components.

Prevalence of Cardiovascular Risk Factors in Osteoarthritis Patients Derived from Primary Care Records: A Systematic Review of Observational Studies.

BackgroundPeople with osteoarthritis are at a high risk of cardiovascular disease (CVD). Detecting CVD risk factors in this high-risk population will help to improve CVD outcomes. Primary care electronic health records (EHRs) provide opportunities for the surveillance of CVD risk factors in the osteoarthritis population. This paper aimed to systematically review evidence of prevalence estimates of CVD risk factors in people with osteoarthritis derived from primary care EHRs.MethodsEight databases including MEDLINE were systematically searched till January 2019. Observational studies using primary care EHRs data to estimate the prevalence of six CVD risk factors in people with osteoarthritis were included. A narrative review was conducted to summarize study results.ResultsSix studies were identified. High heterogeneity between studies prevented the calculation of pooled estimates. One study reported the prevalence of smoking (12.5%); five reported hypertensions (range: 19.7%-55.5%); four reported obesities (range: 34.4%-51.6%); two reported dyslipidemias (6.0%, 13.3%); five reported diabetes (range: 5.2%-18.6%); and one reported chronic kidney disease (1.8%) in people with osteoarthritis. One study reported a higher prevalence of hypertension (Odds Ratio (OR) 1.25, 95% confidence interval (CI) 1.19-1.32), obesity (OR 2.44, 95%CI 2.33-2.55), dyslipidemia (OR 1.24, 95%CI 1.14-1.35) and diabetes (1.11, 95%CI 1.02-1.22) in the osteoarthritis population compared with the matched non-osteoarthritis population.ConclusionsFrom studies identified in this review that had used primary care EHRs, prevalence estimates of CVD risk factors were higher in people with osteoarthritis compared with those without. These estimates may provide baseline frequency of CVD risk factors in osteoarthritis patients in primary care, although this is limited by the small number of studies and high heterogeneity. Further studies of frequency, using primary care EHRs, will help to answer whether this data source can be used for evaluating approaches to manage CVD risk factors in osteoarthritis patients.

Community and Social Context: An Important Social Determinant of Cardiovascular Disease.

Disease prevention frameworks and clinical practice guidelines in the United States (US) have traditionally ignored upstream social determinants of health (SDOH), which are critical for reducing disparities in cardiovascular disease (CVD)—the leading cause of death in the US. Existing evidence demonstrates a protective effect of social support, social cohesion, and community engagement on overall health and wellbeing. Increasing community and social support is a major objective of the Healthy People 2030 initiative, with special provisions for vulnerable populations. However, to date, existing evidence of the association between community and social context (CSC)—an integral SDOH domain—and CVD has not been reviewed extensively. In particular, the individual and cumulative impact of CSC on CVD risk and the pathways linking CSC to cardiovascular outcomes are not well understood. In this review, we critically appraise current knowledge of the association between CSC and CVD, describe potential pathways linking CSC to CVD, and identify opportunities for evidence-based policy and practice interventions to improve CVD outcomes.

Preventing Cardiovascular Complications in Type 1 Diabetes: The Need for a Lifetime Approach.

Cardiovascular disease (CVD) remains the main cause of morbidity and mortality in individuals with type 1 diabetes (T1D). Adolescence appears to be a critical time for the development of early subclinical manifestations of CVD, with these changes likely driven by a deterioration in glycemic control during the progression through puberty, combined with the emergence of numerous other traditional cardiometabolic risk factors (e.g., hypertension, dyslipidemia, smoking, alcohol use, obesity, etc.) which emerge at this age. Although hemoglobin A1C has long been the primary focus of screening and treatment strategies, glycemic control remains poor in youth with T1D. Furthermore, screening for cardiovascular risk factors—which are often elevated in youth with T1D—is suboptimal, and use of pharmacological interventions for hypertension and dyslipidemia remains low. As such, there is a clear need not only for better screening strategies for CVD risk factors in youth, but also early interventions to reduce these, if future CVD events have to be prevented. Accumulating evidence has recently suggested that early increases in urinary albumin excretion, even within the normal range, may identify adolescents with T1D who are at an increased risk of complications, and results from pharmacological intervention with statins and ACE inhibitors in these individuals have been encouraging. These data join a growing evidence highlighting the need for a whole-life approach to prevention starting from childhood if efforts to improve CVD outcomes and related mortality in T1D are to be maintained.

Dietary Policies and Programs: Moving Beyond Efficacy and Into "Real-World" Settings.

Purpose: Dietary behaviors are key modifiable risk factors in averting cardiovascular disease (CVD), the leading cause of morbidity, mortality, and disability in the United States. Before investing in adoption and implementation, community-based organizations, public health practitioners, and policymakers—often working with limited resources—need to compare the population health impacts of different food policies and programs to determine priorities, build capacity, and maximize resources. Numerous reports, reviews, and policy briefs have synthesized across evidence-based policies and programs to make recommendations, but few have made a deep acknowledgment that dietary policies and programs are not implemented in a vacuum, and that “real-world” settings are complex, multifaceted and dynamic.Methods: A narrative review was conducted of currently recommended evidence-based approaches to improving dietary behaviors, to describe and characterize applied and practical factors for consideration when adopting and implementing these dietary policies and programs across diverse settings.Results: From the narrative review, six key considerations emerged to guide community-based organizations, public health practitioners, and policymakers on moving from the evidence base, toward implementation in local and community settings.Conclusions: Considerations of “real-world” contextual factors are necessary and important when adopting and selecting evidence-based policies and programs to improve dietary behaviors and ultimately improve CVD outcomes. Promising approaches include those that apply community-partnered research and systems science to examine the equitable implementation of evidence-based dietary policies and programs.

Risk Factors and Cardiovascular Disease (CVD) Related Outcomes in Hospitalized Patients with Hemophilia 10 Year Follow up

Introduction: Comprehensive management for patients with hemophilia has drastically improved outcomes, quality of care, and longevity. Because of increases in life span, patients with hemophilia may be at risk for other chronic conditions including cardiovascular disease (CVD). Though initially it was thought that hemophilia might have been protective for cardiovascular disease further research has shown that CVD remains a significant risk for the aging hemophilia population. This study aims to determine the prevalence of risk factors and outcomes for CVD in hospitalized adult and pediatric patients with the discharge diagnosis of Hemophilia A or B compared to patients without Hemophilia. We examine longitudinal changes over the previous decade. WMethods: The Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (HCUP-NIS) was utilized for analysis of years 2007 and 2017. The NIS uses a stratified probability sample of 20% of all inpatient discharges (representing more than 97% of the US population). Hemophilia-A and B were identified using ICD-9 code 286.0 and 286.1, ICD-10 codes D66 and D67 respectively and sampling weights were applied to generate nationally representative estimates. Cardiovascular risk factors and outcomes were determined by evaluating ICD-9 codes for 2007 data and ICD-10 codes for 2017 data. For comparative historical data, 2007 NIS data from a prior published study [Goel et al., Hemophilia (2012), 18, 688-692] were used. The NIS is a de-identified, publicly available data set. This study was deemed exempt from review from the Johns Hopkins Institutional Review Board. This analysis was conducted in accordance with the HCUP data use agreement guidelines. Results: In 2017, there were 10,555 admissions with Hemophilia A or B listed as one of all diagnoses. The mean age of hemophilia patients was 44.31 years compared to 49.57. years for all admissions. The most prevalent risk factor in 2017 was hypertension (32.4% for admissions with hemophilia as compared to 35.3% for all admissions) followed by hyperlipidemia (19.4% compared to 27.5%), diabetes (17.4% compared to 22.8%) and obesity (10.8% compared to 14.4%). CVD outcomes, in descending order of frequency were atherosclerotic coronary artery disease (11.6% for admissions with hemophilia compared to 16.9% for all admissions), heart failure (10.2% compared to 14.2%), acute myocardial infarction (AMI) (2.2% compared to 3.9%), and stroke (2.2% compared to 2.4% respectively). Comparing to 10 year prior data, in 2007, there were 9,737 admissions with Hemophilia A or B listed as one of all diagnoses. The mean age of hemophilia patients was 30.89 years compared to 47.16 years for all admissions. The most prevalent risk factor in 2007 was hypertension (27.0% in admissions with hemophilia compared to 36.7% for all admissions); followed by diabetes (11.2% compared to 18.5%), hyperlipidemia (9.5% compared to 17%), and obesity (3.6% compared to 5.8%). CVD outcomes, in descending order of frequency were, atherosclerotic coronary artery disease (10.1% compared to 16.7%), heart failure (6.6% compared to 10.8%), AMI (2.1% compared to 2.4%), and stroke (2.0% compared to 1.7%). Between 2007 and 2017 the crude prevalence rates of all CVD risk factors as well as CVD outcomes generally increased for admissions with hemophilia as well as all-cause hospitalizations. Conclusions: The frequency of all CVD risk factors (obesity, diabetes, hypertension, and hyperlipidemia) as well as CVD outcomes (atherosclerosis, congestive heart failure, AMI, and stroke) increased between 2007 and 2017 in hospitalized patients both with and without hemophilia. While the unadjusted prevalence rates for all CVD risk factors and CVD outcomes were less in hospitalized patients with hemophilia compared to the general hospitalized population in both 2007 and 2017, CVD remains a significant risk for the hemophilia population. An improved understanding of the various risk factors will help to improve CVD outcomes in the aging hemophilia population. Disclosures Takemoto: Genentech: Membership on an entity's Board of Directors or advisory committees; Novartis: Other: DSMB Aplastic Anemia Trial.

Digital Health Innovations to Improve Cardiovascular Disease Care.

Purpose of ReviewTo review the current evidence supporting the use of digital health technologies in cardiovascular disease (CVD) care.Recent FindingsStudies have evaluated the impact of the use of digital health technologies to improve CVD outcomes through several modalities: text-messaging programmes, smartphone applications (apps) and wearable devices. Text-messaging programmes are to date the most studied type of digital health interventions, and studies have demonstrated reduced CVD risk and improved medication adherence. Literature supporting the use of smartphone apps is also growing but remains limited, with some studies favouring the use of health apps but others showing negative results. Wearable devices are the latest type of technology investigated, and studies have shown positive outcomes in terms of physical activity and detection of arrhythmias.SummaryDigital health is a growing and evolving area of investigation. To date, the scientific evidence overall supports the use of such technologies in CVD care and management. Future research using new models are needed to continue to evaluate these new technologies.

A Review of Obesity, Physical Activity, and Cardiovascular Disease.

The focus of this review is to discuss obesity, physical activity (and physical inactivity/sedentary behavior), cardiovascular disease (CVD), and their often interrelated health implications. The authors summarize the pathophysiological changes associated with obesity, which lead to the development of CVD, recommendations for interventions such as diet, increased physical activity, and weight loss according to current literature and guidelines, and the critical importance of cardiorespiratory fitness (CRF). Clinical trials continue to demonstrate improved outcomes among overweight or obese individuals who achieve a healthy weight using various methods. Increasing CRF levels appears to demonstrate the largest health improvements, regardless of underlying comorbidities or achieving weight loss. CRF, which is perhaps the single most important predictor of overall health, seems more important than weight loss alone regarding improved CVD outcomes in the obese population. These findings are reproduced in studies involving patients with various forms of CVD and CVD risk factors. The importance of CRF is well established; future endeavors to establish specific CRF targets for various patient cohorts are needed.

Antihyperglycemic Therapies With Expansions of US Food and Drug Administration Indications to Reduce Cardiovascular Events: Prescribing Patterns Within an Academic Medical Center.

Sodium-glucose cotransport protein-2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) have been shown to reduce cardiovascular events in high-risk patients with type 2 diabetes mellitus (T2DM). We examined real-world use of these agents at a US academic medical center in the state of Mississippi. Prescriptions, provider specialty, and insurance status of users of SGLT2is and GLP-1RAs in patients with T2DM, and T2DM and cardiovascular disease (CVD) seen from 1st January 2013 to 30th June 2019 were obtained by electronic health records review. We identified 21,173 patients with T2DM and CVD. Overall, 306 (1.4%) and 349 (1.6%) patients received a SGLT2i and GLP-1RA, respectively. After the US Food and Drug Administration (FDA) expanded empagliflozin and liraglutide indications, a mean difference of 19.2 and 12.7 greater quarterly new prescriptions was noted, respectively, whereas no such rise in canagliflozin was observed. Primary care physicians accounted for 53.4% SGLT2i prescriptions, endocrinology for 30.3%, and cardiology for 6.0%. Primary care physicians accounted for 45.1% GLP-1RA prescriptions, endocrinology for 45.0%, and cardiology for 1.4%. Prescription patterns did not largely differ by patient insurance status. In conclusion, prescription of evidence-based therapies to improve CVD outcomes in high-risk patients with T2DM remains very low after several years of evidence generation. Low uptake was evident across insurance types. Modest increases in use were observed after regulatory expansions in labeling; however, cardiologists rarely engaged in prescription, underscoring the need for widespread implementation strategies across health care systems.