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AbstractFirst developed in 1990, the Agatston coronary artery calcium (CAC) score is an international guideline-endorsed decision aid for further risk assessment and personalized management in the primary prevention of atherosclerotic cardiovascular disease. This review discusses key international studies that have informed this 30 year journey, from an initial coronary plaque screening paradigm to its current role informing personalized shared decision making. Special attention is paid to the prognostic value of a CAC score of zero (the so called “power of zero”), which, in a context of low estimated risk thresholds for the consideration of preventive therapy with statins in current guidelines, may be used to de-risk individuals and thereby inform the safe delay or avoidance of certain preventive therapies. We also evaluate current recommendations for CAC scoring in clinical practice guidelines around the world, and past and prevailing barriers for its use in routine patient care. Finally, we discuss emerging approaches in this field, with a focus on the potential role of CAC informing not only the personalized allocation of statins and aspirin in the general population, but also of other risk-reduction therapies in special populations, such as individuals with diabetes and people with severe hypercholesterolemia.

AbstractObjectiveTo examine the effect of the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guidelines on the prevalence of hypertension and eligibility for initiation and intensification of treatment in nationally representative populations from the United States and China.DesignObservational assessment of nationally representative data.SettingUS National Health and Nutrition Examination Survey (NHANES) for the most recent two cycles (2013-14, 2015-16) and China Health and Retirement Longitudinal Study (CHARLS) (2011-12).ParticipantsAll 45-75 year old adults who would have a diagnosis of hypertension and be candidates for treatment on the basis of the ACC/AHA guidelines, compared with current guidelines.Main outcome measuresDiagnosis of hypertension and candidacy for initiation and intensification of antihypertensive treatment.ResultsAdoption of the 2017 ACC/AHA hypertension guidelines in the US would label 70.1 (95% confidence interval 64.9 to 75.3) million people in the 45-75 year age group as having hypertension, representing 63% (60.6% to 65.4%) of the population in this age group. Their adoption in China would lead to labeling of 266.9 (252.9 to 280.8) million people or 55% (53.4% to 56.7%) of the same age group as having hypertension. This would represent an increase in prevalence of 26.8% (23.2% to 30.9%) in the US and 45.1% (41.3% to 48.9%) in China. Furthermore, on the basis of treatment patterns and current guidelines, 8.1 (6.5 to 9.7) million Americans with hypertension are untreated, which would be expected to increase to 15.6 (13.6 to 17.7) million after the implementation of the ACC/AHA guidelines. In China, on the basis of current treatment patterns, 74.5 (64.1 to 84.8) million patients with hypertension are untreated, estimated to increase to 129.8 (118.7 to 140.9 million. In addition, the ACC/AHA guidelines would label 8.7 (6.0 to 11.5) million adults in the US and 51 (40.3 to 61.6) million in China as having hypertension that would not require antihypertensive treatment, compared with 1.5 (1.2 to 2.1) million and 23.4 (12.1 to 35.1) million with the current guidelines. Finally, even among people receiving treatment, the proportion that are candidates for intensification of treatment is estimated to increase by 13.9 (12.2 to 15.6) million (from 24.0% to 54.4% of treated patients) in the US, and 30 (24.3 to 35.7) million (41.4% to 76.2% of treated patients) in China, if the ACC/AHA treatment targets are adopted.ConclusionsIf adopted, the 2017 ACC/AHA hypertension guidelines will markedly increase the number of people labeled as having hypertension and treated with drugs in both the US and China, leading to more than half of those aged 45-75 years in both countries being considered hypertensive.

The global burden of cardiovascular disease morbidity and mortality demands increased awareness of effective prevention strategies by patients, communities and health-care providers. The new 2019 ACC/AHA guidelines provide evidence-based, preventive recommendations for patients without known cardiovascular disease, focusing on risk estimation, a healthy lifestyle and selective indications for pharmacotherapy.

Sex is increasingly recognized as an important factor in the epidemiology and outcome of many diseases. This also appears to hold for coronavirus disease 2019 (COVID-19). Evidence from China and Europe has suggested that mortality from COVID-19 infection is higher in men than women, but evidence from US populations is lacking. Utilizing data from a large healthcare provider, we determined if males, as compared to females have a higher likelihood of SARS-CoV-2 susceptibility, and if among the hospitalized COVID-19 patients, male sex is independently associated with COVID-19 severity and poor in-hospital outcomes. Using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines, we conducted a cross-sectional analysis of data from a COVID-19 Surveillance and Outcomes Registry (CURATOR). Data were extracted from Electronic Medical Records (EMR). A total of 96,473 individuals tested for SARS-CoV-2 RNA in nasopharyngeal swab specimens via Polymerized Chain Reaction (PCR) tests were included. For hospital-based analyses, all patients admitted during the same time-period were included. Of the 96,473 patients tested, 14,992 (15.6%) tested positive, of whom 4,785 (31.9%) were hospitalized and 452 (9.5%) died. Among all patients tested, men were significantly older. The overall SARS-CoV-2 positivity among all tested individuals was 15.5%, and was higher in males as compared to females 17.0% vs. 14.6% [OR 1.20]. This sex difference held after adjusting for age, race, ethnicity, marital status, insurance type, median income, BMI, smoking and 17 comorbidities included in Charlson Comorbidity Index (CCI) [aOR 1.39]. A higher proportion of males (vs. females) experienced pulmonary (ARDS, hypoxic respiratory failure) and extra-pulmonary (acute renal injury) complications during their hospital course. After adjustment, length of stay (LOS), need for mechanical ventilation, and in-hospital mortality were significantly higher in males as compared to females. In this analysis of a large US cohort, males were more likely to test positive for COVID-19. In hospitalized patients, males were more likely to have complications, require ICU admission and mechanical ventilation, and had higher mortality than females, independent of age. Sex disparities in COVID-19 vulnerability are present, and emphasize the importance of examining sex-disaggregated data to improve our understanding of the biological processes involved to potentially tailor treatment and risk stratify patients.

Several population-based studies have examined the prevalence and trends of the American Heart Association's ideal cardiovascular health (CVH) metrics as well as its association with cardiovascular disease (CVD)–related morbidity and mortality and with non-CVD outcomes. However, no efforts have been made to aggregate these studies. Accordingly, we conducted a systematic review to synthesize available data on the distribution and outcomes associated with ideal CVH metrics in both US and non-US populations. We conducted a systematic search of relevant studies in the MEDLINE and CINAHL databases, as well as the Cochrane Register of Controlled Trials (CENTRAL). Search terms used included “life's simple 7”, “AHA 2020” and “ideal cardiovascular health”. We included articles published in English Language from January 1, 2010, to July 31, 2015. Of the 14 US cohorts, the prevalence of 6 to 7 ideal CVH metrics ranged from as low as 0.5% in a population of African Americans to 12% in workers in a South Florida health care organization. Outside the United States, the lowest prevalence was found in an Iranian study (0.3%) and the highest was found in a large Chinese corporation (15%). All 6 mortality studies reported a graded inverse association between the increasing number of ideal CVH metrics and the all-cause and CVD-related mortality risk. A similar relationship between ideal CVH metrics and incident cardiovascular events was found in 12 of 13 studies. Finally, an increasing number of ideal CVH metrics was associated with a lower prevalence and incidence of non-CVD outcomes such as cancer, depression, and cognitive impairment. The distribution of ideal CVH metrics in US and non-US populations is similar, with low proportions of persons achieving 6 or more ideal CVH metrics. Considering the strong association of CVH metrics with both CVD and non-CVD outcomes, a coordinated global effort for improving CVH should be considered a priority.

ObjectiveDespite an upsurge in the incidence of atherosclerotic cardiovascular diseases (ASCVD) among young adults, the attributable risk of recreational substance use among young patients has been incompletely evaluated. We evaluated the association of all recreational substances with premature and extremely premature ASCVD.MethodsIn a cross-sectional analysis using the 2014–2015 nationwide Veterans Affairs Healthcare database and the Veterans wIth premaTure AtheroscLerosis (VITAL) registry, patients were categorised as having premature, extremely premature or non-premature ASCVD. Premature ASCVD was defined as having first ASCVD event at age <55 years for men and <65 years for women. Extremely premature was defined as having first ASCVD event at age <40 years while non-premature ASCVD was defined as having first ASCVD event at age ≥55 years for men and ≥65 years for women. Patients with premature ASCVD (n=135 703) and those with extremely premature ASCVD (n=7716) were compared against patients with non-premature ASCVD (n=1 112 455). Multivariable logistic regression models were used to study the independent association of all recreational substances with premature and extremely premature ASCVD.ResultsCompared with patients with non-premature ASCVD, patients with premature ASCVD had a higher use of tobacco (62.9% vs 40.6%), alcohol (31.8% vs 14.8%), cocaine (12.9% vs 2.5%), amphetamine (2.9% vs 0.5%) and cannabis (12.5% vs 2.7%) (p<0.01 for all comparisons). In adjusted models, the use of tobacco (OR 1.97, 95% CI 1.94 to 2.00), alcohol (OR 1.50, 95% CI 1.47 to 1.52), cocaine (OR 2.44, 95% CI 2.38 to 2.50), amphetamine (OR 2.74, 95% CI 2.62 to 2.87), cannabis (OR 2.65, 95% CI 2.59 to 2.71) and other drugs (OR 2.53, 95% CI 2.47 to 2.59) was independently associated with premature ASCVD. Patients with polysubstance use had a graded response with the highest risk (~9-fold) of premature ASCVD among patients with use of ≥4 recreational substances. Similar trends were observed among patients with extremely premature ASCVD. Gender interactions with substance use were significant (p-interaction <0.05), with recreational substance use and premature ASCVD showing stronger associations among women than in men with premature ASCVD.ConclusionsAll subgroups of recreational substances were independently associated with a higher likelihood of premature and extremely premature ASCVD. Recreational substance use confers a greater magnitude of risk for premature ASCVD among women. A graded response relationship exists between increasing number of recreational substances used and higher likelihood of early-onset ASCVD.

The JUPITER trial showed that some patients with LDL-cholesterol concentrations less than 3·37 mmol/L (<130 mg/dL) and high-sensitivity C-reactive protein (hsCRP) concentrations of 2 mg/L or more benefit from treatment with rosuvastatin, although absolute rates of cardiovascular events were low. In a population eligible for JUPITER, we established whether coronary artery calcium (CAC) might further stratify risk; additionally we compared hsCRP with CAC for risk prediction across the range of low and high hsCRP values. 950 participants from the Multi-Ethnic Study of Atheroslcerosis (MESA) met all criteria for JUPITER entry. We compared coronary heart disease and cardiovascular disease event rates and multivariable-adjusted hazard ratios after stratifying by burden of CAC (scores of 0, 1–100, or >100). We calculated 5-year number needed to treat (NNT) by applying the benefit recorded in JUPITER to the event rates within each CAC strata. Median follow-up was 5·8 years (IQR 5·7–5·9). 444 (47%) patients in the MESA JUPITER population had CAC scores of 0 and, in this group, rates of coronary heart disease events were 0·8 per 1000 person-years. 74% of all coronary events were in the 239 (25%) of participants with CAC scores of more than 100 (20·2 per 1000 person-years). For coronary heart disease, the predicted 5-year NNT was 549 for CAC score 0, 94 for scores 1–100, and 24 for scores greater than 100. For cardiovascular disease, the NNT was 124, 54, and 19. In the total study population, presence of CAC was associated with a hazard ratio of 4·29 (95% CI 1·99–9·25) for coronary heart disease, and of 2·57 (1·48–4·48) for cardiovascular disease. hsCRP was not associated with either disease after multivariable adjustment. CAC seems to further stratify risk in patients eligible for JUPITER, and could be used to target subgroups of patients who are expected to derive the most, and the least, absolute benefit from statin treatment. Focusing of treatment on the subset of individuals with measurable atherosclerosis could allow for more appropriate allocation of resources. National Institutes of Health–National Heart, Lung, and Blood Institute.

Purpose of ReviewWe sought to examine the role of social and environmental conditions that determine an individual’s behaviors and risk of disease—collectively known as social determinants of health (SDOH)—in shaping cardiovascular (CV) health of the population and giving rise to disparities in risk factors, outcomes, and clinical care for cardiovascular disease (CVD), the leading cause of death in the United States (US).Recent FindingsTraditional CV risk factors have been extensively targeted in existing CVD prevention and management paradigms, often with little attention to SDOH. Limited evidence suggests an association between individual SDOH (e.g., income, education) and CVD. However, inequities in CVD care, risk factors, and outcomes have not been studied using a broad SDOH framework.SummaryWe examined existing evidence of the association between SDOH—organized into 6 domains, including economic stability, education, food, neighborhood and physical environment, healthcare system, and community and social context—and CVD. Greater social adversity, defined by adverse SDOH, was linked to higher burden of CVD risk factors and poor outcomes, such as stroke, myocardial infarction (MI), coronary heart disease, heart failure, and mortality. Conversely, favorable social conditions had protective effects on CVD. Upstream SDOH interact across domains to produce cumulative downstream effects on CV health, via multiple physiologic and behavioral pathways. SDOH are major drivers of sociodemographic disparities in CVD, with a disproportionate impact on socially disadvantaged populations. Efforts to achieve health equity should take into account the structural, institutional, and environmental barriers to optimum CV health in marginalized populations. In this review, we highlight major knowledge gaps for each SDOH domain and propose a set of actionable recommendations to inform CVD care, ensure equitable distribution of healthcare resources, and reduce observed disparities.

IntroductionData on race and ethnic disparities for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are limited. We analysed sociodemographic factors associated with higher likelihood of SARS-CoV-2 infection and explore mediating pathways for race and ethnic disparities in the SARS-CoV-2 pandemic.MethodsThis is a cross-sectional analysis of the COVID-19 Surveillance and Outcomes Registry, which captures data for a large healthcare system, comprising one central tertiary care hospital, seven large community hospitals and an expansive ambulatory/emergency care network in the Greater Houston area. Nasopharyngeal samples for individuals inclusive of all ages, races, ethnicities and sex were tested for SARS-CoV-2. We analysed sociodemographic (age, sex, race, ethnicity, household income, residence population density) and comorbidity (Charlson Comorbidity Index, hypertension, diabetes, obesity) factors. Multivariable logistic regression models were fitted to provide adjusted OR (aOR) and 95% CI for likelihood of a positive SARS-CoV-2 test. Structural equation modelling (SEM) framework was used to explore three mediation pathways (low income, high population density, high comorbidity burden) for the association between non-Hispanic black (NHB) race, Hispanic ethnicity and SARS-CoV-2 infection.ResultsAmong 20 228 tested individuals, 1551 (7.7%) tested positive. The overall mean (SD) age was 51.1 (19.0) years, 62% were females, 22% were black and 18% were Hispanic. NHB and Hispanic ethnicity were associated with lower socioeconomic status and higher population density residence. In the fully adjusted model, NHB (vs non-Hispanic white; aOR, 2.23, CI 1.90 to 2.60) and Hispanic ethnicity (vs non-Hispanic; aOR, 1.95, CI 1.72 to 2.20) had a higher likelihood of infection. Older individuals and males were also at higher risk of infection. The SEM framework demonstrated a significant indirect effect of NHB and Hispanic ethnicity on SARS-CoV-2 infection mediated via a pathway including residence in densely populated zip code.ConclusionsThere is strong evidence of race and ethnic disparities in the SARS-CoV-2 pandemic that are potentially mediated through unique social determinants of health.