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Digital health technologies, such as telehealth, remote patient monitoring, and smartphone apps, have the potential to reduce access disparities faced by rural patients with cardiovascular disease, but little is known about rural health care providers' perspectives on adopting digital health in their practice. This study used diffusion of innovations theory as a guiding framework to interpret interview findings on rural and rural-serving health care providers' perspectives on the use of digital health to deliver rural cardiovascular care. We conducted semistructured interviews with rural and rural-serving health care providers, including primary care advanced practice providers and physicians, as well as referring cardiologists from 6 primary care clinics in Alaska, Idaho, and Washington. We performed a directed content analysis of interview data informed by diffusion of innovations theory and identified emergent subthemes related to each of the 5 factors that influence adoption: relative advantage, compatibility, complexity, trialability, and observability. Seventeen health care providers participated in this study. Participants described cycles of adopting and discontinuing the use of digital health in their practice. Participants identified advantages of digital health including reduced patient travel, the ability to leverage nonphysician health care workers, and the availability of objective patient data from remote patient monitoring. Compatibilities included increased patient adherence and follow-up and the ability to involve specialists in patient care. The trialability of digital health was described through experiences with remote patient monitoring and scaled-up use of telehealth during the COVID-19 pandemic, and participants observed the benefits of digital health in other disciplines and as patients. We also identified several disadvantages, incompatibilities, and complexities that may hinder the adoption of digital health technologies in rural practice, most of which were highlighted at the clinic and patient levels. These disadvantages, incompatibilities, and complexities included substandard equipment, inability to perform a physical examination, connectivity issues caused by poor internet and cell phone service, concerns about patient age and technical abilities, concerns about proper fit and distribution of remote patient monitoring equipment, and questions about billing and data management for digital health technologies. Rural health care providers recognize the many advantages of using digital health in caring for patients with cardiovascular disease but find that digital health is often complex and incompatible with their needs and the needs of their patients. There may be a disconnect between the potential of digital health and how it works in practice, as evidenced by the cycles of adoption and discontinuance of digital health technologies described by rural health care providers. Future rural digital health interventions in cardiovascular care should take into consideration specific complexities and incompatibilities in the rural context.

Advances in breast cancer (BC) treatment have contributed to improved survival, but BC survivors experience significant short-term and long-term cardiovascular mortality and morbidity, including an elevated risk of heart failure with preserved ejection fraction (HFpEF). Most research has focused on HF with reduced ejection fraction (HFrEF) after BC; however, recent studies suggest HFpEF is the more prevalent subtype after BC and is associated with substantial health burden. The increased HFpEF risk observed in BC survivors may be explained by treatment-related toxicity and by shared risk factors that heighten risk for both BC and HFpEF. Beyond risk factors with physiological impacts that drive HFpEF risk, such as hypertension and obesity, social determinants of health (SDOH) likely contribute to HFpEF risk after BC, impacting diagnosis, management and prognosis.Increasing clinical awareness of HFpEF after BC and screening for cardiovascular (CV) risk factors, in particular hypertension, may be beneficial in this high-risk population. When BC survivors develop HFpEF, treatment focuses on initiating guideline-directed medical therapy and addressing underlying comorbidities with pharmacotherapy or behavioural intervention. HFpEF in BC survivors is understudied. Future directions should focus on improving HFpEF prevention and treatment by building a deeper understanding of HFpEF aetiology and elucidating contributing risk factors and their pathogenesis in HFpEF in BC survivors, in particular the association with different BC treatment modalities, including radiation therapy, chemotherapy, biological therapy and endocrine therapy, for example, aromatase inhibitors. In addition, characterising how SDOH intersect with these therapies is of paramount importance to develop future prevention and management strategies.

Breast cancer survivors are at risk for both poor quality of life (QoL) and cardiovascular disease (CVD). This study examines whether incident CVD after breast cancer independently predicts QoL. Using data from the Women's Health Initiative, we included women who were diagnosed with invasive breast cancer during follow-up and free of prevalent CVD prior to breast cancer. CVD was defined as adjudicated coronary heart disease, heart failure, or stroke. Physical and mental QoL, measured by the SF-36 Physical and Mental Component Scores (PCS and MCS, respectively), were recorded after breast cancer. Poor PCS and MCS were defined as scores < 40. We used adjusted time-dependent Cox proportional hazards models, accounting for time to CVD. Among 2912 BC survivors (mean age at BC diagnosis = 67), 1094 (37.6%) and 313 (10.7%) women had a post-breast cancer PCS and MCS score < 40, respectively, at a median of 2.5 years. A higher proportion of women had poor PCS scores post-BC (37.5% vs. 19.2%, P < 0.001) but not MCS (10.4% vs. 8.2%, P = 0.10). After adjustment for key covariates, incident CVD was associated with a 1.95-fold (95% CI 1.42, 2.67) greater risk of poor PCS scores (P < 0.001), but was not associated with poor MCS (HR 1.23, 95% CI 0.57, 2.65, P = 0.59)). Incident CVD after breast cancer was associated with poor physical QoL but not mental QoL. This study highlights the importance of regular assessments of QoL and need for strategies to improve physical QoL in breast cancer survivors with CVD.

Immune checkpoint inhibitors (ICIs) are a class of cancer immunotherapy with growing indications for treatment of various malignancies. Immune checkpoint inhibitors are monoclonal antibodies that block inhibitory pathways in immune cells, including cytotoxic T lymphocyte antigen-4 (CTLA4), programmed death 1 receptor (PD1), and programmed cell death ligand-1 (PDL1), to activate the immune system. However, these agents can disrupt self-tolerance and lead to immune-related adverse events. Fulminant myocarditis, a feared complication of ICIs, can be highly fatal, and there is a need for effective treatment options. A 70-year-old patient with recurrent metastatic disease of urothelial carcinoma subsequently developed fulminant myocarditis after receiving eight cycles of pembrolizumab. He developed cardiogenic shock and required inotropes and a percutaneous microaxial flow pump placement for temporary mechanical circulatory support. He received methylprednisolone initially and then was started on second-line immunosuppression agents, ruxolitinib and abatacept, for steroid-refractory myocarditis. Abatacept is thought to inhibit activation of T-cell CTLA4 and PD1/PDL1 pathways and reverse ICI-activated pathways. Ruxolitinib is a Janus kinase inhibitor that impairs immune activation through suppressing cytokine sensing and production and T-cell activation. After these treatments, the patient subsequently clinically improved and his myocarditis resolved. This case highlights ICI myocarditis refractory to corticosteroids leading to treatment with second-line immunosuppression. As immunotherapies are increasingly applied to a broader range of cancers, further research is needed to evaluate the optimal treatment strategy for ICI-related myocarditis and other immune-related adverse events.

HIV preexposure prophylaxis (PrEP), a key strategy for preventing HIV transmission, requires awareness and access to PrEP services. Although all patients should be made aware of HIV PrEP; the diagnosis of bacterial sexually transmitted infections (STIs) is an important indicator of potential HIV PrEP need. In a previous evaluation of Get2PrEP (G2P), we found that an electronic medical record laboratory comments did not increase the frequency of PrEP discussions between patients and providers. In Get2PrEP2 (G2P2), we hypothesized that active, personalized messaging to providers about HIV PrEP would increase the documentation of PrEP discussions, referrals, and/or provision of HIV PrEP to individuals diagnosed with an STI. G2P2 was a parallel 3-arm, unblinded, randomized controlled design. Participants were allocated 2:1 to intervention or control. Participants in the intervention arm were further allocated to receive provider messaging through the electronic medical record chat message or e-mail. The 191 randomized encounters resulted in a modest 7.8% (odds ratio, 1.078; confidence interval, 1.02-1.13) increase in documented PrEP discussions in intervention encounters versus none in the standard care group. There was no statistical difference by intervention modality. All documented discussions occurred in the outpatient or emergency department and were more frequent in women and those aged <25 years. An e-mail or electronic medical record chat message sent to providers of patients testing positive for an STI had a small but significant effect on documented patient-provider PrEP discussions. Further investigation is required to determine whether provider messaging can increase PrEP uptake among eligible patients and longer-term outcomes.

This double-blind study randomly assigned adults with obesity (or overweight and with one or more weight-related coexisting conditions) without diabetes to 68 weeks of once-weekly subcutaneous semaglutide (2.4 mg) or placebo, plus lifestyle intervention. Semaglutide therapy was associated with sustained, clinically relevant weight reduction.