Contemporary Homozygous Familial Hypercholesterolemia in the United States: Insights From the CASCADE FH Registry

Background Homozygous familial hypercholesterolemia (HoFH) is a rare, treatment-resistant disorder characterized by early-onset atherosclerotic and aortic valvular cardiovascular disease if left untreated. Contemporary information on HoFH in the United States is lacking, and the extent of underdiagnosis and undertreatment is uncertain. Methods and Results Data were analyzed from 67 children and adults with clinically diagnosed HoFH from the CASCADE (Cascade Screening for Awareness and Detection) FH Registry. Genetic diagnosis was confirmed in 43 patients. We used the clinical characteristics of genetically confirmed patients with HoFH to query the Family Heart Database, a US anonymized payer health database, to estimate the number of patients with similar lipid profiles in a "real-world" setting. Untreated low-density lipoprotein cholesterol levels were lower in adults than children (533 versus 776 mg/dL; P=0.001). At enrollment, atherosclerotic cardiovascular disease and supravalvular and aortic valve stenosis were present in 78.4% and 43.8% and 25.5% and 18.8% of adults and children, respectively. At most recent follow-up, despite multiple lipid-lowering treatment, low-density lipoprotein cholesterol goals were achieved in only a minority of adults and children. Query of the Family Heart Database identified 277 individuals with profiles similar to patients with genetically confirmed HoFH. Advanced lipid-lowering treatments were prescribed for 18%; 40% were on no lipid-lowering treatment; atherosclerotic cardiovascular disease was reported in 20%; familial hypercholesterolemia diagnosis was uncommon. Conclusions Only patients with the most severe HoFH phenotypes are diagnosed early. HoFH remains challenging to treat. Results from the Family Heart Database indicate HoFH is systemically underdiagnosed and undertreated. Earlier screening, aggressive lipid-lowering treatments, and guideline implementation are required to reduce disease burden in HoFH.

Associations of Adipokine Levels with Levels of Remnant Cholesterol: the Multi-Ethnic Study of Atherosclerosis (MESA)

Background

The metabolic syndrome phenotype of individuals with obesity is characterized by elevated levels of triglyceride (TG)-rich lipoproteins and remnant particles, which have been shown to be significantly atherogenic. Understanding the association between adipokines, endogenous hormones produced by adipose tissue, and remnant cholesterol (RC) would give insight into the link between obesity and atherosclerotic cardiovascular disease.

Methods

We studied 1,791 MESA participants of an ancillary study on body composition who had adipokine levels measured (leptin, adiponectin, resistin) at either visit 2 or 3. RC was calculated as non-high density lipoprotein cholesterol minus low-density lipoprotein cholesterol (LDL-C), measured at the same visit as the adipokines, as well as subsequent visits 4 through 6. Multivariable-adjusted linear mixed effects models were used to assess the cross-sectional and longitudinal associations between adipokines and levels of RC.

Results

Mean (SD) age was 64.5±9.6 years and for body mass index (BMI) was 29.9±5.0 kg/m2; 52.0% were women. In fully adjusted models that included BMI, LDL-C and lipid-lowering therapy, for each 1-unit increment in adiponectin, there was 14.4% (12.0, 16.8) lower RC. With each 1-unit increment in leptin and resistin, there was 4.5% (2.3, 6.6) and 5.1% (1.2, 9.2) higher RC, respectively. Lower adiponectin and higher leptin were also associated with longitudinal increases in RC levels over median follow-up of 5(4-8) years.

Conclusions

Lower adiponectin and higher leptin levels were independently associated with higher levels of RC at baseline and longitudinal RC increase, even after accounting for BMI and LDL-C.

CLINICAL PERSPECTIVE

What is new?: - Among individuals without history of cardiovascular disease, adiponectin is inversely associated with cross-sectional levels of remnant cholesterol, whereas leptin and resistin are directly associated.- Adiponectin had an inverse association with progression of remnant cholesterol levels over time.What are the clinical implications?: - Adiponectin levels were not associated with LDL-C levels but with levels of triglyceride-rich lipoproteins, particularly remnant cholesterol.-Incrementing adiponectin via lifestyle modification and/or pharmacological therapies (i.e. GLP-1 agonists) could be a mechanism to reduce remnant cholesterol levels and ultimately cardiovascular risk.

A clinician's guide to addressing cardiovascular health based on a revised AHA framework

The American Heart Association recently published updates to its definition of cardiovascular health (CVH) in its Presidential Advisory called Life's Essential 8. In particular, the update from Life's Simple 7 added a new component of sleep duration and refined definitions of prior components, including measurement of diet, nicotine exposure, blood lipids, and blood glucose. Physical activity, BMI, and blood pressure were unchanged. Together, these eight components create a composite CVH score that clinicians, policy-makers, patients, communities, and businesses can utilize to communicate in a consistent way. Life's Essential 8 also emphasizes the critical role of addressing social determinants of health to improve these individual CVH components, which strongly correlate with future cardiovascular outcomes. This framework should be used across the life spectrum including during pregnancy and childhood to allow improvements in and prevention of CVH at critical time-points. Clinicians can use this framework to advocate for digital health technologies and societal policies that help address and more seamlessly measure the 8 components of CVH with the goal of increasing quality and quantity of life.

Design and Rationale of the Home Blood Pressure Telemonitoring Linked with Community Health Workers to Improve Blood Pressure (LINKED-BP) Program

BACKGROUND

Disparities in hypertension outcomes persist among Black and Hispanic adults and persons living in poverty in the United States. The "LINKED-BP Program" is a multi-level intervention linking home blood pressure (BP) monitoring with a mobile health application, support from community health workers (CHWs), and BP measurement training at primary care practices to improve BP. This study is part of the American Heart Association RESTORE (AddREssing Social Determinants TO pRevent hypErtension) Network. This study aims to examine the effect of the LINKED-BP Program on BP reduction and to evaluate the reach, adoption, sustainability, and cost-effectiveness of the intervention.

METHODS

Using a hybrid type I effectiveness-implementation design, 600 adults who have elevated BP or untreated stage 1 hypertension without diabetes, chronic kidney disease, history of cardiovascular disease (stroke or coronary heart disease) and age < 65 years will be recruited from 20 primary care practices including community health centers in the Maryland area. The practices are randomly assigned to the intervention or the enhanced usual care arms. Patients in the LINKED-BP Program receive training on home BP monitoring, BP telemonitoring through the Sphygmo app, and CHW telehealth visits for education and counseling on lifestyle modification over 12 months. The primary clinical outcome is change from baseline in systolic BP at 6 and 12 months.

DISCUSSIONS

The LINKED-BP Program tests a sustainable, scalable approach to prevent hypertension and advance health equity. The findings will inform implementation strategies that address social determinants of health and barriers to hypertension prevention in underserved populations.

CLINICALTRIALS.GOV IDENTIFIER

NCT05180045.

Nutraceutical approaches to non-alcoholic fatty liver disease (NAFLD): A position paper from the International Lipid Expert Panel (ILEP)

Non-Alcoholic Fatty Liver Disease (NAFLD) is a common condition affecting around 10-25% of the general adult population, 15% of children, and even > 50% of individuals who have type 2 diabetes mellitus. It is a major cause of liver-related morbidity, and cardiovascular (CV) mortality is a common cause of death. In addition to being the initial step of irreversible alterations of the liver parenchyma causing cirrhosis, about 1/6 of those who develop NASH are at risk also developing CV disease (CVD). More recently the acronym MAFLD (Metabolic Associated Fatty Liver Disease) has been preferred by many European and US specialists, providing a clearer message on the metabolic etiology of the disease. The suggestions for the management of NAFLD are like those recommended by guidelines for CVD prevention. In this context, the general approach is to prescribe physical activity and dietary changes the effect weight loss. Lifestyle change in the NAFLD patient has been supplemented in some by the use of nutraceuticals, but the evidence based for these remains uncertain. The aim of this Position Paper was to summarize the clinical evidence relating to the effect of nutraceuticals on NAFLD-related parameters. Our reading of the data is that whilst many nutraceuticals have been studied in relation to NAFLD, none have sufficient evidence to recommend their routine use; robust trials are required to appropriately address efficacy and safety.

Abstract P398: Using Human-Centered Design Methodology to Identify Challenges and Inform the Development of a Digital Toolkit to Optimize Heart Failure Guideline-Directed Medical Therapy From Diverse Clinician, Patient, and Patient Health Partner Perspectives

Introduction: Despite overwhelming evidence that guideline-directed medical therapies (GDMT) for heart failure (HF) can reduce mortality and improve quality of life, significant gaps in treatment optimization persist. GDMT initiation and up-titration are especially critical for improving patient outcomes post-hospitalization.

Objective: Identify challenges encountered post-hospitalization in optimizing GDMT for HF management by engaging key stakeholders in human-centered design (HCD) to guide the development of a digital toolkit to increase HF GDMT optimization.

Methods: HCD is used to solve complex problems by soliciting input from stakeholders. We recruited: a) clinicians (physicians and advanced practice providers) who provide care to patients with HF across three health systems, b) patients with HF with Reduced Ejection Fraction (HFrEF, EF < 40%) discharged from the hospital within 30 days of enrollment, and c) patient health partners when available. We conducted separate virtual sessions for clinicians and patients/health partners using semi-structured interview guides to identify challenges, motivators and themes.

Results: We enrolled 10 clinicians, 10 patients, and 2 patient health partners. The clinicians had a median age of 37 years (IQR: 35-41) and 12 years (IQR: 14-9) experience caring for patients with HF; 80% (8/10) were women, and 50% (5/10) were physicians. Patients had a median age of 53 years (IQR: 48-64); 40% (4/10) were women, 60% (6/10) were a racial/ethnic minority, and 50% (5/10) were married. Top challenges to HF GDMT optimization (e.g. number of medications) and digital toolkit features identified during the clinician HCD sessions are reported in Figure 1.

Conclusions: The clinician and patient/health partner HCD findings will inform the development of the digital toolkit, including a patient-facing smartphone application and clinician dashboard, for HF GDMT optimization. We will also conduct HCD sessions in Brazil to further co-design the digital toolkit for low resource settings.

Abstract P376: Home Blood Pressure Telemonitoring Linked With Community Health Workers to Improve Blood Pressure: The LINKED-BP Program

Background: Hypertension disparities persist in underserved populations in the United States. Presently, few implementation trials have focused on adults with elevated blood pressure (BP) or untreated stage 1 hypertension. To address this scientific gap, we have developed a pragmatic cluster-randomized controlled trial, the “LINKED-BP Program,” a patient-centered, multi-level intervention linking home blood pressure monitoring (HBPM) via a telemonitoring platform (the Sphygmo BP application) that integrates Bluetooth-enabled validated BP devices, support from community health workers, and BP measurement training at primary care practices to improve BP. The LINKED-BP Program is one of the five studies in the RESTORE (Add RE ssing S ocial Determinants TO p R event hyp E rtension) Network, an American Heart Association-funded initiative focused on the prevention of hypertension. The study aims to examine the effect of the LINKED-BP Program on BP reduction, as well as to evaluate the reach, adoption, sustainability, and cost-effectiveness of the intervention.

Methods: We are recruiting 600 adults with elevated BP or untreated stage 1 hypertension from 20 primary care practices that provide care to underserved populations in Maryland and Pennsylvania. The practices are randomly assigned to the intervention or the enhanced usual care arm. Patients in the LINKED-BP Program receive training on HBPM with a validated home BP monitor, BP telemonitoring through the Sphygmo app, and community health worker visits for education and counseling on lifestyle modification over 12 months. Data are collected at baseline, 6, 12, and 24 months. The primary clinical outcome is a change from baseline in systolic BP at 6 and 12 months.

Discussion: The LINKED-BP Program tests a sustainable, scalable approach to prevent hypertension and advance health equity. The study findings will inform implementation strategies that address social determinants of health and barriers to hypertension prevention in underserved populations.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports 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 Epidemiology and Prevention 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 with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the 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, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Virtual Healthcare Solutions for Cardiac Rehabilitation: A Literature Review

Aims

Adherence to cardiac rehabilitation following a primary event has been demonstrated to improve quality of life, increase functional capacity, and decrease hospitalizations and mortality. Mobile technologies offer an opportunity to improve both the quality and utilization of cardiac rehabilitation and recent clinical studies investigated this technology. This literature review summarizes the current use of mobile health, wearable activity monitors, and other multi-component technologies deployed to support home-based virtual cardiac rehabilitation.

Methods and results

Methodology was adapted from the Cochrane Handbook for Systematic Reviews of Interventions. We identified 2,094 records, of which 113 were eligible for qualitative analysis. Different virtual cardiac rehabilitation solutions were implemented in the studies, (1) multi-component interventions in 48 studies (42.5%), (2) wearable activity monitors in 27 studies (23.9%), (3) web-based communications solutions, and (4) mobile apps, both in 19 studies (16.4%). Functional capacity was the most frequently reported primary outcome (k=37, 32.7%), followed by user adherence/compliance (k=35, 31.0%), physical activity (k=27, 23.9%), and quality of life (k=14, 12.4%). Studies provided a mixed assessment of the efficacy of virtual cardiac rehabilitation in attaining either significant improvements over baseline, or significant improvements in outcomes compared with conventional rehabilitation.

Conclusions

Efficacy outcomes with virtual cardiac rehabilitation sometimes improve on the centre-based outcomes, however, superior clinical efficacy may not necessarily be the only outcome of interest. The promise of virtual cardiac rehabilitation includes the potential for increased user adherence and longer-term patient engagement. If these outcomes can be improved, that would be a significant justification for using this technology.

Association of Depression and Poor Mental Health With Cardiovascular Disease and Suboptimal Cardiovascular Health Among Young Adults in the United States

Background Depression is a nontraditional risk factor for cardiovascular disease (CVD). Data on the association of depression and poor mental health with CVD and suboptimal cardiovascular health (CVH) among young adults are limited. Methods and Results We used data from 593 616 young adults (aged 18-49 years) from the 2017 to 2020 Behavioral Risk Factor Surveillance System, a nationally representative survey of noninstitutionalized US adults. Exposures were self-reported depression and poor mental health days (PMHDs; categorized as 0, 1-13, and 14-30 days of poor mental health in the past 30 days). Outcomes were self-reported CVD (composite of myocardial infarction, angina, or stroke) and suboptimal CVH (≥2 cardiovascular risk factors: hypertension, hypercholesterolemia, overweight/obesity, smoking, diabetes, physical inactivity, and inadequate fruit and vegetable intake). Using logistic regression, we investigated the association of depression and PMHDs with CVD and suboptimal CVH, adjusting for sociodemographic factors (and cardiovascular risk factors for the CVD outcome). Of the 593 616 participants (mean age, 34.7±9.0 years), the weighted prevalence of depression was 19.6% (95% CI, 19.4-19.8), and the weighted prevalence of CVD was 2.5% (95% CI, 2.4-2.6). People with depression had higher odds of CVD than those without depression (odds ratio [OR], 2.32 [95% CI, 2.13-2.51]). There was a graded association of PMHDs with CVD. Compared with individuals with 0 PMHDs, the odds of CVD in those with 1 to 13 PMHDs and 14 to 30 PHMDs were 1.48 (95% CI, 1.34-1.62) and 2.29 (95% CI, 2.08-2.51), respectively, after adjusting for sociodemographic and cardiovascular risk factors. The associations did not differ significantly by sex or urban/rural status. Individuals with depression had higher odds of suboptimal CVH (OR, 1.79 [95% CI, 1.65-1.95]) compared with those without depression, with a similar graded relationship between PMHDs and suboptimal CVH. Conclusions Depression and poor mental health are associated with premature CVD and suboptimal CVH among young adults. Although this association is likely bidirectional, prioritizing mental health may help reduce CVD risk and improve CVH in young adults.

US Trends in Cholesterol Screening, Lipid Levels, and Lipid-Lowering Medication Use in US Adults, 1999 to 2018

Background Understanding current trends in cholesterol screening, lipid levels, and lipid management therapies may inform health policy and practice. Methods and Results In 50 928 US adult National Health and Nutrition Examination Survey (NHANES) participants, trends were assessed in cholesterol screening, mean levels of total cholesterol, triglycerides, low-density-lipoprotein cholesterol, and lipid-lowering medication use from 1999 through 2018. Point estimates were also calculated using the 2017 to March 2020 prepandemic data set. The age- and sex-adjusted proportion of having cholesterol screened within 5 years increased from 63.2% (95% CI, 60.0-66.3) in 1999 to 2000 to 72.5% (95% CI, 69.5-75.3) in 2017 to 2018 (P<0.001 for linear trend). Mean total cholesterol decreased from 203.3 mg/dL (95% CI, 201.0-205.7) in 1999 to 2000 to 188.4 mg/dL in 2017 to 2018 (95% CI, 185.4-191.5) (P<0.001 for nonlinear trend). The mean triglyceride level decreased from 121.3 mg/dL (95% CI, 116.4-126.4) in 1999 to 2000 to 91.4 mg/dL (95% CI, 88.4-94.6) in 2017 to 2018 (P<0.001 for nonlinear trend). Low-density lipoprotein cholesterol decreased from 127.9 mg/dL (95% CI, 125.3-130.5) in 1999 to 2000 to 111.7 mg/dL (95% CI, 109.0-114.4) in 2017 to 2018 (P<0.001 for nonlinear trend). Among statin-eligible US adults, the proportion of statin use increased from 14.9% (95% CI, 12.2-17.9) in 1999 to 2000 to 27.8% (95% CI, 23.0-33.2) in 2017 to 2018 (P<0.001 for nonlinear trend). Statin use increased in adults with diabetes aged 40 to 75 years from 21.4% in 1999 to 2000 to 51.9% in 2017 to 2018 (P<0.001 for overall linear trend). Statin use plateaued in all other groups. The proportions of using ezetimibe and proprotein convertase subtilisin/kexin type 9 inhibitors were 3.7% (95% CI, 1.3-9.8) and 0.03% (95% CI, 0.01-0.15) in 2017 to March 2020, respectively. Conclusions From 1999 through 2018, cholesterol screening increased while mean total cholesterol, triglycerides, and low-density lipoprotein cholesterol levels decreased, with a modest increase in statin use and low uptake of nonstatin therapy in the US population.

Grains of Sand to Clinical Pearls: Realizing the Potential of Wearable Data

Despite the rapid growth of wearables as a consumer technology sector and a growing evidence base supporting their use, they have been slow to be adopted by the health system into clinical care. As regulatory, reimbursement, and technical barriers recede, a persistent challenge remains how to make wearable data actionable for clinicians-transforming disconnected grains of wearable data into meaningful clinical "pearls". In order to bridge this adoption gap, wearable data must become visible, interpretable, and actionable for the clinician. We showcase emerging trends and best practices that illustrate these 3 pillars, and offer some recommendations on how the ecosystem can move forward.

Computed Tomography Radiomics to Differentiate Intrahepatic Cholangiocarcinoma and Hepatocellular Carcinoma

AIMS

Intrahepatic cholangiocarcinoma (iCCA) and hepatocellular carcinoma (HCC) differ in prognosis and treatment. We aimed to non-invasively differentiate iCCA and HCC by means of radiomics extracted from contrast-enhanced standard-of-care computed tomography (CT).

MATERIALS AND METHODS

In total, 94 patients (male, n = 68, mean age 63.3 ± 12.4 years) with histologically confirmed iCCA (n = 47) or HCC (n = 47) who underwent contrast-enhanced abdominal CT between August 2014 and November 2021 were retrospectively included. The enhancing tumour border was manually segmented in a clinically feasible way by defining three three-dimensional volumes of interest per tumour. Radiomics features were extracted. Intraclass correlation analysis and Pearson metrics were used to stratify robust and non-redundant features with further feature reduction by LASSO (least absolute shrinkage and selection operator). Independent training and testing datasets were used to build four different machine learning models. Performance metrics and feature importance values were computed to increase the models' interpretability.

RESULTS

The patient population was split into 65 patients for training (iCCA, n = 32) and 29 patients for testing (iCCA, n = 15). A final combined feature set of three radiomics features and the clinical features age and sex revealed a top test model performance of receiver operating characteristic (ROC) area under the curve (AUC) = 0.82 (95% confidence interval =0.66-0.98; train ROC AUC = 0.82) using a logistic regression classifier. The model was well calibrated, and the Youden J Index suggested an optimal cut-off of 0.501 to discriminate between iCCA and HCC with a sensitivity of 0.733 and a specificity of 0.857.

CONCLUSIONS

Radiomics-based imaging biomarkers can potentially help to non-invasively discriminate between iCCA and HCC.

A New Era in Cardiac Rehabilitation Delivery: Research Gaps, Questions, Strategies, and Priorities

Cardiac rehabilitation (CR) is a guideline-recommended, multidisciplinary program of exercise training, risk factor management, and psychosocial counseling for people with cardiovascular disease (CVD) that is beneficial but underused and with substantial disparities in referral, access, and participation. The emergence of new virtual and remote delivery models has the potential to improve access to and participation in CR and ultimately improve outcomes for people with CVD. Although data suggest that new delivery models for CR have safety and efficacy similar to traditional in-person CR, questions remain regarding which participants are most likely to benefit from these models, how and where such programs should be delivered, and their effect on outcomes in diverse populations. In this review, we describe important gaps in evidence, identify relevant research questions, and propose strategies for addressing them. We highlight 4 research priorities: (1) including diverse populations in all CR research; (2) leveraging implementation methodologies to enhance equitable delivery of CR; (3) clarifying which populations are most likely to benefit from virtual and remote CR; and (4) comparing traditional in-person CR with virtual and remote CR in diverse populations using multicenter studies of important clinical, psychosocial, and cost-effectiveness outcomes that are relevant to patients, caregivers, providers, health systems, and payors. By framing these important questions, we hope to advance toward a goal of delivering high-quality CR to as many people as possible to improve outcomes in those with CVD.

Cardiovascular health trajectories and subsequent cardiovascular disease and mortality: The multi-ethnic study of atherosclerosis (MESA)

Objective

Longitudinal trajectories of cardiovascular health (CVH) may reflect vascular risk burden due to prolonged cumulative exposure to non-ideal CVH levels. Identifying individuals who have a higher risk CVH trajectory may facilitate treatment, screening, and prevention. We aimed to characterize 10-year trajectories of CVH and examine the associations between CVH trajectories and subsequent cardiovascular disease (CVD) and mortality.

Methods

We analyzed 3674 MESA participants who completed four exams and remained CVD-free from 2000 to 2011. A 12-point CVH score was calculated based on physical activity, smoking status, body mass index, cholesterol, blood pressure, and glucose. Ideal CVH was defined as a score ≥ 9. Group-based trajectory modeling was used to identify trajectories of ideal CVH. Cox models were used to examine the association of CVH trajectories with incident CVD and death from 2011 to 2018, adjusting for age, sex, race/ethnicity, income, education, and marital status.

Results

Three trajectories were identified based on the probability of achieving ideal CVH: high (n = 1251), medium (n = 760), and persistently low (n = 1663). Almost half (45.3%) of the participants had a persistently low trajectory. During a median of 7.7 years follow-up, 392 incident CVD events and 459 deaths occurred. Compared with the high CVH group, participants in the persistently low CVH trajectory group had elevated risks for CVD (adjusted hazard ratios 1.49, 95% confidence interval 1.15-1.93) and mortality (1.34, 1.06-1.70), and participants in the medium group had moderate risks for CVD (1.17, 0.86-1.59) and mortality (1.15, 0.87-1.53) (p-value for trend 0.002 for CVD, 0.014 for mortality).

Conclusion

Persistently nonideal CVH is a common trajectory. Targeted prevention programs might benefit individuals with persistently nonideal CVH given their elevated risk of subsequent CVD and mortality.

Medicine 2032: The future of cardiovascular disease prevention with machine learning and digital health technology

Machine learning (ML) refers to computational algorithms that iteratively improve their ability to recognize patterns in data. The digitization of our healthcare infrastructure is generating an abundance of data from electronic health records, imaging, wearables, and sensors that can be analyzed by ML algorithms to generate personalized risk assessments and promote guideline-directed medical management. ML's strength in generating insights from complex medical data to guide clinical decisions must be balanced with the potential to adversely affect patient privacy, safety, health equity, and clinical interpretability. This review provides a primer on key advances in ML for cardiovascular disease prevention and how they may impact clinical practice.

Homozygous Familial Hypercholesterolemia: Luck Meets Opportunity Meets Knowledge

This case report describes a 67-year-old African-American woman with homozygous familial hypercholesterolemia caused by 2 pathogenic variants in the LDLR gene. Initial surgical, pharmacological, and low-density lipoprotein apheresis interventions were insufficient; the addition of proprotein convertase subtilisin-kexin type 9 and angiopoietin-like 3 inhibitors lowered her low-density lipoprotein cholesterol to <70 mg/dL. (Level of Difficulty: Advanced.).

Association Between Subclinical Thyroid Dysfunction and Fracture Risk

IMPORTANCE

Clinical hyperthyroidism accelerates bone resorption without compensatory bone formation, reducing bone density and increasing the risk of fracture. The association between subclinical hyperthyroidism and fracture risk is less clear.

OBJECTIVE

To investigate the association of endogenous subclinical thyroid dysfunction and fracture risk, independent of clinical confounders.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included 10 946 participants from the Atherosclerosis Risk in Communities Study, an ongoing prospective cohort study of community-dwelling individuals conducted from 1987-1989 through December 31, 2019, in Washington County, Maryland; Forsyth County, North Carolina; Jackson, Mississippi; and the suburbs of Minneapolis, Minnesota. Participants were not taking thyroid medications and had no history of fractures.

EXPOSURES

Thyrotropin and free thyroxine levels were measured at visit 2 (1990-1992). Subclinical hyperthyroidism was defined as a thyrotropin level lower than 0.56 mIU/L, subclinical hypothyroidism as a thyrotropin level higher than 5.1 mIU/L, and euthyroidism as a thyrotropin level of 0.56 to 5.1 mIU/L, with normal free thyroxine levels from 0.85 to 1.4 ng/dL.

MAIN OUTCOMES AND MEASURES

Incident fracture was ascertained using hospitalization discharge codes through 2019 and linkage to inpatient and outpatient Medicare claims through 2018.

RESULTS

Of 10 946 participants (54.3% women; mean [SD] age, 57 [5.7] years), 93.0% had euthyroidism, 2.6% had subclinical hyperthyroidism, and 4.4% had subclinical hypothyroidism. During a median follow-up of 21 years (IQR, 13.0-27.3 years), there were 3556 incident fractures (167.1 per 10 000 person-years). The adjusted hazard ratios of fracture were 1.34 (95% CI, 1.09-1.65) for those with subclinical hyperthyroidism and 0.90 (95% CI, 0.77-1.05) for those with subclinical hypothyroidism compared with individuals with euthyroidism. Among those with normal free thyroxine levels, thyrotropin levels in the lower-than-normal range were significantly associated with higher fracture-related hospitalization risk; fracture risk was greater among individuals with thyrotropin concentrations below 0.56 mIU/L.

CONCLUSIONS AND RELEVANCE

This community-based cohort study suggests that subclinical hyperthyroidism was an independent risk factor associated with fracture. The increased risk for fracture among individuals with a thyrotropin level lower than 0.56 mIU/L highlights a potential role for more aggressive screening and monitoring of patients with subclinical hyperthyroidism to prevent bone mineral disease.

The Virtual Inclusive Digital Health Intervention Design to Promote Health Equity (iDesign) Framework for Atrial Fibrillation: Co-design and Development Study

Background

Smartphone ownership and mobile app use are steadily increasing in individuals of diverse racial and ethnic backgrounds living in the United States. Growing adoption of technology creates a perfect opportunity for digital health interventions to increase access to health care. To successfully implement digital health interventions and engage users, intervention development should be guided by user input, which is best achieved by the process of co-design. Digital health interventions co-designed with the active engagement of users have the potential to increase the uptake of guideline recommendations, which can reduce morbidity and mortality and advance health equity.

Objective

We aimed to co-design a digital health intervention for patients with atrial fibrillation, the most common cardiac arrhythmia, with patient, caregiver, and clinician feedback and to describe our approach to human-centered design for building digital health interventions.

Methods

We conducted virtual meetings with patients with atrial fibrillation (n=8), their caregivers, and clinicians (n=8). We used the following 7 steps in our co-design process: step 1, a virtual meeting focused on defining challenges and empathizing with problems that are faced in daily life by individuals with atrial fibrillation and clinicians; step 2, a virtual meeting focused on ideation and brainstorming the top challenges identified during the first meeting; step 3, individualized onboarding of patients with an existing minimally viable version of the atrial fibrillation app; step 4, virtual prototyping of the top 3 ideas generated during ideation; step 5, further ranking by the study investigators and engineers of the ideas that were generated during ideation but were not chosen as top-3 solutions to be prototyped in step 4; step 6, ongoing engineering work to incorporate top-priority features in the app; and step 7, obtaining further feedback from patients and testing the atrial fibrillation digital health intervention in a pilot clinical study.

Results

The top challenges identified by patients and caregivers included addressing risk factor modification, medication adherence, and guidance during atrial fibrillation episodes. Challenges identified by clinicians were complementary and included patient education, addressing modifiable atrial fibrillation risk factors, and remote atrial fibrillation episode management. Patients brainstormed more than 30 ideas to address the top challenges, and the clinicians generated more than 20 ideas. Ranking of the ideas informed several novel or modified features aligned with the Theory of Health Behavior Change, features that were geared toward risk factor modification; patient education; rhythm, symptom, and trigger correlation for remote atrial fibrillation management; and social support.

Conclusions

We co-designed an atrial fibrillation digital health intervention in partnership with patients, caregivers, and clinicians by virtually engaging in collaborative creation through the design process. We summarize our experience and describe a flexible approach to human-centered design for digital health intervention development that can guide innovative clinical investigators.

Comparison of low-density lipoprotein cholesterol equations in patients with dyslipidaemia receiving cholesterol ester transfer protein inhibition

AIMS

Low-density lipoprotein (LDL-C) lowering is imperative in cardiovascular disease prevention. We aimed to compare accuracy of three clinically-implemented LDL-C equations in a clinical trial of cholesterol ester transfer protein (CETP) inhibition.

METHODS AND RESULTS

Men and women aged 18-75 years with dyslipidaemia were recruited from 17 sites in the Netherlands and Denmark. Patients were randomly assigned to one of nine groups using various combinations of the CETP inhibitor TA-8995 (obicetrapib), statin therapy, and placebo. In pooled measurements over 12 weeks, we calculated LDL-C by the Friedewald, Martin/Hopkins, and Sampson equations, and compared values with preparative ultracentrifugation (PUC) LDL-C overall and with a special interest in the low LDL-C/high triglycerides subgroup. There were 242 patients contributing 921 observations. Overall median LDL-C differences between estimates and PUC were small: Friedewald, 0.00 (25th, 75th: -0.10, 0.08) mmol/L [0 (-4, 3) mg/dL]; Martin/Hopkins, 0.02 (-0.08, 0.10) mmol/L [1 (-3, 4) mg/dL]; and Sampson, 0.05 (-0.03, 0.15) mmol/L [2 (-1, 6) mg/dL]. In the subgroup with estimated LDL-C <1.8 mmol/L (<70 mg/dL) and triglycerides 1.7-4.5 mmol/L (150-399 mg/dL), the Friedewald equation underestimated LDL-C with a median difference versus PUC of -0.25 (-0.33, -0.10) mmol/L [-10 (-13, -4) mg/dL], whereas the median difference by Martin/Hopkins was 0.00 (-0.08, 0.10) mmol/L [0 (-3, 4) mg/dL] and by Sampson was -0.06 (-0.13, 0.00) mmol/L [-2 (-5, 0) mg/dL]. In this subgroup, the proportion of LDL-C observations <1.8 mmol/L (<70 mg/dL) that were correctly classified compared with PUC was 71.4% by Friedewald vs. 100.0% by Martin/Hopkins and 93.1% by Sampson.

CONCLUSION

In European patients with dyslipidaemia receiving a CETP inhibitor, we found improved LDL-C accuracy using contemporary equations vs. the Friedewald equation, and the greatest accuracy was observed with the Martin/Hopkins equation.

REGISTRATION

ClinicalTrials.gov, NCT01970215.

Associations of Demographic, Socioeconomic, and Cognitive Characteristics With Mobile Health Access: MESA (Multi-Ethnic Study of Atherosclerosis)

Background

Mobile health (mHealth) has an emerging role in the prevention of cardiovascular disease. This study evaluated possible inequities in mHealth access in older adults.

Methods and Results

mHealth access was assessed from 2019 to 2020 in MESA (Multi‐Ethnic Study of Atherosclerosis) telephone surveys of 2796 participants aged 62 to 102 years. A multivariable logistic regression model adjusted for general health status assessed associations of mHealth access measures with relevant demographic, socioeconomic, and cognitive characteristics. There were lower odds of all access measures with older age (odds ratios [ORs], 0.37–0.59 per 10 years) and annual income <$50 000 (versus ≥$50 000 ORs, 0.55–0.62), and higher odds with higher Cognitive Abilities Screening Instrument Score (ORs, 1.22–1.29 per 5 points). Men (versus women) had higher odds of internet access (OR, 1.32 [95% CI,1.05–1.66]) and computing device ownership (OR, 1.31 [95% CI, 1.05–1.63]) but lower fitness tracker ownership odds (OR, 0.70 [95% CI, 0.49–0.89]). For internet access and computing device ownership, we saw lower odds for Hispanic participants (versus White participants OR, 0.61 [95% CI, 0.44–0.85]; OR, 0.69 [95% CI, 0.50–0.95]) and less than a high school education (versus bachelor's degree or higher OR, 0.27 [95% CI, 0.18–0.40]; OR, 0.32 [95% CI, 0.28–0.62]). For internet access, lower odds were seen for Black participants (versus White participants OR, 0.64 [95% CI, 0.47–0.86]) and other health insurance (versus health maintenance organization/private OR, 0.59 [95% CI, 0.47–0.74]). Chinese participants (versus White participants) had lower internet access odds (OR, 0.63 [95% CI, 0.44–0.91]) but higher computing device ownership odds (OR, 1.87 [95% CI, 1.28–2.77]).

Conclusions

Among older‐age adults, mHealth access varied by major demographic, socioeconomic, and cognitive characteristics, suggesting a digital divide. Novel mHealth interventions should consider individual access barriers.

Registration

URL: https://www.clinicaltrials.gov/; Unique identifier: NCT00005487.