JAHA Spotlight on Racial and Ethnic Disparities in Cardiovascular Disease

Race and ethnicity and pharmacy dispensing of SGLT2 inhibitors and GLP-1 receptor agonists in type 2 diabetes

Background

Sodium-Glucose Cotransporter 2 Inhibitors (SGLT2i) and Glucagon-Like Peptide-1 Receptor Agonists (GLP-1 RA) improve cardiorenal outcomes in patients with type 2 diabetes. Equitable use of SGLT2i and GLP-1 RA has the potential to reduce racial and ethnic health disparities. We evaluated trends in pharmacy dispensing of SGLT2i and GLP-1 RA by race and ethnicity.

Methods

Retrospective cohort study of patients (≥18 years) with type 2 diabetes using 2014-2022 electronic health record data from six US care delivery systems. Entry was at earliest pharmacy dispensing of any type 2 diabetes medication. We used multivariable logistic regression to evaluate the association between pharmacy dispensing of SGLT2i and GLP1-RA and race and ethnicity.

Findings

Our cohort included 687,165 patients (median 6 years of dispensing data; median 60 years; 0.3% American Indian/Alaska Native (AI/AN), 16.6% Asian, 10.5% Black, 1.4% Hawaiian or Pacific Islander (HPI), 31.1% Hispanic, 3.8% Other, and 36.3% White). SGLT2i was lower for AI/AN (OR 0.80, 95% confidence interval 0.68-0.94), Black (0.89, 0.86-0.92) and Hispanic (0.87, 0.85-0.89) compared to White patients. GLP-1 RA was lower for AI/AN (0.78, 0.63-0.97), Asian (0.50, 0.48-0.53), Black (0.86, 0.83-0.90), HPI (0.52, 0.46-0.57), Hispanic (0.69, 0.66-0.71), and Other (0.78, 0.73-0.83) compared to White patients.

Interpretation

Dispensing of SGLT2is, and GLP-1 RAs was lower in minority group patients. There is a need to evaluate approaches to increase use of these cardiorenal protective drugs in patients from racial and ethnic minority groups with type 2 diabetes to reduce adverse cardiorenal outcomes and improve health equity.

Funding

Patient-Centered Outcomes Research Institute and National Institutes of Health.

Racial and Socioeconomic Determinants of Cardiovascular Health: A Comprehensive Review

Cardiovascular diseases (CVDs) are the leading cause of death globally. Their prevalence and mortality rates continue to rise. This narrative review explores well-known risk factors for CVDs such as dyslipidemia, hypertension, diabetes, obesity, and smoking, and their prevalence among different racial and ethnic groups. In addition, we expand the discussion to include the impact of socioeconomic status (SES) on cardiovascular outcomes. The data demonstrate that non-Hispanic Black and Hispanic populations not only exhibit higher rates of hypertension, obesity, diabetes, and smoking but also face systemic barriers linked to lower SES, which worsen their cardiovascular outcomes. These barriers include a lack of education, lower income, higher rates of unemployment, and poor living conditions. Beyond these commonly studied factors, these groups also suffer from higher levels of food and housing insecurity and a lack of adequate insurance coverage, all of which contribute to poorer health. Additionally, there is a higher prevalence of mental health disorders, such as depression and anxiety, among these populations. This further compounds the risks and adverse outcomes associated with CVDs. It is essential to conduct further research into how SES and race influence cardiovascular health and to refine risk assessment methods. Concentrating on these aspects would make it possible to create interventions designed to meet the needs of diverse communities and strategies that could potentially reduce morbidity and mortality from CVD across populations. Moreover, this review advocates for integrating comprehensive socioeconomic data into cardiovascular health strategies, which is crucial for developing effective public health initiatives.

Implications of Bias in Artificial Intelligence: Considerations for Cardiovascular Imaging

PURPOSE OF REVIEW

Bias in artificial intelligence (AI) models can result in unintended consequences. In cardiovascular imaging, biased AI models used in clinical practice can negatively affect patient outcomes. Biased AI models result from decisions made when training and evaluating a model. This paper is a comprehensive guide for AI development teams to understand assumptions in datasets and chosen metrics for outcome/ground truth, and how this translates to real-world performance for cardiovascular disease (CVD).

RECENT FINDINGS

CVDs are the number one cause of mortality worldwide; however, the prevalence, burden, and outcomes of CVD vary across gender and race. Several biomarkers are also shown to vary among different populations and ethnic/racial groups. Inequalities in clinical trial inclusion, clinical presentation, diagnosis, and treatment are preserved in health data that is ultimately used to train AI algorithms, leading to potential biases in model performance. Despite the notion that AI models themselves are biased, AI can also help to mitigate bias (e.g., bias auditing tools). In this review paper, we describe in detail implicit and explicit biases in the care of cardiovascular disease that may be present in existing datasets but are not obvious to model developers. We review disparities in CVD outcomes across different genders and race groups, differences in treatment of historically marginalized groups, and disparities in clinical trials for various cardiovascular diseases and outcomes. Thereafter, we summarize some CVD AI literature that shows bias in CVD AI as well as approaches that AI is being used to mitigate CVD bias.

30-year Cardiovascular Disease Risk for Young Adults with Serious Mental Illness

Objective

To estimate 30-year CVD risk and modifiable risk factors in young adults with serious mental illness (SMI) versus those without, and assess variations in CVD risk by race, ethnicity, and sex.

Method

In this cross-sectional study, we estimated and compared the Framingham 30-year CVD risk score and individual modifiable CVD risk factors in young adult (20-39 years) primary care patients with and without SMI at two US healthcare systems (January 2016-Septemeber 2018). Interaction terms assessed whether the SMI-risk association differed across demographic groups.

Results

Covariate-adjusted 30-year CVD risk was significantly higher for those with (n=4228) versus those without (n=155,363) SMI (RR 1.28, 95% CI [1.26, 1.30]). Patients with SMI had higher rates of hypertension (OR 2.02 [1.7, 2.39]), diabetes (OR 3.14 [2.59, 3.82]), obesity (OR 1.93 [1.8, 2.07]), and smoking (OR 4.94 [4.6, 5.36]). The increased 30-year CVD risk associated with SMI varied significantly by race and sex: there was an 8% higher risk in Black compared to White patients (RR 1.08, [1.04, 1.12]) and a 9% lower risk in men compared to women (RR 0.91 [0.88, 0.94]).

Conclusions

Young adults with SMI are at increased 30-year risk of CVD, and further disparities exist for Black individuals and women.

Participation in the Georgia Food for Health programme and CVD risk factors: a longitudinal observational study

OBJECTIVE

To assess the relationship between programme attendance in a produce prescription (PRx) programme and changes in cardiovascular risk factors.

DESIGN

The Georgia Food for Health (GF4H) programme provided six monthly nutrition education sessions, six weekly cooking classes and weekly produce vouchers. Participants became programme graduates attending at least 4 of the 6 of both the weekly cooking classes and monthly education sessions. We used a longitudinal, single-arm approach to estimate the association between the number of monthly programme visits attended and changes in health indicators.

SETTING

GF4H was implemented in partnership with a large safety-net health system in Atlanta, GA.

PARTICIPANTS

Three hundred thirty-one participants living with or at-risk of chronic disease and food insecurity were recruited from primary care clinics. Over three years, 282 participants graduated from the programme.

RESULTS

After adjusting for programme site, year, participant sex, age, race and ethnicity, Supplemental Nutrition Assistance Program participation and household size, we estimated that each additional programme visit attended beyond four visits was associated with a 0·06 kg/m2 reduction in BMI (95 % CI -0·12, -0·01; P = 0·02), a 0·37 inch reduction in waist circumference (95 % CI -0·48, -0·27; P < 0·001), a 1·01 mmHg reduction in systolic blood pressure (95 % CI -1·45, -0·57; P < 0·001) and a 0·43 mmHg reduction in diastolic blood pressure (95 % CI -0·69, -0·17; P = 0·001).

CONCLUSIONS

Each additional cooking and nutrition education visit attended beyond the graduation threshold was associated with modest but significant improvements in CVD risk factors, suggesting that increased engagement in educational components of a PRx programme improves health outcomes.

Race, Class, and Place Modify Mortality Rates for the Leading Causes of Death in the United States, 1999-2021

BACKGROUND

Race and ethnicity, socioeconomic class, and geographic location are well-known social determinants of health in the US. Studies of population mortality often consider two, but not all three of these risk factors.

OBJECTIVES

To disarticulate the associations of race (whiteness), class (socioeconomic status), and place (county) with risk of cause-specific death in the US.

DESIGN

We conducted a retrospective analysis of death certificate data. Bayesian regression models, adjusted for age and race/ethnicity from the American Community Survey and the county Area Deprivation Index, were used for inference.

MAIN MEASURES

County-level mortality for 11 leading causes of death (1999-2019) and COVID-19 (2020-2021).

KEY RESULTS

County "whiteness" and socioeconomic status modified death rates; geospatial effects differed by cause of death. Other factors equal, a 20% increase in county whiteness was associated with 5-8% increase in death from three causes and 4-15% reduction in death from others, including COVID-19. Other factors equal, advantaged counties had significantly lower death rates, even when juxtaposed with disadvantaged ones. Patterns of residual risk, measured by spatial county effects, varied by cause of death; for example: cancer and heart disease death rates were better explained by age, socioeconomic status, and county whiteness than were COVID-19 and suicide deaths.

CONCLUSIONS

There are important independent contributions from race, class, and geography to risk of death in the US.

Impact of Social Vulnerability and Demographics on Ischemic Heart Disease Mortality in the United States

Background

Cardiovascular disease is a leading cause of morbidity and mortality, largely dominated by ischemic heart diseases (IHDs). Social determinants of health, including geographic, psychosocial, and socioeconomic factors, influence the development of IHD.

Objectives

This study aimed to evaluate yearly trends and disparities in IHD mortality and to assess the impact of social vulnerability.

Methods

We performed cross-sectional analyses using United States county-level mortality data and social vulnerability index (SVI) obtained from the Centers for Disease Control and Prevention databases. Age-adjusted mortality rates (AAMRs) per 100,000 population were compared between aggregated U.S. county groups, stratified by demographic information and SVI quartiles. Log-linear regression models were used to identify mortality trends from 1999 to 2020, with inflection points determined through the Monte-Carlo permutation test.

Results

We identified a total of 9,108,644 deaths related to IHD between 1999 and 2020. Overall AAMR decreased from 194.6 in 1999 to 91.8 in 2020. Males (AAMR: 161.51) and Black (AAMR: 141.49) populations exhibited higher AAMR compared to females (AAMR: 93.16) and White (AAMR: 123.34) populations, respectively. Disproportionate AAMRs were observed among nonmetropolitan (AAMR: 136.17) and Northeastern (AAMR: 132.96) regions. Counties with a higher SVI experienced a greater AAMR, with a cumulative excess of 20.91 deaths per 100,000 person-years associated with increased social vulnerability.

Conclusions

Despite a decline in IHD mortality from 1999 to 2020, disparities persisted among racial, gender, and geographic subgroups. A higher SVI was linked to increased IHD mortality. Policy interventions should prioritize integrating the SVI into health care delivery systems to effectively address these disparities.

Applications of Mobile Health Technologies to Address Cardiometabolic Health Disparities in the United States: A Systematic Review

Introduction

Black and Hispanic adults are disproportionately burdened by cardiometabolic disorders. The aim of this systematic review was to examine the effectiveness of mobile health technologies to promote disease prevention and self-management among US adults in diverse communities.

Methods

Potential studies were identified using a comprehensive search of the PubMed and EMBASE databases for recent studies published from December 2018 through 2021. Keywords and search strategies were established to focus on health disparity populations and the application of mobile health technology for cardiovascular disease risk reduction. Titles and abstracts were assessed and, if a study was eligible, 2 independent reviewers completed a full-length review with extraction in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Results

A total of 13 studies met our inclusion criteria. Study sample sizes ranged from 8 to 533 baseline participants. Studies were conducted in diverse communities (eg, North Carolina and California). Most studies used mobile applications (n=11) and a majority used accelerometers or similar technologies (eg, smartwatches) to assess changes in dietary behavior, blood pressure control, and physical activity. Overall, studies reported positive associations between mobile technology use and risk factor reduction actions and behaviors. Long-term adherence varied across studies. Those that prioritized culturally tailored approaches reported more significant impacts than those that did not.

Conclusions

Evidence suggests that mobile technology may be useful in promoting disease self-management and risk reduction among populations at higher risk of cardiometabolic diseases. The use of mobile health technologies, particularly when tailored to target populations, may be a practical approach to advancing population health equity.

Systematic review and meta-analysis of church-based interventions to improve cardiovascular disease risk factors

BACKGROUND

Church-based interventions have been shown to reduce cardiovascular disease (CVD) risk factors and could reduce health disparities in groups with a high burden of CVD. We aim to conduct a systematic review and meta-analysis to determine the effectiveness of church-based interventions for CVD risk factor improvement and to examine the types of interventions that are effective.

METHODS

Systematic searches of MEDLINE, Embase, and manual reference searches were conducted through November 2021. Study inclusion criteria were church-based interventions delivered in the United States to address CVD risk factors. Interventions targeted barriers to improving blood pressure, weight, diabetes, physical activity, cholesterol, diet, or smoking. Two investigators independently extracted study data. Random effects meta-analyses were conducted.

RESULTS

A total of 81 studies with 17,275 participants were included. The most common interventions included increasing physical activity (n = 69), improving diet (n = 67), stress management (n = 20), medication adherence (n = 9), and smoking cessation (n = 7). Commonly used approaches for implementation included cultural tailoring of the intervention, health coaching, group education sessions, inclusion of spiritual components in the intervention, and home health monitoring. Church-based interventions were associated with significant reductions in body weight (-3.1 lb, [95% CI, -5.8, -1.2], N = 15), waist circumference (-0.8 in, [CI, -1.4, -0.1], N = 6), and systolic blood pressure (-2.3 mm Hg, [CI, -4.3, -0.3], N = 13).

CONCLUSIONS

Church-based interventions targeting CVD risk factors are effective for reducing CVD risk factors, particularly in populations with health disparities. These findings can be used to design future church-based studies and programs to improve cardiovascular health.

The Influence of Racism in Healthcare: COVID-19 Vaccine Hesitancy Among Black Mothers in Chicago

Black mothers and children experience significant health disparities in the USA. These health disparities have been attributed, in part, to experiencing racism in healthcare. This study aimed to explore how experiences of healthcare discrimination and mistreatment experienced by Black mothers may influence COVID-19 vaccine beliefs and decision-making for themselves and their families. From April 2021 to November 2021, we conducted 50 semi-structured interviews among Chicago residents. Ten participants self-identified as female and with reported children; these data were extracted from the larger sample for data analysis. Interview content included perceptions and experiences with the COVID-19 vaccine and experiences with healthcare discrimination, mistreatment, and medical mistrust. Interview transcripts were transcribed verbatim and coded using the MAXQDA 2022 qualitative software. Themes were identified using a team-based thematic analysis to understand how experiences of racism in healthcare may influence COVID-19 vaccine decision-making. Four themes were generated from the data: (1) experiences of healthcare discrimination and mistreatment, (2) distrust and fears of experimentation, (3) the influence of discrimination and distrust on COVID-19 vaccine decision-making, and (4) overcoming vaccine hesitancy. The results of this study highlight the current literature; Black mothers experience racism and discrimination in healthcare when seeking care for themselves and their children. It is evident in their stories that medical racism and historical medical abuse influence vaccine decision-making. Therefore, healthcare and public health initiatives should be intentional in addressing past and present racism in healthcare to improve vaccine distrust.

Trends in Cardiogenic Shock-Related Mortality in Patients With Acute Myocardial Infarction in the United States, 1999 to 2019

Data on mortality trends in patients with acute myocardial infarction (AMI) with cardiogenic shock (CS) are scant. This study aimed to assess the trends in CS-AMI-related mortality in United States (US) subjects over the latest 21 years. Mortality data of US subjects with AMI listed as the underlying cause of death and CS as contributing cause were obtained from the Centers for Disease Control and Prevention WONDER (Wide-Ranging Online Data for Epidemiologic Research) dataset from January 1999 to December 2019. CS-AMI-related age-adjusted mortality rates (AAMRs) per 100,000 US population were stratified by gender, race and ethnicity, geographic areas, and urbanicity. Nationwide annual trends were assessed as annual percent change (APC) and average APC with relative 95% confidence intervals (CIs). Between 1999 and 2019, CS-AMI was listed as the underlying cause of death in 209,642 patients, (AAMR of 3.01 per 100,000 people [95% CI 2.99 to 3.02]). AAMR from CS-AMI remained stable from 1999 to 2007 (APC -0.2%, [95% CI -2.0 to 0.5], p = 0.22) and then significantly increased (APC 3.1% [95% CI 2.6 to 3.6], p <0.0001), especially in male patients. Starting in 2009, the AAMR increase was more pronounced in those <65 years, Black Americans, and residents of rural areas. The higher AAMRs were clustered in the South (average APC 4.5%, [95% CI 4.4 to 4.6]) of the country. In conclusion, CS-AMI-related mortality in US patients increased from 2009 to 2019. Targeted health policy measures are needed to address the rising burden of CS-AMI in US subjects.

Comorbidity burden and health-related quality of life in men with advanced prostate cancer

PURPOSE

Identifying clinically relevant comorbidities and their effect on health-related quality of life (HRQoL) outcomes among men with advanced prostate cancer (APC) can inform patient care and improve outcomes; however, this is poorly understood. The aim of this observational study was to examine the prevalence of comorbidities, and the relationship of comorbidity burden to HRQoL and other patient-reported outcomes (PROs) among men with APC.

METHODS

Participants were 192 men (average age 68.8) with APC (stage III or IV) who completed a psychosocial battery including measures of sociodemographic factors, HRQoL and other PROs, and the Charlson Comorbidity Index (CCI). Hierarchical multiple regression analysis was used to examine the relationships between CCI, HRQOL, and PROs.

RESULTS

The vast majority (82%) of participants had at least one comorbidity, with the most common being: hypertension (59%), connective tissue disease or arthritis (31%), diabetes (24%), and problems with kidneys, vision, or another organ (24%). After controlling for covariates, regressions showed that a higher CCI score was significantly associated with worse HRQoL (p < 0.001), lower levels of positive affect (p < 0.05), and higher levels of depression (p < 0.05), fatigue (p < 0.001), pain (p < 0.01), stress (p < 0.01), and cancer-specific distress (p < 0.05).

CONCLUSIONS

Comorbidities were common among men with APC, and a greater CCI score was associated with detriments in several domains of HRQoL and other PROs. Our findings show the need to address comorbidities in the presence of a cancer diagnosis and subsequent treatment. TRIAL REGISTRATION CLINICALTRIALS.

GOV IDENTIFIER

NCT03149185.

An aerobic exercise intervention to improve metabolic health among people living with HIV with at-risk alcohol use: the ALIVE-Ex research study protocol

BACKGROUND

Effective antiretroviral therapy (ART) in people living with HIV (PLWH) has improved life expectancy and increased risk of age-associated cardiometabolic comorbidities. At-risk alcohol use is more frequent among PLWH and increases the risk of health challenges. PLWH with at-risk alcohol use are more likely to meet criteria for prediabetes/diabetes and this is associated with impaired whole-body glucose-insulin dynamics.

METHODS

The Alcohol & Metabolic Comorbidities in PLWH: Evidence Driven Interventions Study (ALIVE-Ex Study, NCT03299205) is a longitudinal, prospective, interventional study to determine the effects of an aerobic exercise protocol on improving dysglycemia among PLWH with at-risk alcohol use. The intervention is a moderate intensity aerobic exercise protocol implemented 3 days per week for 10 weeks at the Louisiana State University Health Sciences Center-New Orleans. Participants who have a fasting blood glucose level between 94 and 125 mg/dl will be enrolled in the study. Oral glucose tolerance tests, fitness assessments, and skeletal muscle biopsies will be performed pre- and post-exercise intervention. The primary outcome is to determine whether the exercise protocol improves measures of whole-body glucose-insulin dynamics, cardiorespiratory fitness, and skeletal muscle metabolic and bioenergetic function. Secondary outcomes are to determine whether the exercise intervention improves cognitive function and overall quality of life. Results generated will demonstrate the effect of exercise on glycemic measures in PLWH with subclinical dysglycemia and at-risk alcohol use.

CONCLUSIONS

The proposed intervention will also have the potential to be scalable to promote lifestyle changes among PLWH, particularly in underserved communities.

Identification of White Matter Hyperintensities in Routine Emergency Department Visits Using Portable Bedside Magnetic Resonance Imaging

Background White matter hyperintensity (WMH) on magnetic resonance imaging (MRI) of the brain is associated with vascular cognitive impairment, cardiovascular disease, and stroke. We hypothesized that portable magnetic resonance imaging (pMRI) could successfully identify WMHs and facilitate doing so in an unconventional setting. Methods and Results In a retrospective cohort of patients with both a conventional 1.5 Tesla MRI and pMRI, we report Cohen's kappa (κ) to measure agreement for detection of moderate to severe WMH (Fazekas ≥2). In a subsequent prospective observational study, we enrolled adult patients with a vascular risk factor being evaluated in the emergency department for a nonstroke complaint and measured WMH using pMRI. In the retrospective cohort, we included 33 patients, identifying 16 (49.5%) with WMH on conventional MRI. Between 2 raters evaluating pMRI, the interrater agreement on WMH was strong (κ=0.81), and between 1 rater for conventional MRI and the 2 raters for pMRI, intermodality agreement was moderate (κ=0.66, 0.60). In the prospective cohort we enrolled 91 individuals (mean age, 62.6 years; 53.9% men; 73.6% with hypertension), of which 58.2% had WMHs on pMRI. Among 37 Black and Hispanic individuals, the Area Deprivation Index was higher (versus White, 51.8±12.9 versus 37.9±11.9; P<0.001). Among 81 individuals who did not have a standard-of-care MRI in the preceding year, we identified WMHs in 43 of 81 (53.1%). Conclusions Portable, low-field imaging could be useful for identifying moderate to severe WMHs. These preliminary results introduce a novel role for pMRI outside of acute care and the potential role for pMRI to reduce disparities in neuroimaging.

Nutraceuticals in the Prevention and Therapeutic Treatment of Cardiovascular and Cerebrovascular Disease

PURPOSE

This review overviews and highlights arterial stiffening as a key physiological process and target for the prevention and/or lowering of cardio- and cerebrovascular disease (collectively CVD) risk.

METHODS

We identified nutraceutical approaches from randomized controlled trials and discussed the associated mechanisms by which these compounds lower age-related arterial stiffness. Age-related CVD are the leading cause of mortality in modernized societies. Arterial dysfunction, specifically stiffening of the large elastic arteries during midlife, is a key physiological process resulting in increased CVD risk. Current pharmaceutical approaches for lowering age-related arterial stiffness have limited efficacy, thus highlighting the need to identify novel approaches for lowering arterial stiffness and thereby CVD risk. Lifestyle interventions are a historical first-line approach to prevent and/or lower the adverse arterial stiffening effects observed with aging. Nutraceutical interventions, defined as a food or part of a food providing health benefits, are a nonpharmacological, novel lifestyle approach to lower age-associated arterial stiffness. Therefore, identifying nutraceutical approaches to lower CVD risk is clinically significant.

SUMMARY

This review provides a basic, yet essential, understanding for emerging nutraceutical strategies for the prevention and therapeutic treatment of CVD.

Development of models to predict 10-30-year cardiovascular disease risk using the Da Qing IGT and diabetes study

BACKGROUND

This study aimed to develop cardiovascular disease (CVD) risk equations for Chinese patients with newly diagnosed type 2 diabetes (T2D) to predict 10-, 20-, and 30-year of risk.

METHODS

Risk equations for forecasting the occurrence of CVD were developed using data from 601 patients with newly diagnosed T2D from the Da Qing IGT and Diabetes Study with a 30-year follow-up. The data were randomly assigned to a training and test data set. In the training data set, Cox proportional hazard regression was used to develop risk equations to predict CVD. Calibration was assessed by the slope and intercept of the line between predicted and observed probabilities of outcomes by quintile of risk, and discrimination was examined using Harrell's C statistic in the test data set. Using the Sankey flow diagram to describe the change of CVD risk over time.

RESULTS

Over the 30-year follow-up, corresponding to a 10,395 person-year follow-up time, 355 of 601 (59%) patients developed incident CVD; the incidence of CVD in the participants was 34.2 per 1,000 person-years. Age, sex, smoking status, 2-h plasma glucose level of oral glucose tolerance test, and systolic blood pressure were independent predictors. The C statistics of discrimination for the risk equations were 0.748 (95%CI, 0.710-0.782), 0.696 (95%CI, 0.655-0.704), and 0.687 (95%CI, 0.651-0.694) for 10-, 20-, and 30- year CVDs, respectively. The calibration statistics for the CVD risk equations of slope were 0.88 (P = 0.002), 0.89 (P = 0.027), and 0.94 (P = 0.039) for 10-, 20-, and 30-year CVDs, respectively.

CONCLUSIONS

The risk equations forecast the long-term risk of CVD in patients with newly diagnosed T2D using variables readily available in routine clinical practice. By identifying patients at high risk for long-term CVD, clinicians were able to take the required primary prevention measures.

Allostatic load and cardiovascular outcomes in males with prostate cancer

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death in men with prostate cancer (PC). Accumulated stress plays an important role in CVD development. The cumulative burden of chronic stress and life events can be measured using allostatic load (AL).

METHODS

The initial cohort included males aged 18 years and older diagnosed with PC (2005-2019). AL was modeled as an ordinal variable (0-11). Fine-Gray competing risk regressions measured the impact of precancer diagnosis AL and postdiagnosis AL in 2-year major cardiac events (MACE). The effect of AL changes over time on MACE development was calculated via piecewise Cox regression (before, and 2 months, 6 months, and 1 year after PC diagnosis).

RESULTS

We included 5261 PC patients of which 6.6% had a 2-year MACE. For every 1-point increase in AL before and within 60 days after PC diagnosis, the risk of MACE increased 25% (adjusted hazard ratio [aHR] =1.25, 95% confidence interval [CI] = 1.18 to 1.33) and 27% (aHR = 1.27, 95% CI = 1.20 to 1.35), respectively. Using AL as a time-varying exposure, the risk of MACE increased 19% (aHR = 1.19, 95% CI = 1.11 to 1.27), 22% (aHR = 1.22, 95% CI = 1.14 to 1.33), 28% (aHR = 1.28, 95% CI = 1.23 to 1.33), and 31% (aHR = 1.31, 95% CI = 1.27 to 1.35) for every 1-point increase in AL before, 2 months after, 6 months after, and 1 year after PC diagnosis, respectively.

CONCLUSION

AL and its changes over time are associated with MACE in PC patients, suggesting a role of a biological measure of stress as a marker of CVD risk among men with PC.

Social Determinants of Cardiovascular Health: A Longitudinal Analysis of Cardiovascular Disease Mortality in US Counties From 2009 to 2018

Background Disparities in cardiovascular disease (CVD) outcomes persist across the United States. Social determinants of health play an important role in driving these disparities. The current study aims to identify the most important social determinants associated with CVD mortality over time in US counties. Methods and Results The authors used the Agency for Healthcare Research and Quality's database on social determinants of health and linked it with CVD mortality data at the county level from 2009 to 2018. The age-standardized CVD mortality rate was measured as the number of deaths per 100 000 people. Penalized generalized estimating equations were used to select social determinants associated with county-level CVD mortality. The analytic sample included 3142 counties. The penalized generalized estimating equation identified 17 key social determinants of health including rural-urban status, county's racial composition, income, food, and housing status. Over the 10-year period, CVD mortality declined at an annual rate of 1.08 (95% CI, 0.74-1.42) deaths per 100 000 people. Rural counties and counties with a higher percentage of Black residents had a consistently higher CVD mortality rate than urban counties and counties with a lower percentage of Black residents. The rural-urban CVD mortality gap did not change significantly over the past decade, whereas the association between the percentage of Black residents and CVD mortality showed a significant diminishing trend over time. Conclusions County-level CVD mortality declined from 2009 through 2018. However, rural counties and counties with a higher percentage of Black residents continued to experience higher CVD mortality. Median income, food, and housing status consistently predicted higher CVD mortality.

Toward equitable utilization of durable left ventricular assist device therapy in advanced heart failure-Raising the veil of health disparities

Heart failure (HF) is a progressive disease with high attendant morbidity and mortality. Contemporary guideline-directed medical therapies have led to remarkable improvements in HF outcomes. However, in a subset of patients, progression to advanced HF stages requiring durable left ventricular assist device (LVAD) and or heart transplantation is inevitable. LVADs improve survival and quality of life in eligible patients with advanced HF. However, access to LVAD therapy is marked by disparities, attributable to race and ethnicity, social-economic status, geography, and sex and gender categories. This commentary addresses the findings by Jones and colleagues on "The Impact of Race on Utilization of Durable Left Ventricular Assist Device Therapy in Patients with Advanced Heart Failure" and also highlights the importance of social determinants of health in defining health disparities as well as the urgent work needed to improve HF clinical outcomes by dismantling these disparities.

Disparities in Geographic Access to Cardiac Rehabilitation in Los Angeles County

Background Exercise-based cardiac rehabilitation (CR) is known to reduce morbidity and mortality for patients with cardiac conditions. Sociodemographic disparities in accessing CR persist and could be related to the distance between where patients live and where CR facilities are located. Our objective is to determine the association between sociodemographic characteristics and geographic proximity to CR facilities. Methods and Results We identified actively operating CR facilities across Los Angeles County and used multivariable Poisson regression to examine the association between sociodemographic characteristics of residential proximity to the nearest CR facility. We also calculated the proportion of residents per area lacking geographic proximity to CR facilities across sociodemographic characteristics, from which we calculated prevalence ratios. We found that racial and ethnic minorities, compared with non-Hispanic White individuals, more frequently live ≥5 miles from a CR facility. The greatest geographic disparity was seen for non-Hispanic Black individuals, with a 2.73 (95% CI, 2.66-2.79) prevalence ratio of living at least 5 miles from a CR facility. Notably, the municipal region with the largest proportion of census tracts comprising mostly non-White residents (those identifying as Hispanic or a race other than White), with median annual household income <$60 000, contained no CR facilities despite ranking among the county's highest in population density. Conclusions Racial, ethnic, and socioeconomic characteristics are significantly associated with lack of geographic proximity to a CR facility. Interventions targeting geographic as well as nongeographic factors may be needed to reduce disparities in access to exercise-based CR programs. Such interventions could increase the potential of CR to benefit patients at high risk for developing adverse cardiovascular outcomes.

Interaction Between Race, Ethnicity, Severe Mental Illness, and Cardiovascular Disease

Severe mental illnesses, such as schizophrenia or bipolar disorder, affect ≈1% of the population who, as a group, experience significant disadvantage in terms of physical health and reduced life expectancy. In this review, we explore the interaction between race, ethnicity, severe mental illness, and cardiovascular disease, with a focus on cardiovascular care pathways. Finally, we discuss strategies to investigate and address disparities in cardiovascular care for patients with severe mental illness.

Racial Disparities and Cardiometabolic Risk: New Horizons of Intervention and Prevention

PURPOSE OF REVIEW

Cardiometabolic diseases are a leading cause of morbidity and mortality in the USA and disproportionately impact racial and ethnic minorities. Multiple factors contribute to this disparity including genetic and socioeconomic factors, the latter of which contributes to disparities both through systemic barriers such as healthcare access and by directly impacting metabolism through epigenetics and environment-related alterations in the gut microbiome. This review will discuss advances in medicine that can be used to identify, prognosticate, and treat cardiometabolic diseases, and how these may be used to address existing disparities.

RECENT FINDINGS

There is growing research aimed at identifying novel cardiometabolic disease targets and expanding the use of existing pharmacotherapies based on comorbidities. Advances in metabolomics and genomics can give insight into an individual's unique biochemical profile, providing the means for earlier identification of disease and specific treatment targets. Moreover, developments in telehealth and related medical device technologies can expand access to underserved minority populations and improve control of chronic conditions such as diabetes and hypertension. Precision medicine may be integral to bridging the racial gap in cardiometabolic disease outcomes. Developments in genomics, metabolomics, wearable medical devices, and telehealth can result in personalized treatments for patients that account for the socioeconomic and genetic factors that contribute to poor health outcomes in minorities. As research in this field rapidly progresses, special efforts must be made to ensure inclusion of racial and ethnic minority populations in clinical research and equal access to all treatment modalities.

Carotid Intima-media Thickness and Midlife Cognitive Function: Impact of Race and Social Disparities in the Bogalusa Heart Study

BACKGROUND AND OBJECTIVE

Carotid intima-media thickness (c-IMT) is a measurement of atherosclerosis, a progressive disease that develops as early as childhood and has been linked with cognitive impairment and dementia in the elderly. However, the relationship between c-IMT and midlife cognitive function as well as race and social disparities on this relationship remains unclear. We examined the association between c-IMT and cognitive function in midlife among Black and White participants from a semi-rural community-based cohort in Bogalusa, Louisiana.

METHODS

In this cross-sectional analysis of participants from the Bogalusa Heart Study, linear regression models were used to determine the association between c-IMT dichotomized above the 50^th percentile (> 0.87mm), an a demographically standardized global cognitive (GCS) and individual cognitive domain-based z-scores. Stratified analyses were performed to evaluate the impact of race and the individual's education status.

RESULTS

A total of 1,217 participants (age 48 ± 5.28 years) were included, 66% (804) self-identified as White and 34% (413) as Black. Of those, 58% (708) were women, and 42% (509) were men Having a c-IMT > 50^th percentile was inversely associated with GCS ([B ± SE]: -0.39 ± 0.18, P=0.03), independent of cardiovascular risk factors (CVRFs) and achieved education. The effect remained significant in Black and White participants after adjustment for CVRFs (Blacks: [B ± SE]: -1.25 ± 0.45, P=0.005; Whites: [B ± SE]: -0.92 ± 0.35, P=0.008), but not for education. The interaction between c-IMT >50^th percentile and education was significant (P=0.03), and stratified analysis showed an association with GCS among those with lower achieved education ([B ± SE]: -0.81 ± 0.33, P=0.013) independent of major CVRFs.

DISCUSSION

Subclinical atherosclerosis, measured as c-IMT, was associated with worse midlife cognitive function, independent of major CVRFs. The association was buffered by education and may be stronger among Black than White participants, likely due to corresponding structural and social determinants. These findings underscore the importance of establishing preventive measures in midlife and suggest subclinical atherosclerosis as a potential target to prevent cognitive decline.

Sex, Gender and Health: Mapping the Landscape of Research and Policy

Including sex and gender considerations in health research is considered essential by many funders and is very useful for policy makers, program developers, clinicians, consumers and other end users. While longstanding confusions and conflations of terminology in the sex and gender field are well documented, newer conceptual confusions and conflations continue to emerge. Contemporary social demands for improved health and equity, as well as increased interest in precision healthcare and medicine, have made obvious the need for sex and gender science, sex and gender-based analyses (SGBA+), considerations of intersectionality, and equity, diversity and inclusion initiatives (EDI) to broaden representation among participants and diversify research agendas. But without a shared and precise understanding of these conceptual areas, fields of study, and approaches and their inter-relationships, more conflation and confusion can occur. This article sets out these areas and argues for more precise operationalization of sex- and gender-related factors in health research and policy initiatives in order to advance these varied agendas in mutually supportive ways.

Usage of Digital Health Tools and Perception of mHealth Intervention for Physical Activity and Sleep in Black Women

Black women of reproductive age are disproportionately affected by chronic health conditions and related disease risk factors such as physical inactivity and obesity. Health promotion studies need to focus on this population since optimizing preconception health will lead to improvement of both birth outcomes and the woman’s long-term health. mHealth interventions that utilize wearable sensors to provide personalized and timely feedback can be used to promote physical activity (PA). This study aimed to examine Black women’s wearable sensor usage and their perceptions about future mHealth interventions that target PA and sleep. Our analysis included 497 Black women (aged 18–47 years) who completed a cross-sectional online survey. Ninety-two percent of participants did not meet the recommended level of PA, and 32.3% reported poor sleep quality. More participants indicated interest in a remote PA program (77%) than an in-person one (73%). More than half of participants indicated interest in receiving personalized feedback messages based on wearable trackers about PA (58.1%) and sleep (63.5%). This perceived acceptability of remote intervention and wearable-based feedback messages did not differ by socioeconomic status. Remotely delivered mHealth interventions that utilize wearables can be a viable behavioral change strategy to promote PA and sleep quality in Black women.