Background: Heart failure (HF) remains a leading cause of morbidity and mortality, yet national data on where patients with HF die and how this varies across demographic groups are limited. Understanding death location is essential to improving end-of-life care and promoting equity in the United States. Hypothesis: We hypothesized that the location of death among patients with HF has shifted over time and differs by age, sex, race, and ethnicity. Methods: Using national mortality data from the National Center for Health Statistics for 2003–2021, we identified all U.S. adults aged ≥25 years whose underlying cause of death was HF (ICD-10: I110, I130, I132, I500, I509). Location of death was categorized as inpatient hospital, outpatient hospital, dead-on-arrival (DOA), scene, hospice, nursing home, or unknown. Demographic predictors included age group, sex, race, ethnicity, and year of death. Multivariable logistic regression evaluated associations with each category, and Joinpoint regression quantified temporal trends. Results: Among 1,615,353 HF deaths, 45.7% occurred in inpatient hospitals, 22.0% in nursing facilities, 6.6% in hospice, 4.0% in outpatient settings, 0.1% were DOA, and 21.0% occurred at the scene. From 2003–2021, inpatient hospital deaths declined 3.2% annually and nursing home deaths 2.1%, while hospice deaths rose 19.6% (all p<0.001). Older adults (≥65 years) were more likely to die in nursing homes (OR 8.05) and hospice (OR 2.68) but less likely in hospitals. Males had higher odds of inpatient (OR 1.33) and lower odds of nursing home deaths (OR 0.66). Compared with White patients, Black patients had higher odds of hospital (OR 1.47) and outpatient (OR 2.57) deaths but lower odds of nursing home (OR 0.53) and hospice (OR 0.85) deaths. Hispanic patients had higher inpatient death (OR 1.40) but lower hospice (OR 0.65) and nursing home (OR 0.40) deaths. Conclusions: Over two decades, HF deaths occurring in inpatient hospitals have declined, while hospice deaths increased sharply, signaling shifts toward community- and palliative-based end-of-life care. Persistent racial and ethnic disparities remain, with Black and Hispanic individuals more likely to die in acute-care settings and less likely in hospice or nursing facilities. These findings highlight ongoing inequities in end-of-life care access and emphasize the need for culturally informed palliative strategies to improve care for patients with HF.

Familial hypercholesterolemia (FH) is a common genetic disorder characterized by lifelong elevated low-density lipoprotein cholesterol (LDL-C), leading to a high risk of early onset atherosclerotic cardiovascular disease (ASCVD). This document provides an update to the National Lipid Association's 2011 clinical guidance, summarizing the remarkable progress in the field. With a global prevalence of approximately 1 in 311, FH remains severely underdiagnosed. This guidance reviews current diagnostic criteria, including the expanding role of genetic testing to complement diagnosis and to facilitate cascade screening, and emphasizes a thorough differential diagnosis. It provides recommendations for universal pediatric screening and systematic cascade screening in families to improve detection. Management strategies include intensified LDL-C treatment goals for both primary and secondary prevention of ASCVD. A stepwise approach to optimal therapy is outlined, beginning with lifestyle interventions and pharmacotherapy with maximally tolerated statins and ezetimibe. This update incorporates newer agents, including proprotein convertase subtilisin/kexin type 9 inhibitors and bempedoic acid. Additional therapies, such as lomitapide and evinacumab for homozygous FH and lipoprotein apheresis for heterozygous and homozygous FH, are discussed. Further topics include cardiovascular imaging for risk stratification, management in specific populations and circumstances, such as planning for and during pregnancy and in pediatrics, and recognition of health disparities. This guidance equips clinicians with evidence-based strategies to improve the identification and care of patients with FH, ultimately reducing the high morbidity and mortality associated with this condition.

Secondary prevention of cardiovascular disease (CVD) in older adults plays a pivotal role in reducing morbidity and mortality, improving quality of life, and minimizing health care costs. This aspect of care is essential in enhancing life expectancy as the aging population is increasingly affected by CVD. This review focuses on the strategies, challenges, and recent advancements in secondary prevention for elderly populations. It examines pharmacologic and nonpharmacological interventions, discusses the barriers to effective implementation, and highlights the need for individualized care strategies. The paper also underscores the importance of multidisciplinary approaches in managing secondary prevention in this vulnerable population.

Therapeutic Area ASCVD/CVD in Special Populations Background South Asian (SA) individuals are known to have a higher risk of heart disease when compared to Caucasians. The role of coronary artery size in modifying this risk has been debated. Prior angiographic studies using coronary artery diameters showed smaller vessels in SA, whereas studies using cross sectional area from non-contrast Computed Tomography (CT) did not show this difference. Studies assessing volumes by contrast CTA (CT Angiography) in this population are minimal and are limited by small sample size. We aimed to expand on this literature with estimation of coronary artery volumes in a South Asian cohort using CTA. Methods We evaluated total, and vessel specific body surface area (BSA) adjusted coronary artery luminal volumes in 341 South Asian patients receiving clinically indicated CTAs in the DIL wellness and Arterial health Longitudinal Evaluation registry. A separate analysis was performed in patients with no plaque to eliminate any influence of plaque burden on luminal volumes. We then compared the difference in luminal volumes between men and women. All patients received vasodilators as part of the protocol. Vessel volumes were calculated by using a commercially available vessel analysis tool. To compare patient demographics factors, baseline characteristics, and BSA-adjusted lumen volume, Mann Whitney U test or T- test was applied to continuous variables. Chi-square test or Fisher’s exact test was applied to categorical variables. A significance level of 5% was used at all statistical tests stated above. All analyses were performed using R statistical software version 4.4.0. Results Baseline demographics are shown in Table 1. Risk factors were equally distributed between men and women except smoking, which was more common in men. The total lumen volume/BSA was 925 mm3/m2 in all SA and 963mm3/m2 in the subset with no plaque. Individual vessel volumes are demonstrated in Table 1. Total BSA indexed lumen volume was significantly higher in men when compared to women (958 vs 851 mm3/m22; p= 0.005). This was true in the subset without any plaque as well. Compared with prior literature on coronary artery volumes in a smaller cohort of SA, all indexed volumes appeared smaller in our study (Total 1434 mm3/m2 vs 925 mm2/m3). The volumes were also smaller when compared with data on Caucasians in this study. Conclusions Our study provides a comprehensive assessment of coronary artery luminal volumes in a South Asian cohort using CT angiography (CTA). The assessment of CT derived coronary volumes in patients with and without plaque expands on previous literature from angiographic and non-contrast CT studies. Future investigations in larger cohorts of SA should include assessment of coronary artery volumes indexed to myocardial mass to improve prognostication.

BACKGROUND:High intensity statin therapy is currently recommended for primary prevention of atherosclerotic cardiovascular disease (ASCVD) in patients with severe hyperlipidemia (HLD), defined as low-density lipoprotein cholesterol (LDL-C) of ≥190 mg/dL. OBJECTIVE:We investigated rates and dosages of statin use and associated ASCVD outcomes for patients with severe HLD. METHODS:In a large healthcare system network, patients without ASCVD with an LDL-C ≥ 190 mg/dL were identified and stratified further based on American College of Cardiology /American Heart Association 10-year risk score. Statin use was stratified as: guideline directed statin intensity (GDSI) (high intensity statin) or <GDSI (less than high intensity) or no statin use. Time to initiation of GDSI was calculated using the Kaplan-Meier method. Incident rates (per thousand person years) and Cox proportional hazards models were used to assess the relationship between statin use and adverse outcomes. RESULTS:Out of 282,298 primary prevention patients, a total of 5205 (1.8%) had LDL-C ≥ 190 mg/dL out of whom 3.7% were on GDSI at the index visit. Over a 5-year follow up, 42% of high-risk patients with severe HLD achieved new GDSI initiation. Compared to patients on GDSI, those on no statin therapy were at significantly higher risk of myocardial infarction (MI) (hazard ratio [HR] = 2.36, 95% CI [1.38-4.04]) and stroke/transient ischemic attack (HR = 2.70, 95% CI [1.43-5.09]). Patients on <GDSI were found to have significantly higher risk of MI (HR = 1.72, 95% CI [1.05-2.81]) compared to patients on GDSI. CONCLUSION:High intensity statins are underutilized among patients with severe HLD, which is linked to greater risk of ASCVD events.

The role of low-density lipoprotein-cholesterol in the pathogenesis of atherosclerotic cardiovascular disease (ASCVD) is well established. Lipid management remains the cornerstone of addressing ASCVD. In addition to statin therapy, there is a large and growing number of nonstatin therapies available to manage elevated cholesterol levels. This expert panel seeks to review current international recommendations regarding lipid management. In addition, complex yet commonly encountered lipid-management cases are provided. Guidance on applying guideline-based recommendations as well as newer evidence to the evaluation and management of ASCVD-risk lipid management is then provided.

Cardiovascular disease remains a leading cause of death in the United States, with an alarming rise in the proportion of young adults experiencing cardiovascular events. Many adolescents enter adulthood with significant cardiovascular disease risk factors. This scientific statement addresses the critical need for cardiovascular health promotion during emerging adulthood, a transitional stage between the ages of 18 and 25 or 29 years of age. We discuss the significance of social determinants of health and the interplay between individual‐level risk factors and developmental changes, including shifts in substance use, social connections, and emotional well‐being. We conclude by outlining strategies for optimizing cardiovascular health promotion and disease prevention, underscoring the importance of primordial prevention, early intervention, and tailored approaches to address the unique needs of emerging adults. Addressing these multifaceted factors is crucial for mitigating the burden of cardiovascular disease risk factors among emerging adults and promoting long‐term cardiovascular well‐being.

BACKGROUND:Coronary artery calcium (CAC) testing is guideline-recommended to enhance atherosclerotic cardiovascular disease (ASCVD) risk prediction, yet there are no sex-specific CAC reference data for South Asians in the United States (SAUS) across their adult lives. OBJECTIVES:The purpose of this study was to determine the sex-specific distribution of CAC scores across the adult lifespan of SAUS. METHODS:We studied 2743 SAUS adults (ages 33-75 years old) free of known ASCVD from the MASALA (Mediators of Atherosclerosis in South Asians Living in America), a community-based cohort study, and the DILWALE (DIL Wellness and Arterial health Longitudinal Evaluation), a clinic-based study. We estimated the likelihood of CAC >0 and calculated sex-specific CAC percentiles as a function of age, employing nonparametric methods. RESULTS:Participants had a mean age of 52 ± 9 years, with 37.8% women. The probability of CAC >0 for women and men was 20% and 45% at age 50 years, 40% and 70% at age 60 years, and 70% and 90% at 70 years old, respectively. The 75th and the 90th percentiles of CAC at age 60 years were 26 and 115 for SAUS women and 186 and 580 for SAUS men. A CAC score of 100 was at approximately the 75th percentile for a 55-year-old man or a 65-year-old woman. CONCLUSIONS:These data address the current knowledge gap regarding the distribution of CAC scores among SAUS adults. Utilizing these CAC percentiles in the clinical assessment of ASCVD risk may enhance personalized interpretation of CAC scoring and guide ASCVD prevention efforts in SAUS.

Coronary artery calcium (CAC) testing is guideline-recommended to enhance atherosclerotic cardiovascular disease (ASCVD) risk prediction, yet there are no sex-specific CAC reference data for South Asians in the United States (SAUS) across their adult lives. The purpose of this study was to determine the sex-specific distribution of CAC scores across the adult lifespan of SAUS. We studied 2743 SAUS adults (ages 33-75 years old) free of known ASCVD from the MASALA (Mediators of Atherosclerosis in South Asians Living in America), a community-based cohort study, and the DILWALE (DIL Wellness and Arterial health Longitudinal Evaluation), a clinic-based study. We estimated the likelihood of CAC >0 and calculated sex-specific CAC percentiles as a function of age, employing nonparametric methods. Participants had a mean age of 52 ± 9 years, with 37.8% women. The probability of CAC >0 for women and men was 20% and 45% at age 50 years, 40% and 70% at age 60 years, and 70% and 90% at 70 years old, respectively. The 75th and the 90th percentiles of CAC at age 60 years were 26 and 115 for SAUS women and 186 and 580 for SAUS men. A CAC score of 100 was at approximately the 75th percentile for a 55-year-old man or a 65-year-old woman. These data address the current knowledge gap regarding the distribution of CAC scores among SAUS adults. Utilizing these CAC percentiles in the clinical assessment of ASCVD risk may enhance personalized interpretation of CAC scoring and guide ASCVD prevention efforts in SAUS.

Coronary artery calcium (CAC) assessment has long been reserved for intermediate-risk individuals in mid- to older-adult populations. However, a growing body of evidence supports expanding CAC measurement to younger adults who exhibit multiple risk factors or other risk-enhancing features. We describe a case of a very young, 20-year-old, South Asian man with a CAC score of 15.7 Agatston Units. Despite his age and lack of overt symptoms, his CAC score placed him at the 99th percentile for his age and sex, underscoring the limitations of relying solely on traditional risk algorithms. Early CAC detection in such patients has potential for significant clinical impact, allowing timely implementation of intensive lifestyle modification and the most aggressive possible pharmacotherapy for cardiovascular risk reduction.Evidence indicates that even minimal CAC in very young individuals can progress exponentially, markedly increasing the risk of future atherosclerotic cardiovascular disease. Nonetheless, current guidelines do not recommend CAC testing in this population, creating a missed opportunity to detect and intervene in high-risk individuals during early adulthood. These observations underscore the need for more precise risk stratification strategies in select high-risk populations. Incorporating CAC measurements into care for young, high-risk individuals—alongside newer tools such as polygenic risk scores and low-radiation coronary CT angiography—could revolutionize preventive cardiology. Further research is needed to refine the cost-effectiveness and implementation strategies for early CAC measurement, develop more inclusive guidelines, and ensure a specialized workforce capable of delivering comprehensive preventive care.

Background: Type 2 diabetes (T2D) is a well-established risk factor for ischemic stroke (IS), yet national trends in IS mortality with T2D as a contributing cause remain poorly characterized. Understanding these patterns is essential for informing targeted stroke prevention efforts among high-risk populations. Research Questions: What are the temporal trends in IS mortality in the United States when T2D is listed as a contributing cause of death? Additionally, how do these mortality trends vary by sex, race, urbanization level, and geographic region? Methods: We analyzed national mortality data from the CDC WONDER database from 1999 to 2020 for individuals aged > 35 years. IS (ICD-10: I63, I69.3) was designated as the underlying cause of death, with T2D (E11.0–E11.9) listed as a contributing cause. Age-adjusted mortality rates (AAMRs) per 1,000,000 population were calculated. Joinpoint regression was used to assess temporal trends and estimate annual percent change (APC). Results: A total of 9,011 IS deaths with comorbid T2D were identified. AAMR declined from 2.6 (95% CI, 2.3–2.8) in 1999 to 1.2 (95% CI, 1.1–1.4) in 2011 (APC = –7.6%; p<0.001), followed by a sharp increase to 5.6 (95% CI, 5.3–6.0) in 2020 (APC = 19.8%; p<0.001). Cumulative AAMR was higher among males (2.7 [95% CI, 2.6–2.7]) than females (2.2 [95% CI, 2.1–2.2]). Racial disparities were evident: American Indians had the highest AAMR (3.6 [95% CI, 2.9–4.5]), followed by African Americans (3.1 [95% CI, 2.9–3.3]), Asians (2.6 [95% CI, 2.3–2.9]), and White individuals (2.3 [95% CI, 2.2–2.4]). Micropolitan rural areas had the highest AAMR (3.0 [95% CI, 2.8–3.2]) compared to large fringe metropolitan areas (1.8 [95% CI, 1.7–1.9]). By region, the West had the highest AAMR (3.2 [95% CI, 3.1–3.3]), followed by the South (2.5 [95% CI, 2.4–2.6]), Midwest (2.5 [95% CI, 2.4–2.6]), and Northeast (1.3 [95% CI, 1.2–1.4]). Conclusions: After an initial decline, mortality from IS with comorbid T2D has risen markedly since 2011, with disproportionate burden among males, American Indian and African American populations, rural areas, and residents of the Western U.S. These findings highlight the urgent need for integrated strategies focused on diabetes management, stroke prevention, and health equity across high-risk communities.

Background: Hypertension (HTN), a prevalent comorbidity in type 2 diabetes mellitus (T2DM), increases the risk of cardiovascular (CV) events, mortality, and kidney complications. However, optimal blood pressure (BP) targets in patients with T2DM remain unclear. Research Question: Does intensive BP control, compared to standard targets, reduce CV, renal, and mortality outcomes in patients with T2DM? Aims: We aim to conduct an updated meta-analysis to evaluate the effects of intensive vs. standard BP control on CV and kidney outcomes and mortality in T2DM patients. Methods: A comprehensive search of PubMed, Cochrane Library, and Scopus was conducted through December 2024 for trials comparing intensive vs. standard BP control in patients with T2DM. Outcomes assessed included all-cause mortality, CV mortality, major adverse CV events (MACE), stroke, myocardial infarction (MI), incident heart failure (HF), chronic kidney disease (CKD) development, albuminuria, and serious adverse events (SAEs). Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using a random effects model. Results: 28 trials encompassing 104,634 patients were included. Intensive BP control significantly reduced the risk of CV mortality (RR: 0.75, 95% CI: 0.65–0.87, P = 0.0001), all-cause mortality (RR: 0.85, 95% CI: 0.76–0.95, P = 0.004), MACE (RR: 0.81, 95% CI: 0.75–0.87, P < 0.00001), stroke (RR: 0.70, 95% CI: 0.61–0.80, P < 0.00001), MI (RR: 0.86, 95% CI: 0.79–0.94, P = 0.001), HF (RR: 0.78, 95% CI: 0.64–0.96, P = 0.02), and albuminuria (RR: 0.89, 95% CI: 0.82–0.97, P = 0.005). There were no significant differences in CKD development (RR: 1.08, 95% CI: 0.92–1.26, P = 0.36) or SAEs (RR: 1.16, 95% CI: 0.97–1.40, P = 0.10). Conclusions: Intensive BP control in patients with T2DM was associated with a lower risk of all-cause mortality, CV mortality, MACE, stroke, MI, HF, and albuminuria as compared to standard control, without an increased risk of serious adverse events.

Atherosclerotic cardiovascular disease (ASCVD) continues to be a growing global health concern with ischemic heart disease and stroke as leading causes of years of life lost. While aging is a major ASCVD risk factor, recent trends show a concerning rise in its incidence among younger adults driven, in part, by increased rates of risk factors such as hypertension and diabetes. These individuals with ASCVD are at elevated risk of recurrence years following their initial event, further underscoring the need for aggressive implementation of secondary prevention strategies to reduce morbidity and mortality. This case-based review discusses evidence-based pharmacological approaches to ASCVD secondary prevention-focusing on the roles of antiplatelets, lipid lowering therapies, antihypertensive medications, and glucose lowering treatments, in practical clinical settings.

Chronic coronary disease (CCD) is the leading cause of death in the United States. There is an ongoing imperative to disseminate evidence-based and patient-centered care recommendations that further align the management of patients with CCD to updated evidence-based guidelines. The writing committee developed a comprehensive CCD measure set comprising 10 performance measures and 3 quality measures, the focus of which is to include practical steps to specifically advance care in the CCD population. The measure set begins with an assessment of tobacco use and evidence-based cessation interventions. Also included are topics such as antiplatelet therapy, lipid assessment and low-density lipoprotein cholesterol goals, and guideline-directed management and therapy for hypertension and reduced left ventricular dysfunction in patients with CCD. The measure set concludes with an emphasis on the importance of cardiac rehabilitation referral and patient education, including symptom management and lifestyle modification.

Chronic coronary disease (CCD) is the leading cause of death in the United States. There is an ongoing imperative to disseminate evidence-based and patient-centered care recommendations that further align the management of patients with CCD to updated evidence-based guidelines. The writing committee developed a comprehensive CCD measure set comprising 10 performance measures and 3 quality measures, the focus of which is to include practical steps to specifically advance care in the CCD population. The measure set begins with an assessment of tobacco use and evidence-based cessation interventions. Also included are topics such as antiplatelet therapy, lipid assessment and low-density lipoprotein cholesterol goals, and guideline-directed management and therapy for hypertension and reduced left ventricular dysfunction in patients with CCD. The measure set concludes with an emphasis on the importance of cardiac rehabilitation referral and patient education, including symptom management and lifestyle modification.

The role of low-density lipoprotein-cholesterol in the pathogenesis of atherosclerotic cardiovascular disease (ASCVD) is well established. Lipid management remains the cornerstone of addressing ASCVD. In addition to statin therapy, there is a large and growing number of nonstatin therapies available to manage elevated cholesterol levels. This expert panel seeks to review current international recommendations regarding lipid management. In addition, complex yet commonly encountered lipid-management cases are provided. Guidance on applying guideline-based recommendations as well as newer evidence to the evaluation and management of ASCVD-risk lipid management is then provided.