Over the past two decades, approaches to managing patients with coronary artery disease have improved substantially with advances in percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG) surgery, pharmacological secondary prevention, anti-anginal agents and lifestyle interventions. Accordingly, clinical management choices in non-acute myocardial ischaemic syndromes (NAMIS) remain a timely and important topic. The risks and benefits of an invasive strategy combined with optimal medical therapy (OMT) versus a conservative strategy of OMT alone should be discussed with patients to facilitate shared clinical decision making. The findings from high-quality, randomized, controlled trials in the era of modern OMT form an essential platform for these informed conversations. In totality, the evidence from randomized, controlled trials supports OMT as the first-line therapeutic approach in patients with NAMIS, whereas selected patients at high anatomical risk or those with persistent anginal symptoms despite initial OMT often derive further symptom relief from invasive therapy with PCI. In patients with high-risk NAMIS, including those with multivessel disease and diabetes mellitus, CABG surgery improves survival, whereas the benefit is less clear for PCI. In this Review, we discuss the findings from contemporary trials evaluating outcomes in patients with NAMIS treated invasively or conservatively with OMT alone, and we conclude with proposed management pathways.

BACKGROUND:Cardiovascular-kidney-metabolic (CKM) syndrome highlights the inter-related nature of cardiometabolic risk factors, kidney disease, and cardiovascular disease (CVD) and represents an important target for intervention amid rising cardiovascular mortality in the United States. However, contemporary treatment patterns of major cardiometabolic risk factors in this high-risk population are not well defined. OBJECTIVES:The purpose of this study was to characterize national treatment rates of hypertension, diabetes, and hyperlipidemia among U.S. adults with CKM syndrome and to assess risk factor control among treated individuals from 2015 through 2023. METHODS:We analyzed data from adults aged ≥20 years with CKM stage 2 and above who participated in the National Health and Nutrition Examination Survey from 2015 through August 2023. Treatment rates for hypertension, diabetes, and hyperlipidemia and rates of blood pressure, glycemic, and cholesterol control among treated individuals were estimated using age- and sex-adjusted analyses that accounted for the complex survey design. RESULTS:The study included 6,384 adults with CKM stage 2 and above (weighted mean age 44.2 years; 51.2% women). Only approximately one-half of adults with hypertension (51.3% [95% CI: 49.7%-52.8%]) or hyperlipidemia (48.8% [95% CI: 46.7%-51.0%]) were receiving treatment, while diabetes treatment rates were higher (83.4% [95% CI: 80.1%-86.6%]). Among treated individuals, blood pressure control was achieved in 44.7% (95% CI: 41.6%-47.7%), glycemic control in 47.3% (95% CI: 42.7%-51.8%), and cholesterol control in 68.2% (95% CI: 65.2%-71.1%). Treatment rates for hypertension and hyperlipidemia increased across higher risk strata, while blood pressure and glycemic control were lower among treated adults with higher 10-year CVD risk. Adults aged 20-44 years consistently had the lowest treatment rates across all 3 conditions (hypertension 27.6% [95% CI: 24.8%-30.3%], diabetes 73.7% [95% CI: 63.8%-83.7%], hyperlipidemia 19.7% [95% CI: 15.2%-24.3%]), while women were less likely than men to receive treatment for diabetes and hyperlipidemia. Among racial and ethnic subgroups, Hispanic adults had the lowest treatment rates for hypertension and hyperlipidemia. CONCLUSIONS:Among U.S. adults with CKM syndrome, treatment of hypertension and hyperlipidemia was low, and fewer than one-half of treated individuals achieved blood pressure or glycemic control. Gaps in treatment initiation were most pronounced among young adults, women, and Hispanic adults, and inadequate risk factor control was particularly evident among those with higher cardiovascular risk. These findings highlight substantial opportunities to improve cardiometabolic care in this high-risk population.

6593 Background: Despite growing observational data linking clonal hematopoiesis of indeterminate potential (CHIP) to adverse cardiovascular outcomes, the cardiovascular evaluation and management of individuals with clonal hematopoiesis remain undefined. We report the experience of a dedicated CHIP Cardiology Clinic. Methods: We conducted a retrospective review of patients evaluated in the CHIP Cardiology Clinic at the Brigham and Women’s Hospital. Baseline demographics, comorbidities, medication use, and treatment interventions were extracted from the electronic medical record. Results: Fifty-three patients were evaluated between 2020 and 2025, of whom 39 (73.6%) had clonal hematopoiesis (CH), out of which 12 (30.8%) met criteria for CHIP. Among individuals with CH, the most frequently identified mutations were D N M T 3 A (30, 76.9%), T E T 2 (23, 59.0%), and A S X L 1 (6, 15.4%). The mean age was 65.9 years (range 40-81), and 23 (58.9%) were male. Hypertension and dyslipidemia were each present in 23 (59.0%) patients. Existing cardiovascular diseases included coronary artery disease (7, 18.0%) and arrhythmias (3, 7.7%). Following evaluation in the CHIP Clinic, and shared decision-making discussion in view of the dearth of evidence regarding outcome improvement in those with CHIP, lipid-lowering therapies were initiated or increased in 28 (71.8%) patients, with statins initiated or dose escalated in 21 (53.8%) and ezetimibe in 11 (28.2%). Blood pressure medications were initiated or intensified in 5 (12.8%) patients. Ischemic evaluation was performed in 3 (7.7%) patients due to suggestive symptoms. We developed a “patient page” to acquaint the patients and families with CHIP. (https://doi.org/10.1001/jamacardio.2024.3773). Conclusions: In this first longitudinal report from a dedicated CHIP Cardiology Clinic, a substantial proportion of patients harbored somatic mutations associated with elevated cardiovascular risk. Institution of preventive cardiovascular medications, in particular lipid-lowering therapies, was a frequent intervention. These findings support the feasibility of CHIP-focused cardiovascular care but underscore the need for prospective trials to evaluate the impact of targeted preventive strategies in this population.

This Viewpoint discusses the US Centers for Medicare & Medicaid Services’ Advancing Chronic Care With Effective, Scalable Solutions (ACCESS) model, an effort to improve chronic disease care within traditional Medicare.

Introduction: Diabetes is increasing in the US. The USPSTF and ADA recommend screening based on body mass index (BMI). We evaluated if waist circumference was a better predictor of diabetes than BMI. Methods: We used NHANES (2015-2018). We identified nonpregnant adults ages ≥20 years (N=10,614). A mediation analysis was performed, assessing if the association of BMI (kg/m2) with diabetes prevalence was mediated by waist circumference (cm), using survey weighted logistic regression. Estimates were US representative. Results: We identified 233,874,251 weighted adults. A one-point BMI increase was associated with a 0.95% (95% CI: 0.84%, 1.07%, P<0.001) increase in diabetes prevalence. Similarly, a one-centimeter increase in waist circumference was associated with a 0.51% (95% CI: 0.46%, 0.55%, P<0.001) increase in diabetes prevalence. After adjusting for waist circumference, BMI was not associated with diabetes prevalence (P<0.001) (Figure), while waist circumference continued to predict diabetes prevalence by 0.87% (95% CI: 0.73%, 1.01%, P<0.001) per one-centimeter increase. The association of BMI for diabetes prevalence was fully mediated by waist circumference (indirect effect ≥ total effect). Conclusion: The predictive ability of BMI for diabetes is fully mediated by waist circumference. Clinical guidelines could consider waist circumference to replace BMI in screening guidelines. Disclosure R.Aggarwal: None. N.Chiu: None. D.L.Bhatt: Board Member; Bristol-Myers Squibb Company, Research Support; Lexicon Pharmaceuticals, Inc., Sanofi, Lilly, Boehringer Ingelheim Inc., AstraZeneca, Novo Nordisk.

This study uses National Health and Nutrition Examination Survey data to examine lipid control among adults in the US with coronary artery disease from January 2015 to March 2020.

Background: Hypertension control has worsened nationally, and treatment intensification is important for control. National trends for appropriate blood pressure intensification for older adults are unknown. We determine the proportion of ambulatory visits where older adults with hypertension were appropriately intensified on antihypertensives from 2008 to 2018. Methods: Data from National Ambulatory Medical Care Survey were used. National Ambulatory Medical Care Survey is a nationally representative sample of ambulatory visits. Adults 60 years or older were included. Appropriate antihypertensive intensification was defined as addition of an antihypertensive for a blood pressure reading above target. We examined appropriate intensification by blood pressure targets set by the American College of Cardiology–American Heart Association, the European Society of Cardiology, and the American College of Physicians–American Academy of Family Physicians guidelines for older adults. Further, we defined an additional all-inclusive criterion meeting all 3 guidelines. Results: From 2008 to 2018, appropriate intensification by American College of Cardiology/American Heart Association occurred at 11.1% (95% CI, 9.8%–12.5%) of visits, decreasing from 13.6% (95% CI, 15.6%–28.7%) of visits in 2008 to 2009 to 10.4% (95% CI, 10.9%–26.4%) in 2015 to 2018. Appropriate intensification by European Society of Cardiology occurred at 14.2% (12.1%–16.6%) of visits over 2008 to 2018, decreasing from 16.9% (95% CI, 13.5%–21.0%) in 2008 to 2009 to 12.5% (95% CI, 7.4%–20.3%) from 2015 to 2018. Appropriate intensification by American Academy of Family Physicians/American College of Physicians occurred at 18.9% (16.2%–22.0%) of visits over 2008 to 2018, decreasing from 24.7% (95% CI, 20.2%–29.0%) in 2008 to 2009 to 14.9% (95% CI, 9.0%–23.7%) from 2015 to 2018. By all-inclusive criteria, intensification trended toward worsening with time: odds ratio: 0.93 ([95% CI, 0.87–1.00]; P=0.07). Conclusions: Appropriate treatment intensification for older adults with hypertension in the United States was suboptimal over the past decade.

Introduction: Hypertension control has worsened in recent years, yet trends for appropriate blood pressure intensification practices for older adults is unknown. Hypothesis: We determine the proportion of ambulatory visits where older adults with hypertension were appropriately intensified on anti-hypertensives over the past decade. We hypothesize that treatment intensification may not have improved over time. Methods: Data from National Ambulatory Medical Care Survey (NAMCS, 2008-2018) were used. NAMCS is a nationally representative sample of ambulatory medical visits. Adults ages 60 years or older were included. Appropriate antihypertensive intensification was defined as the addition of an antihypertensive for a blood pressure reading above target. We examined appropriate intensification by blood pressure targets set by the ACC/AHA, the ESC, and the ACP/AAFP guidelines for older adults. Further, we defined an additional all-inclusive criterion meeting all three guidelines. Results: From 2008-2018, appropriate treatment intensification by ACC/AHA guidelines occurred at 11.1% (95% CI:9.8-12.5%) of visits, decreasing from 13.6% (95% CI:15.6-28.7%) of visits in 2008-2009 to 10.4% (95% CI:10.9-26.4%) in 2015-2018. Appropriate intensification by ESC occurred at 14.2% (12.1-16.6%) of visits over 2008-2018, decreasing from 16.9% (95% CI:13.5-21.0%) in 2008-2009 to 12.5% (95% CI:7.4-20.3%) from 2015-2018. Appropriate intensification by AAFP/ACP occurred at 18.9% (16.2-22.0%) of visits over 2008-2018, decreasing from 24.7% (95% CI:20.2-29.0%) in 2008-2009 to 14.9% (95% CI:9.0-23.7%) from 2015-2018. By all-inclusive criteria, intensification trended towards worsening with time: odds ratio: 0.93 (95% CI:0.87-1.00; p=0.07). Conclusions: Appropriate treatment intensification for older adults with hypertension in the US was suboptimal over the past decade despite growing trial evidence showing beneficial effects for intensive blood-pressure control in older adults. Strategies to mitigate therapeutic inertia are needed, and clinical practices should make concerted efforts to improve appropriate treatment intensification in older adults.

Introduction: Hypertension control has worsened in recent years, yet trends for appropriate blood pressure intensification practices for older adults is unknown. Hypothesis: We determine the proportion of ambulatory visits where older adults with hypertension were appropriately intensified on anti-hypertensives over the past decade. We hypothesize that treatment intensification may not have improved over time. Methods: Data from National Ambulatory Medical Care Survey (NAMCS, 2008-2018) were used. NAMCS is a nationally representative sample of ambulatory medical visits. Adults ages 60 years or older were included. Appropriate antihypertensive intensification was defined as the addition of an antihypertensive for a blood pressure reading above target. We examined appropriate intensification by blood pressure targets set by the ACC/AHA, the ESC, and the ACP/AAFP guidelines for older adults. Further, we defined an additional all-inclusive criterion meeting all three guidelines. Results: From 2008-2018, appropriate treatment intensification by ACC/AHA guidelines occurred at 11.1% (95% CI:9.8-12.5%) of visits, decreasing from 13.6% (95% CI:15.6-28.7%) of visits in 2008-2009 to 10.4% (95% CI:10.9-26.4%) in 2015-2018. Appropriate intensification by ESC occurred at 14.2% (12.1-16.6%) of visits over 2008-2018, decreasing from 16.9% (95% CI:13.5-21.0%) in 2008-2009 to 12.5% (95% CI:7.4-20.3%) from 2015-2018. Appropriate intensification by AAFP/ACP occurred at 18.9% (16.2-22.0%) of visits over 2008-2018, decreasing from 24.7% (95% CI:20.2-29.0%) in 2008-2009 to 14.9% (95% CI:9.0-23.7%) from 2015-2018. By all-inclusive criteria, intensification trended towards worsening with time: odds ratio: 0.93 (95% CI:0.87-1.00; p=0.07). Conclusions: Appropriate treatment intensification for older adults with hypertension in the US was suboptimal over the past decade despite growing trial evidence showing beneficial effects for intensive blood-pressure control in older adults. Strategies to mitigate therapeutic inertia are needed, and clinical practices should make concerted efforts to improve appropriate treatment intensification in older adults.

This cohort study compares patient-reported experiences at safety-net and non–safety-net hospitals before and after the Centers for Medicare & Medicaid Services implemented the Hospital Value-Based Purchasing program.