BACKGROUND:Metabolic syndrome (MetSyn) is associated with frailty in older adults, with few data among midlife women. We examined MetSyn, including duration, for associations with the development of prefrailty and frailty. METHODS:The Study of Women's Health Across the Nation is a multiethnic, longitudinal cohort study of women aged 42-52 years at the time of enrollment (1996-1997). MetSyn was measured longitudinally, using ATP III criteria, starting at baseline. Pre-frailty and frailty were measured at two later visits (2012/13 and 2015/16) using Fried criteria. Associations of pre-frailty and frailty with prevalent MetSyn, the cumulative number of prior visits with MetSyn, and individual MetSyn criteria were examined using multivariable models. RESULTS:A total of 1769 women were included (mean age 59.7 years, SD 3.3). The adjusted odds ratios (aOR) for having pre-frailty or frailty in women with MetSyn compared to those without were 2.77 (95% CI, 2.19-3.50) and 8.73 (95% CI, 5.89-12.95), respectively. Each additional visit a woman met criteria for MetSyn was associated with a higher odds of pre-frailty and frailty (aOR 1.20; 95% CI: 1.14-1.26, and aOR: 1.41; 95% CI: 1.33-1.50, respectively). Individual MetSyn criteria were also associated with the risk of frailty. CONCLUSIONS:Among women in this multiethnic cohort, MetSyn was common during midlife and strongly associated with future development of pre-frailty and frailty while women were in their early 60s. Measurement of MetSyn during midlife can help identify women at high risk for developing frailty early in the aging process.

BACKGROUND:Body mass index (BMI) is commonly used to assess total adiposity, yet does not provide insight into overall body composition, potentially obscuring meaningful heterogeneity in cardiovascular disease (CVD) risk. Waist circumference (WC) and waist-to-hip ratio (WHR) are surrogate measures of central adiposity that are commonly discordant with BMI and may provide additional prognostic information. OBJECTIVES:The purpose of this study was to quantify the reclassification and misclassification of traditional normal weight/overweight/obesity categories using central adiposity and to evaluate the prognostic implications for CVD risk using the CCC (Cross-Cohort Collaboration). METHODS:We included 259,388 participants from 15 cohorts of the CCC with harmonized data on either WC or WHR data and at least 1 of 9 outcomes: time to first fatal and nonfatal myocardial infarction, fatal and nonfatal stroke, heart failure, atrial fibrillation, total coronary heart disease, total CVD, coronary heart disease mortality, CVD mortality, and all-cause mortality. Multivariable Cox proportional hazards models were used to estimate the HR of higher WC and WHR for each outcome across BMI categories. RESULTS:Our sample included 259,351 individuals with WC data and 218,984 with WHR data, with a median follow-up of 20.0 years (95% CI: 12.7-23.5 years). Among individuals with normal weight, 5% had high WC and 18% had high WHR; among those with overweight, 39% had high WC and 40% had high WHR. Among those with obesity, 9% had low WC and 45% had low WHR. Among individuals with normal weight or overweight, clinically defined high WC or WHR was associated with 15% to 50% greater risk for most outcomes. Among those with obesity, low WC was not associated with a significantly different risk compared with normal weight and low WC, except for all-cause mortality, for which risk was significantly lower. In contrast to men, women with obesity but low WHR retained significantly higher risk for all outcomes compared with normal weight and low WHR; however, the HRs were smaller compared with those with obesity and high WHR. Among individuals with obesity, the population attributable risk associated with elevated WC or WHR ranged from 13% to 49%, with the highest estimates observed for elevated WC in heart failure and atrial fibrillation. CONCLUSIONS:WC and WHR identifies misclassification of conventional BMI categories and reclassifies CVD risk across normal weight, overweight, and obesity, adding diagnostic and prognostic value.

BACKGROUND: Automated external defibrillators (AEDs) are rarely used by bystanders in Birmingham, Alabama. We sought to characterize AED availability, accessibility, and usability in the highest-risk out-of-hospital cardiac arrest neighborhoods of Birmingham. METHODS: We conducted a descriptive observational study from June 12 to August 27, 2025, in 3 Birmingham neighborhoods with the highest relative out-of-hospital cardiac arrest risk. Potential public AED sites, defined as properties other than single-family residences, were identified using Google Maps landmark descriptions. Sites were contacted by telephone, email, or in person to confirm AED presence, and device-specific data were collected in person. Outcomes included AED availability (presence of ≥1 AED), accessibility (public access and hours), and usability (ability to power on with pads). At-risk devices contained expired batteries and pads. Observed and effective AED densities were compared with the recommended 5 AEDs per square mile. Observed AED density was defined as AEDs per square mile, regardless of accessibility hours. Effective AED density was defined as AEDs per square mile adjusted for weekly hours of accessibility. RESULTS: A total of 287 potential AED locations were identified, and 284 (99%) were contacted and provided data. Fifty-six AEDs were reported at 43 locations (15.1%). Of these, 19 (33.9%) were not publicly accessible. Among the 37 publicly accessible AEDs, none were available 24 hours per day. Thirty-five (94.6%) were found in usable condition, and 5 (13.5%) were classified as at risk. Two (5.4%) were inoperable. The observed density of publicly usable AEDs was 13.5 AEDs per square mile, with an effective density of 3.7 AEDs per square mile due to limited hours of access. CONCLUSIONS: Despite exceeding the recommended AED density, limited public accessibility and maintenance issues substantially reduce effective AED coverage in Birmingham. Reporting effective AED density, which accounts for hours of access, reveals gaps between device presence and real-world accessibility.

Background Adverse social determinants of health (SDOH) are independently associated with incident heart failure (HF), but the mechanisms underlying this relationship are unknown. Allostatic load (AL)—the cumulative physiologic burden of chronic stress—may represent an etiologic mechanism. We examined whether AL mediates the association between adverse SDOH and incident HF. Methods and Results We examined 13,529 REGARDS participants aged 45-64 years who were free of HF at baseline. Adverse SDOH burden was defined as a count among factors based on the Healthy People 2030 framework. AL was calculated using 11 physiologic markers across cardiovascular, metabolic, immune, and inflammatory systems. The primary outcome was adjudicated incident HF hospitalization or death (ascertained between 2003 and 2021). Mediation was assessed using Inverse Odds Weighting with Cox proportional hazards models, adjusted for age, sex, and geographic region. Over a median follow-up period of 14.30 years (interquartile range (IQR): 7.71–16.40), 500 participants experienced incident HF events. Higher adverse SDOH count was associated with increased HF risk in a stepwise fashion. AL mediated 18.87% of the association between ≥3 adverse SDOH and HF (indirect effect hazard ration (HR): 1.30 [1.14–1.47]) and 13.32% of the association for 2 adverse SDOH. No mediation was observed for 1 adverse SDOH. Conclusions AL partially mediates the relationship between adverse SDOH burden and incident HF. These findings highlight AL as a potential underlying mechanism by which adverse SDOH exerts a negative effect on health.

IntroductionWomen with HIV (WWH) have a higher risk of hypertension compared to women without HIV (WWoH). Exposure to adverse socioeconomic (e.g., area level deprivation) and psychosocial factors (e.g., stigma, inadequate social support) may contribute to inequities in hypertension through their influence on health behaviors (e.g., substance use, diet, physical activity) and psychophysiological (e.g., stress) responses.MethodsWe examined the association between socioeconomic and psychosocial factors, psychological distress, and current uncontrolled blood pressure among WWH (n=998) and WWoH (n=353) enrolled in the Women’s Interagency HIV Study (WIHS) at a single visit between April and September 2019.ResultsSocioeconomic and psychosocial factors were similar among WWH and WWoH. Among WWH and WWOH, 50.2% had current uncontrolled blood pressure, defined as a systolic blood pressure ≥130 mmHg or diastolic pressure ≥ 80 mmHg at the time of the study visit. Among WWH, socioeconomic, psychosocial, and behavioral factors explained 3% of the variance in blood pressure with self-reported health risk behaviors (r=0.15), and use of antihypertensive medication (r=0.09) had weak to moderate impact. Among WWoH, socioeconomic, psychosocial, and behavioral factors explained 10% of the variance in blood pressure, with self-reported health risk behaviors (r=0.19), use of antihypertensive medication (r=0.19), area-level social vulnerability (r=-0.17), and social support (r=0.16) demonstrating weak to moderate impacts.DiscussionTailored interventions that address socioeconomic and psychosocial stressors at the individual and societal levels may improve outcomes and reduce disparities in uncontrolled blood pressure.

Background: Patients treated for hypothyroidism with levothyroxine (LT4) monotherapy may be exposed to periods of excess and/or inadequate circulating thyroid hormone levels, which may increase the risk of cardiovascular disease (CVD). We hypothesized that the risk of CVD events in women treated with LT4 may be higher than in women without thyroid disease in the period from midlife to early old age.Methods: The Study of Women's Health Across the Nation is a multisite longitudinal study of a diverse cohort of midlife women from seven geographic sites across the United States. Women were screened for a history of thyroid disease and the use of LT4. Each participant completed up to 17 follow-up visits during which the occurrence of CVD events was ascertained. The composite CVD outcome was defined as any of the following fatal or nonfatal events myocardial infarction, stroke, heart failure, percutaneous coronary intervention, and coronary artery bypass graft surgery. A multivariable Cox proportional hazards model with time-varying exposure was used to determine the relationship of LT4 treatment to the incidence of the first CVD event. A sensitivity analysis was conducted, stratifying the group with LT4 treatment by thyrotropin (TSH) level.Results: Of the 2647 women who were included in the study, 421 (15.9%) received LT4 treatment during the study period. A total of 33 (7.8%) CVD events occurred in the group with LT4 treatment compared with 191 (8.6%) in the group without thyroid disease (p = 0.616). In the adjusted Cox proportional hazards model, there was no statistically significant relation of LT4 treatment to risk of CVD events (hazard ratio 0.85, confidence interval [0.55-1.31]; p = 0.463). No significant relation was identified after stratification by TSH level at baseline in the LT4 group.Conclusions: In a diverse sample of women with long-term follow-up through the menopause transition, we observed no difference in the risk of CVD events between women receiving LT4 treatment for hypothyroidism compared with women without thyroid disease.

Background Social drivers of health (SDOH) are major contributors to future disease. As the population ages, it is important to understand projections of cardiovascular disease (CVD) according to SDOH. Objectives The objective of the study was to determine CVD projections according to education, insurance, and income. Methods We estimated future projections of risk factors for CVD, individual CVD conditions (ie heart failure), and total CVD from 2020 to 2050 according to SDOH of the United States using the National Health and Nutrition Examination Survey, Medical Expenditure Panel Survey, and U.S. Census. Results By 2050, most risk factors and individual CVD conditions are estimated to worsen and remain the worst for those with less education, Medicare or Medicaid beneficiaries, and lower income. Counterintuitively from 2020 to 2050, total CVD prevalence is expected to incrementally increase with higher levels of education (10.0 percentage points higher for college graduates), reaching similar prevalence across education levels by 2050. Medicare beneficiaries are projected to have the highest prevalence of total CVD throughout the era, reaching 86% by 2050. Increases in total CVD prevalence are projected to be similar across income categories. Conclusions Total CVD prevalence is projected to increase from 2020 to 2050 across education, insurance, and income categories with greatest increases occurring in those with a college degree. However, multiple risk factors, most CVD conditions, and total CVD prevalence are generally projected to be highest among populations with less education, public insurance, and lower income compared to respective SDOH categories. Efforts to address SDOH should be prioritized to mitigate the forecast.

Recently, radial blood pressure cuffs have been developed for use among individuals with large arm circumferences although unique hypertension thresholds for radial assessment are not defined. We compared systolic and diastolic blood pressure measured from the upper arm and forearm among individuals with obesity. In a sub-study of participants who were living with HIV and without HIV with upper arm circumference > 40 cm (n = 88, 2022–2023) in the Multicenter AIDS Cohort Study/Women’s Interagency HIV Study-Combined Cohort Study, both brachial and radial BP were measured with an automated monitor using a thigh cuff and a forearm cuff, respectively. Among 88 participants, 81% were female, 90% were Black, and 72% were living with HIV. The correlation between radial and brachial measurements was 0.60 for systolic and 0.69 for diastolic blood pressure. Average radial values were higher than brachial values for both systolic (16.5 mmHg higher: 148.3 versus 131.8 mmHg, p < 0.001) and diastolic (13.2 mmHg higher: 85.2 versus 72.0 mmHg, p < 0.001) blood pressure. When measured in the same participants, radial blood pressure was substantially higher than brachial blood pressure. When measuring radial blood pressure, a different threshold for hypertension diagnosis or use of a model to estimate brachial blood pressure may be needed.

Research analyzing the link between different screen time activities and childhood health have had varied results. We examined the relationship between total screen time and subtype to beneficial diet and physical activity behaviors (BDPAB) in middle-school children. This cross-sectional study analyzed data from 110 middle schools participating in a school-based health program between September 2013 and February 2023. Based on self-reported health behavior surveys, data from 12,751 sixth graders were available for analysis. BDPAB included ≤ 1 serving/day of sugary beverages; ≤ 1 serving/day sugary foods/chocolate candy; ≤ 1 serving/day fried or fatty foods; ≥ 1 servings/day of fruits or vegetables; ≥ 1 day/week physical education class; ≥ 1 out-of-school sport/year; ≥ 1 team sport/year, and ≥ 1 session/week of moderate to vigorous activity. Independent of media subtype (television, computer, video game, mobile device), consuming > 2 h of screen time was associated with lower odds of all BDPAB, with the exception of physical education class participation. Both moderate screen time (4 – < 8 h) and high screen time (≥ 8 h) usage were associated with lower odds of performing the majority of BDPAB. Temporal trends (2013–2014, 2015–2016, 2017–2019, and 2020–2023) revealed an upward trend of BDPAB up until the COVID-19 pandemic, in which the proportion of students exhibiting BDPAB decreased. Increasing use of screen time, regardless of modality, is associated with reduced frequency of BDPAB. These findings re-enforce the potential negative impact of extensive screen use. Promoting balanced and healthy screen habits represents a potential intervention to promote BDAPB.

OBJECTIVE:To evaluate the effectiveness of multiple decision aid strategies in promoting high quality shared decision making for prevention of stroke in patients with non-valvular atrial fibrillation. DESIGN:Cluster randomized controlled trial. SETTING:Six academic medical centers in the United States. PARTICIPANTS:Patient participants were aged ≥18 with a diagnosis of non-valvular atrial fibrillation, at risk for stroke (CHA2DS2-VASc ≥1 for men, ≥2 for women), and scheduled for a clinical appointment to discuss stroke prevention strategies. Participating clinicians were those who manage stroke prevention strategies for participating patients. INTERVENTION:Patients were randomized to use a patient decision aid or usual care; clinicians were randomized to use an encounter decision aid or usual care with all participating patients. MAIN OUTCOME MEASURES:Primary outcome measures were quality of shared decision making measured by OPTION12, knowledge of atrial fibrillation and its management, and decisional conflict. RESULTS:1117 participants across six sites were included in the analysis. Compared with usual care, the combined use of both the patient decision aid and the encounter decision aid improved the quality of shared decision making (adjusted mean difference 12.1 (95% confidence interval (CI) 8.0 to 16.2; P<0.001), improved patients' knowledge (odds ratio 1.68 (95% CI 1.35 to 2.09; P<0.001), and reduced patients' decisional conflict (adjusted mean difference -6.3 (95% CI -9.6 to -3.1; P<0.001). Statistically significant improvements were also observed with the encounter decision aid alone versus usual care for all three outcomes and with the patient decision aid alone versus usual care for quality of shared decision making and knowledge. No important differences were observed in treatment choices for stroke prevention or in participants' satisfaction. No statistically significant difference in the length of visit across study groups was detected. CONCLUSION:Patients who received any decision aid (encounter decision aid, patient decision aid, or both) had lower decisional conflict, better shared decision making, and greater knowledge than those receiving no decision aid, except for the effect of the patient decision aid on decisional conflict, which did not reach statistical significance. The study establishes that use of either pre-visit or in-visit decision aids individually or in combination is advantageous compared with usual care. TRIAL REGISTRATION:ClinicalTrials.gov NCT04357288.

Body changes including weight gain and visceral adiposity are prevalent among women living with HIV and may pose risks for weight stigma-negative attitudes, beliefs, and judgments about a person related to their body size. We undertook a qualitative investigation to describe experiences of weight stigma and to compare and contrast those experiences among women living with and living without HIV. Participants were recruited from Women's Interagency HIV Study sites in Jackson, MS; Birmingham, AL; and Atlanta GA and invited to participate in an individual phone interview. Interviews were transcribed, coded by two members of the research team, and analyzed using deductive and inductive thematic analysis. Twenty-eight women completed interviews of whom 19 (68 %) were HIV+; 26 (95 %) were Black; with a range of body sizes approximated by BMI (range: 19-40+). Women described community weight stigma as it related to gender, race, HIV status, and age. Enacted weight stigma was pervasive, came from multiple sources, and related to being perceived as too thin or too big. Anticipated and internalized weight stigma were concerns described by women with larger bodies, but not smaller bodies. Women living with HIV expressed worries about abdominal fat accumulation revealing their HIV status. Overall, weight stigma was a common experience among women regardless of HIV status. Women living with HIV are at risk for weight and body changes, introducing opportunities for stigma. Consideration of intersectional stigma related to body size and HIV must be given in any efforts to address weight-related health among women living with HIV.

OBJECTIVES:To evaluate the agreement between bystander cardiopulmonary resuscitation (B-CPR) documented by emergency medical services (EMS) personnel in the Birmingham Cardiac Arrest Registry to Enhance Survival (CARES) and B-CPR identified through 9-1-1 audio review. METHODS:We conducted a retrospective observational analysis of adult non-traumatic out-of-hospital cardiac arrest (OHCA) cases in Birmingham from January 1 to December 31, 2023. We excluded EMS-witnessed events, those in nursing homes, health care facilities, jails/prisons, or involving patients who were conscious during the 9-1-1 call. The provision of B-CPR was classified as "yes" or "no" in CARES based on EMS documentation and compared to B-CPR status determined through review of the corresponding 9-1-1 audio by a single reviewer. Agreement between sources was assessed using percent agreement, Cohen's kappa, Gwet's AC, and McNemar's test. RESULTS:Of 236 total cases, EMS documented a B-CPR rate of 12.3% whereas audio review indicated a B-CPR rate of 27.5%. Concordant classification occurred in 180 (76.3%) cases: 19 cases where both sources indicated B-CPR was performed and 161 where both indicated it was not. Discrepancies occurred in 56 cases (23.7%), including 46 instances where 9-1-1 audio identified B-CPR but EMS did not, and 10 where EMS documented B-CPR but audio review did not. Among the 46 audio-confirmed cases not captured by EMS, most involved B-CPR that ended before EMS arrival (e.g., B-CPR was discontinued by the caller), and 7 appeared to be EMS misclassifications. In the 10 cases where EMS documented B-CPR but audio did not, all involved calls that ended prior to EMS arrival without recognition of OHCA or B-CPR instruction. Overall agreement was fair to moderate: Cohen's kappa = 0.28 [95%CI 0.15, 0.42], Gwet's AC1 = 0.65 [95%CI 0.56, 0.75]), and McNemar's test showed significant asymmetry in classification, p < 0.001. CONCLUSIONS:The provision of B-CPR differed in nearly 25% of OHCA cases when comparing EMS documentation with 9-1-1 audio review. Most discrepancies resulted from early termination of B-CPR by the caller prior to EMS arrival, while a smaller proportion appeared to reflect EMS misclassification. These findings underscore the importance of sustained telecommunicator CPR instruction through EMS arrival at the patient's side.

INTRODUCTION/OBJECTIVES:Primary care organizations increasingly face pressures to implement evidence-based practices that can support patient-centered goals. Foundational to these implementation efforts is how prepared the organization is to change. The purpose of this study was to examine whether different types of external linkages among 47 primary care practices participating in a statewide, community-academic partnership/cooperative focused on improving cardiovascular health outcomes were associated with greater change preparedness. Relatively little research has examined these linkages among smaller primary care practices in the U.S. and the extent to which they may support or hinder efforts to adopt innovative, evidence-based practices. METHODS:The study adopted a non-randomized, pre-post design with primary care clinics as the unit of observation. Cross-sectional regression analysis of data collected via surveys administered in 2022 to 2023. Our dependent variables included 2 summated scales related to change readiness (change commitment and change efficacy) and 1 summated scale related to change process capacity, while controlling for differences in clinic characteristics and community characteristics. RESULTS:Clinics that were part of a network (structural linkage) were associated with lower levels of change commitment (b = -1.36, P = .006) and change efficacy (b = -1.16, P = .021). The other 2 types of external linkages (informational and consumer/patient) were not significantly associated with either change commitment or change efficacy. CONCLUSIONS:Study clinics exhibited relatively high levels of change preparedness, providing a solid foundation for efforts to reduce cardiovascular risks in critical primary care settings. However, primary care clinics that were linked structurally were associated with lower levels of change preparedness. Primary care leaders and policy makers may want to consider the relationships between primary care clinics and other entities in their environment when developing and implementing programs to reduce cardiovascular disease risks in these settings.

BACKGROUND:Inflammation plays a key role in the development of heart failure (HF), and diet is a known modifiable factor that modulates systemic inflammation. The dietary inflammatory score (DIS) is a tool that quantifies the inflammatory components of diet. We sought to determine whether the DIS is associated with incident HF events. METHODS:We examined a total of 17,975 participants without HF at baseline who were in the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. The main exposure variable was the DIS quartile, which was derived from the Food Frequency Questionnaire obtained at baseline study enrollment. The main outcome was an incident HF event, defined as hospitalization due to HF or death. To examine the association between the DIS and incident HF events, we conducted Cox proportional hazard regression modeling, adjusting for total energy intake, sociodemographic factors and pro-inflammatory lifestyle behaviors. RESULTS:The sample mean age was 64 + 9.2 years, 55.8% were female, and 32.3% were Black. Over a median follow-up of 11.1 years, we observed 900 incident HF events, including 752 hospitalizations and 148 deaths due to HF. In an adjusted model, the highest DIS quartile (Q4) was associated with incident HF (HR 1.26 95% CI 1.03-1.54). Of note, these findings remained, even after adjusting for comorbid conditions and physiological parameters. In an age-stratified analysis, the association was present only in those aged < 65 years (Q4: HR 1.65 95% CI 1.08-2.51). Moreover, the association was present for heart failure with reserved ejection fraction (Q4: HR 1.44 95% CI 1.07-1.94) but not for heart failure with preserved ejection fraction. CONCLUSION:The highest DIS quartile was associated with incident HF events. These findings indicate the potential value of specific dietary patterns to prevent HF.

Peripheral artery disease (PAD) is an atherosclerotic condition that affects a growing number of individuals worldwide, with estimates exceeding 220 million. One of the central hallmarks of PAD is lower extremity pain, which may present as intermittent claudication and atypical leg pain, and, in more severe cases, ischemic rest pain, neuropathic pain, or phantom limb pain in those who underwent amputation. Although the majority of individuals with PAD may experience pain that is chronic in nature, the pathogenesis and phenomenology of pain may differ. Nociceptive, inflammatory, and neuropathic mechanisms all play a role in the generation of pain. Pain in PAD results in severe disability and can copresent with distress, sickness behaviors such as avoidance and further deconditioning, and concomitant depression, anxiety, and addiction secondary to opioid use. These factors potentially lead to chronic pain interacting with a multitude of domains of functioning, including physical, emotional, and behavioral. Whereas pain is a normal adaptive response, self-defeating behaviors and cognitions contribute to the persistence or worsening of the chronic pain experience, disability, and distress. Much remains unknown about the phenomenology of pain in PAD and its clinical subgroups and how it affects outcomes. Borrowing from other chronic pain syndromes, multimodal pain management strategies that emphasize a biopsychosocial model have generated a solid evidence base for the use of cognitive behavioral approaches to manage pain. Multimodal pain management in PAD is not the norm, but theoretical pathways and road maps for further research, assessment, and clinical implementation are presented in this scientific statement.

BACKGROUND:Identifying high-risk locations for out-of-hospital cardiac arrest (OHCA) is essential for targeted community interventions. We aimed to use the Social Vulnerability Index (SVI) and geospatial mapping of OHCA data to locate high-risk neighborhoods in Birmingham, Alabama, for community training programs. METHODS:A retrospective observational analysis was conducted using nontraumatic OHCA cases in adults (≥18 years) in Birmingham from January 1, 2020 to December 31, 2023. Census tracts served as proxies for neighborhoods. A 5-step process identified high-risk tracts: (1) OHCA incidents were geocoded in ArcGIS and assigned a geographic identifier by census tract; (2) SVI data were merged with each record; (3) the Getis-Ord GI* statistic identified a hot spot with 99% confidence; (4) tracts with an SVI >90th percentile within the hot spot were flagged; and (5) excess relative risk rates were calculated and stratified by quintiles. The primary outcome was high-risk census tracts defined by hot spot location, high SVI, and high relative risk. RESULTS:A total of 966 OHCA cases from 115 census tracts were included. Hot spot analysis identified 30 tracts (26.1%) with high-risk characteristics. Within these, 17 tracts had an SVI >90th percentile, and 10 tracts had an excess relative risk in the top quintile. Hot spot tracts had a higher proportion of Black residents and lower cardiopulmonary resuscitation rates. No significant difference in survival outcomes were observed; however, the overall neurologically intact survival was 1.2%. CONCLUSIONS:Multiple neighborhoods in Birmingham exhibit extreme levels of social vulnerability and excess relative risk of OHCA, making them ideal candidates for community training initiatives.

Health literacy has an essential role in heart failure (HF), contributing to medication adherence, disease self-management, and interactions with care providers. Yet, data on interventions to enhance health literacy are scarce. HF guidelines identify health literacy as an individual-level barrier to HF management but offer limited guidance on addressing limited health literacy. Healthy People 2030 recognizes individual and organizational health literacy as essential for health equity, calling on organizations to enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others. This review summarizes interventions to address health literacy in individuals with HF. We identify the literature's chief limitations: heterogeneity of health literacy measurement, inconsistent outcomes, generalizability, absence of assessment of sustainability of interventions, and missing role of implementation science. In response to the limitations in the literature identified here, we articulate a call to action to develop and implement effective, sustainable, scalable interventions to address personal and organizational health literacy in HF and thereby advance health equity.

Introduction: It is unknown how comorbid diagnoses affect patients’ disease-specific knowledge or how patients’ health literacy or numeracy affects this relationship. In patients with atrial fibrillation (AF), comorbidities can be quantified by the CHA 2 DS 2 -VASc score. We explore the association of AF/stroke knowledge with CHA 2 DS 2 -VASc score, health literacy, and numeracy for usual care participants in the multi-center Randomized Evaluation of Decision Support Interventions for Atrial Fibrillation (RED-AF) trial evaluating decision aids to initiate (initiation cohort) or continue (monitor cohort) oral anticoagulation (OAC) in AF patients. Methods: This study was conducted at six academic medical centers in the United States. Participants were aged ≥18, diagnosed with non-valvular AF, and at risk for stroke (CHA 2 DS 2 -VASc ≥1 for men, ≥2 for women). Patient demographics were obtained via questionnaires after a baseline clinical encounter; knowledge was evaluated by patient responses to 7 questions about OAC and AF. Health literacy was measured by a validated self-reported screening tool; numeracy by a validated subjective numeracy scale; CHA 2 DS 2 -VASc was calculated from medical records. We applied generalized estimating equations for a binomial outcome to jointly relate patient knowledge to CHA 2 DS 2 -VASc score, health literacy and numeracy, controlling for 5 additional patient factors and accounting for clustering by clinician. Results: We report on 306 patients randomized to the usual care group across six participating sites. Average age 68.7 9, 61.6% male, mean CHA 2 DS 2 -VASc 2 1.5. Patient knowledge was independently associated with numeracy (5% higher odds of correct response per 1 unit increase in numeracy, 95% CI 0-10%, p=0.05) and membership in the monitor cohort (40% odds of correct response, 4-89%, p=0.03) but not health literacy or increased stroke risk. Conclusion: In the RED-AF study , although health literacy and increasing stroke risk were not independently associated with patient knowledge about AF, numeracy had a minimal positive association. Those already on OAC had greater disease knowledge than patients newly starting OAC. These results suggest a need to broadly increase patient education regardless of baseline comorbidity burden and degree of health literacy. Future studies should be performed to better understand other factors that drive patient knowledge regarding AF and stroke.