This cross-sectional study evaluates contemporary patterns of lipoprotein a testing among US veterans receiving care through the Veterans Health Administration.

Objective Lipoprotein (a) [Lp(a)] is a causal, genetically-inherited risk amplifier for atherosclerotic cardiovascular disease (ASCVD). Practice guidelines increasingly recommend broad Lp(a) screening among various populations to optimize preventive care. Corresponding changes in testing rates and population-level detection of elevated Lp(a) in recent years has not been well described. Methods Using Veterans Affairs electronic health record data, we performed a retrospective cohort study evaluating temporal trends in Lp(a) testing and detection of elevated Lp(a) levels (defined as greater than 50 mg/dL) from January 1, 2014 to December 31, 2023 among United States Veterans without prior Lp(a) testing. Testing rates were stratified based on demographic and clinical factors to investigate possible drivers for and disparities in testing: age, sex, race and ethnicity, history of ASCVD, and neighborhood social vulnerability. Results Lp(a) testing increased nationally from 1 test per 10,000 eligible Veterans (558 tests) in 2014 to 9 tests per 10,000 (4,440 tests) in 2023, while the proportion of elevated Lp(a) levels remained stable. Factors associated with higher likelihood of Lp(a) testing over time were a history of ASCVD, Asian race, and residing in neighborhoods with less social vulnerability. Conclusion Despite a 9-fold increase in Lp(a) testing among US Veterans over the last decade, the overall testing rate remains extremely low. The steady proportion of Veterans with elevated Lp(a) over time supports the clinical utility of testing expansion. Efforts to increase testing, especially among Veterans living in neighborhoods with high social vulnerability, will be important to reduce emerging disparities as novel therapeutics to target Lp(a) become available.

Atherosclerotic cardiovascular (CV) disease (ASCVD) prevention encompasses interventions across the lifecourse: from primordial to primary and secondary prevention. Primordial prevention begins in childhood and involves the promotion of ideal CV health (CVH) via optimizing physical activity, body mass index, blood glucose levels, total cholesterol levels, blood pressure, and sleep while minimizing tobacco use. Primary and secondary prevention of ASCVD thereafter centers around mitigating ASCVD risk factors via medical therapy and lifestyle interventions. Disparities in optimal preventive efforts exist among historically marginalized groups in each of these three prongs of ASCVD prevention. Children and adults with a high burden of social determinants of health also face inequity in preventive measures. Inadequate screening, risk factor management and prescription of preventive therapeutics permeate the care of certain groups, especially women, Black, and Hispanic individuals in the United States. Beyond this, individuals belonging to historically marginalized groups also are much more likely to experience other ASCVD risk-enhancing factors, placing them at higher risk for ASCVD over their lifetime. These disparities translate to worse outcomes, with higher rates of ASCVD and CV mortality among these groups. Possible solutions to promoting equity involve community-based youth lifestyle interventions, improved risk-factor screening, and increasing accessibility to healthcare resources and novel preventive diagnostics and therapeutics.

BACKGROUND: Large-scale data on incidental premature ventricular contraction (PVC) prevalence and morphologies have been lacking, leaving many providers without guidance on further cardiac testing for patients with incidental PVCs on ECG. Athletes offer an intriguing cohort to understand the clinical significance, prevalence, and common morphologies of incidental PVCs because they often undergo ECG screening during preparticipation exams. METHODS: Digital ECGs were obtained from 10 728 screened athletes aged 14 to 35 years during mass screenings in schools and professional sports teams between 2014 and 2021. A retrospective analysis of ECGs with PVCs was performed using the simultaneous display of frontal (limb) and horizontal (precordial) plane leads. PVCs were coded for morphology and categorized as benign or nonbenign using recommended criteria. RESULTS: Twenty-six athletes (0.24%) were found to have at least 1 PVC. Among these, 50% were female, 65% were White, 8% were Asian, 4% were Hispanic, and 23% were Black. Nineteen of the 26 (73%) ECGs had PVCs with a left bundle branch block pattern compared with 7 (27%) with a right bundle branch block pattern. Twenty-four ECGs (96%) had PVCs with benign patterns, including 18 with right ventricular outflow tract, 5 with left anterior fascicle, and 2 with left posterior fascicle morphology. CONCLUSIONS: There is a low prevalence of PVCs on routine ECG screening of young athletes, and most PVCs are of benign morphology in this population. This study highlights the value of using digital ECG recorders with simultaneous lead display to guide decision-making about further cardiac testing and referrals in young athletes with PVCs. Using our results and review of the literature, we propose methods and algorithms of PVC evaluation on screening ECGs to help guide many providers with risk stratification and decision-making about further cardiac testing and electrophysiology referrals in young athletes with PVCs.

BACKGROUND:Frequent premature ventricular contractions (PVCs) and nonsustained ventricular tachycardia (NSVT) have been associated with cardiovascular disease and mortality. Their prevalence, especially in ambulatory populations, is understudied and limited by few female participants and the use of short-duration (24- to 48-hour) monitoring. OBJECTIVE:The objective of this study was to report the prevalence of frequent PVCs and NSVT in a community-based population of women likely to undergo electrocardiogram (ECG) screening by sequential patch monitoring. METHODS:Participants from the Women's Health Initiative Strong and Healthy (WHISH) trial with no history of atrial fibrillation (AF) but 5-year predicted risk of incident AF ≥5% by CHARGE-AF score were randomly selected to undergo screening with 7-day ECG patch monitors at baseline, 6 months, and 12 months. Recordings were reviewed for PVCs and NSVT (>5 beats); data were analyzed with multivariate regression models. RESULTS:There were 1067 participants who underwent ECG screening at baseline, 866 at 6 months, and 777 at 12 months. Frequent PVCs were found on at least 1 patch from 4.3% of participants, and 1 or more episodes of NSVT were found in 12 (1.1%) women. PVC frequency directly correlated with CHARGE-AF score and NSVT on any patch. Detection of frequent PVCs increased with sequential monitoring. CONCLUSION:In postmenopausal women at high risk for AF, frequent PVCs were relatively common (4.3%) and correlated with higher CHARGE-AF score. As strategies for AF screening continue to evolve, particularly in those individuals at high risk of AF, the prevalence of incidental ventricular arrhythmias is an important benchmark to guide clinical decision-making.

Background: Statins are the cornerstone of treatment of patients with atherosclerotic cardiovascular disease (ASCVD). Despite this, multiple studies have shown that women with ASCVD are less likely to be prescribed statins than men. The objective of this study was to use Natural Language Processing (NLP) to elucidate factors contributing to this disparity. Methods: Our cohort included adult patients with two or more encounters between 2014 and 2021 with an ASCVD diagnosis within a multisite electronic health record (EHR) in Northern California. After reviewing structured EHR prescription data, we used a benchmark deep learning NLP approach, Clinical Bidirectional Encoder Representations from Transformers (BERT), to identify and interpret discussions of statin prescriptions documented in clinical notes. Clinical BERT was evaluated against expert clinician review in 20% test sets. Results: There were 88,913 patients with ASCVD (mean age 67.8 +/- 13.1 years) and 35,901 (40.4%) were women. Women with ASCVD were less likely to be prescribed statins compared with men (56.6% vs 67.6%, p <0.001), and, when prescribed, less likely to be prescribed guideline-directed high-intensity dosing (41.4% vs 49.8%, p <0.001). These disparities were more pronounced among younger patients, patients with private insurance, and those for whom English is their preferred language. Among those not prescribed statins, women were less likely

Gastroesophageal reflux is increasingly treated with LINX®, a flexible bracelet of magnetic titanium beads (not MRI compatible) that is laparoscopically implanted to wrap around the gastroesophageal junction for providing tone/support aiding passive relaxation of a weak lower esophageal sphincter with peristalsis. The FDA currently cautions against concurrent use of the LINX® system with cardiac implantable electronic devices (CIEDs) given that the risk of electromagnetic interference (EMI) is unknown, and safety has not been established.

Background Tyrosine kinase inhibitors (TKIs) are widely used in the treatment of hematologic malignancies. Limited studies have shown an association between treatment-limiting arrhythmias and TKI, particularly ibrutinib, a Bruton’s tyrosine kinase (BTK) inhibitor. We sought to comprehensively assess the arrhythmia burden in patients receiving ibrutinib vs non-BTK TKI vs non-TKI therapies. Methods We performed a retrospective analysis of consecutive patients who received long-term cardiac event monitors while on ibrutinib, non-BTK TKIs, or non-TKI therapy for a hematologic malignancy between 2014 and 2022. Results One hundred ninety-three patients with hematologic malignancies were included (ibrutinib = 72, non-BTK TKI = 46, non-TKI therapy = 75). The average duration of TKI therapy was 32 months in the ibrutinib group vs 64 months in the non-BTK TKI group ( p = 0.003). The ibrutinib group had a higher prevalence of atrial fibrillation ( n = 32 [44%]) compared to the non-BTK TKI ( n = 7 [15%], p = 0.001) and non-TKI ( n = 15 [20%], p = 0.002) groups. Similarly, the prevalence of non-sustained ventricular tachycardia was higher in the ibrutinib group ( n = 31, 43%) than the non-BTK TKI ( n = 8 [17%], p = 0.004) and non-TKI groups ( n = 20 [27%], p = 0.04). TKI therapy was held in 25% ( n = 18) of patients on ibrutinib vs 4% ( n = 2) on non-BTK TKIs ( p = 0.005) secondary to arrhythmias. Conclusions In this large retrospective analysis of patients with hematologic malignancies, patients receiving ibrutinib had a higher prevalence of atrial and ventricular arrhythmias compared to those receiving other TKI, with a higher rate of treatment interruption due to arrhythmias.

Background Inflammatory cytokines play a role in atrial fibrillation (AF). Interleukin (IL)-1/3, which is targeted in the treatment of ischemic heart disease, has not been well-studied in relation to AF.Methods Postmenopausal women from the Women's Health Initiative were included. Cox proportional hazards regres-sion models were used to evaluate the association between log-transformed baseline cytokine levels and future AF incidence. Models were adjusted for body mass index, age, race, education, hypertension, diabetes, hyperlipidemia, current smoking, and history of coronary heart disease, congestive heart failure, or peripheral artery disease.Results Of 16,729 women, 3,943 developed AF over an average of 8.5 years. Racial and ethnic groups included White (77.4%), Black/African-American (16.1%), Asian (2.7%), American Indian/Alaska Native (1.0%), and Hispanic (5.5%). Baseline IL-1/3 log continuous levels were not significantly associated with incident AF (HR 0.86 per 1 log [pg/mL] increase, P = .24), similar to those of other inflammatory cytokines, IL-7, IL-8, IL-10, IGF-1, and TNF-alpha. There were significant associations between C-reactive protein (CRP) and IL-6 with incident AF.Conclusions In this large cohort of postmenopausal women, there was no significant association between IL-1/3 and incident AF, although downstream effectors, CRP and IL-6, were associated with incident AF. (Am Heart J 2023;258:157- 167.)

HomeCirculation: Arrhythmia and ElectrophysiologyVol. 16, No. 7Evaluating Recommendations About Atrial Fibrillation for Patients and Clinicians Obtained From Chat-Based Artificial Intelligence Algorithms Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBEvaluating Recommendations About Atrial Fibrillation for Patients and Clinicians Obtained From Chat-Based Artificial Intelligence Algorithms Zahra Azizi, Pouria Alipour, Sofia Gomez, Cassandra Broadwin, Sumaiya Islam, Ashish Sarraju, A.J. Rogers, Alexander T. Sandhu and Fatima Rodriguez Zahra AziziZahra Azizi https://orcid.org/0000-0002-7897-0934 Center for Digital Health (Z.A., C.B., S.I.). , Pouria AlipourPouria Alipour https://orcid.org/0000-0002-0751-2995 Department of Medicine, McGill University, Montreal, QC, Canada (P.A.). , Sofia GomezSofia Gomez Department of Medicine, Stanford School of Medicine, CA (S.G.). , Cassandra BroadwinCassandra Broadwin Center for Digital Health (Z.A., C.B., S.I.). , Sumaiya IslamSumaiya Islam https://orcid.org/0000-0001-6901-9883 Center for Digital Health (Z.A., C.B., S.I.). , Ashish SarrajuAshish Sarraju https://orcid.org/0000-0003-1649-2110 Department of Cardiovascular Medicine, Cleveland Clinic, OH (A.S.). , A.J. RogersA.J. Rogers https://orcid.org/0000-0001-6585-534X Stanford University Division of Cardiovascular Medicine & Cardiovascular Institute, Department of Medicine, Stanford University, CA (A.J.R., A.T.S., F.R.). , Alexander T. SandhuAlexander T. Sandhu https://orcid.org/0000-0003-3208-1143 Stanford University Division of Cardiovascular Medicine & Cardiovascular Institute, Department of Medicine, Stanford University, CA (A.J.R., A.T.S., F.R.). Department of Cardiovascular Medicine, Cleveland Clinic, OH (A.S.). and Fatima RodriguezFatima Rodriguez Correspondence to: Fatima Rodriguez, MD, MPH, Division of Cardiovascular Medicine, Stanford University, Mail Code 5687, 453 Quarry Rd, Center for Academic Medicine, Stanford, CA 94304. Email E-mail Address: [email protected] https://orcid.org/0000-0002-5226-0723 Stanford University Division of Cardiovascular Medicine & Cardiovascular Institute, Department of Medicine, Stanford University, CA (A.J.R., A.T.S., F.R.). Originally published19 Jun 2023https://doi.org/10.1161/CIRCEP.123.012015Circulation: Arrhythmia and Electrophysiology. 2023;16:415–417Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: June 19, 2023: Ahead of Print Atrial fibrillation (AF) is the most common arrhythmia worldwide.1 Crowdsourced information and peer-to-peer recommendations online have resulted in the dissemination of sometimes inaccurate information about AF prevention and management.1–3 With the increasing availability of artificial intelligence (AI) and machine learning technologies at the consumer level, patients are likely turn to such modalities for medical guidance.1–3 However, the appropriateness of the advice provided about AF from this chat-based AI models has not yet been investigated. Recently, Sarraju et al4 evaluated the appropriateness of ChatGPT's responses to various questions preventive cardiologists commonly encounter in clinical settings. We extended the work by evaluating performance differences between patient and clinician questions about AF using 2 popular chat-based language models (ChatGPT and Bing AI).Eighteen prompts were designed in consultation with clinicians who have expertise in managing AF to reflect questions that patients commonly ask about AF (using public and free version of ChatGPT v3.5), while another 18 prompts reflected the perspectives of clinicians (using both ChatGPT and Bing AI [GPT-4]). Each question was input into each platform 3 times (Figure).4 Patients' questions were classified into 4 major categories (overall AF, treatments, medications, and daily lifestyle). Clinician questions began with the prompt, "I am a physician," and included the phrases "based on the most recent guidelines" and "with reference" to elicit higher-level scientific or medical responses from the AI engines.Download figureDownload PowerPointFigure. Evaluation of atrial fibrillation recommendations to patients and clinicians from online chat-based artificial intelligence algorithms. Patient-facing and clinician-facing questions as input into the AI tools are listed above, with patient-facing questions categorized by question topic (overall, treatment, medication, and lifestyle). Each question was asked 3 times to ensure the consistency of responses. In case of inquiries by clinicians, we asked the machine to provide evidence and citations for the given recommendation. The output was considered appropriate only if the given response (in all 3 instances) along with its evidence (in case of clinician-related questions) were correct and based on the most recent evidence and guidelines. Each set of responses was graded by 2 clinicians (cardiologist, electrophysiologist) and in case of disagreement, the results were checked by a third clinician. The reviewers' agreement was between 89-100% in all cases. Cohen's Kappa for ChatGPT was between 0.77 to 1 (ChatGPT: Text=1, Reference=0.77; Bing AI:Text=0.77, Reference=0.77). AF indicates atrial fibrillation; AFL, atrial flutter; AI, artificial intelligence; and LAA, left atrial appendage.Each set of responses was reviewed by 3 expert clinicians who categorized them as either appropriate or inappropriate. The agreement between reviewers was determined by calculating Cohen's Kappa statistics. An appropriate response was one that not only contained accurate information, but also employed language deemed to be clear and comprehensible to the user (patient/general public or clinician) given different levels of assumed medical literacy. Clinician question responses were labeled inappropriate if they were either incorrect based on expert judgement or contained inaccurate references or language that was deemed to be unclear. The data that support the findings of this study are available from ZA (zazizi@stanford.edu) and upon reasonable request and ZA takes responsibility for its integrity. This study is not subject to institutional review board approval or request for exemption as no human or animal subjects were utilized.The overall appropriateness of responses is displayed in the Figure. The level of agreement between reviewers was determined to have a kappa statistic of 0.77 to 1, indicating high agreement. Overall, 83.3% (overall AF 83.3%, treatments 100%, medications 100%, and daily lifestyle 71.4%) of patient-initiated prompts had appropriate responses generated by ChatGPT. However, ChatGPT yielded some inaccurate responses to some questions, particularly those pertaining to triggers of AF, such as alcohol and coffee (Figure). For clinician-related questions, the text accuracy of ChatGPT and Bing AI responses was 33.3% and 66.6%, while reference accuracy was 55.5% and 50%, respectively. In cases of appropriate responses, while most cited references included current US and European guidelines, the algorithms were also able to provide responses using appropriately cited primary literature. However, in 2 instances relating to AF management, ChatGPT confabulated references and trials that did not exist.Our findings demonstrate that while ChatGPT may appropriately summarize certain general information regarding AF for patients, it is not completely accurate. Moreover, we found that ChatGPT and Bing AI lacked accuracy and did not provide appropriate scientific basis for recommendations aimed at health care professionals, suggesting that these tools may be unsuitable for clinical decision-making or research.Notable shortcomings of ChatGPT for patient questions included the inability to provide correct responses to AF triggers such as alcohol and coffee consumption. These are nuanced topics with varying opinions in the medical literature, which may contribute to the disagreements seen. Among the accurate responses provided by ChatGPT and Bing AI for clinician focused queries, certain cited references were fictitious or incorrectly cited, commonly called AI hallucinations.5 Compared with ChatGPT, Bing AI had higher response accuracy but a comparable frequency of inaccurate references.One limitation of this study is the use of AI chatbots designed for the general public rather than medical applications. Should the algorithms be trained on health care data, it is possible that the accuracy and scientific merit of responses to clinician queries would improve.In conclusion, current AI chatbots may be a useful tool to provide a cursory overview of diseases for patients and the general public. However, this tool showed limited appropriateness of clinician-facing questions in this study. This tech is rapidly evolving and future models may be updated real time to avoid some of the wrong answers due to outdated information. Finally, it is imperative to note that this tool is not able to replace a human's intuition, situational awareness, and, most importantly, clinical judgment. Much greater accuracy and clinical prowess are expected of clinicians managing diseases such as atrial fibrillation.ARTICLE INFORMATIONSources of FundingDr Rodriguez was funded by grants from the NIH National Heart, Lung, and Blood Institute (1K01HL144607), the American Heart Association/Harold Amos Faculty Development program, and the Doris Duke Foundation (Grant No. 2022051). Dr Azizi was funded by the American Heart Association Health Tech SFRN Fellowship.Nonstandard Abbreviations and AcronymsAFatrial fibrillationAIartificial intelligenceDisclosures Dr Rodriguez reports consulting relationships with HealthPals, Novartis, Amgen, NovoNordisk (CEC), and AstraZeneca. The remaining authors have nothing to disclose.FootnotesThis article was sent to Andrew E. Epstein, MD, Guest Editor, for review by expert referees, editorial decision, and final disposition.For Sources of Funding and Disclosures, see page 416.Correspondence to: Fatima Rodriguez, MD, MPH, Division of Cardiovascular Medicine, Stanford University, Mail Code 5687, 453 Quarry Rd, Center for Academic Medicine, Stanford, CA 94304. Email frodrigu@stanford.eduReferences1. Wilson RE, Rush KL. Engaging Patients in Atrial Fibrillation Self-Care: Opportunities for Future Research. In: Los Angeles, CA: SAGE Publications Sage CA; 2021:1091–1092.Google Scholar2. Palm P, Qvist I, Rasmussen TB, Christensen SW, Håkonsen SJ, Risom SS. Educational interventions to improve outcomes in patients with atrial fibrillation—a systematic review.Int J Clin Pract. 2020; 74:e13629. doi: 10.1111/ijcp.13629CrossrefMedlineGoogle Scholar3. Mann DL. Artificial intelligence discusses the role of artificial intelligence in translational medicine.JACC Basic Transl Sci. 2023; 8:221–223. doi: 10.1016/j.jacbts.2023.01.001CrossrefMedlineGoogle Scholar4. Sarraju A, Bruemmer D, Van Iterson E, Cho L, Rodriguez F, Laffin L. Appropriateness of cardiovascular disease prevention recommendations obtained from a popular online chat-based artificial intelligence model.JAMA. 2023; 329:842–844. doi: 10.1001/jama.2023.1044CrossrefMedlineGoogle Scholar5. Alkaissi H, McFarlane SI. Artificial hallucinations in ChatGPT: implications in scientific writing.Cureus. 2023; 15:e35179. doi: 10.7759/cureus.35179CrossrefMedlineGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetailsCited By Hillmann H, Angelini E, Karfoul N, Feickert S, Mueller-Leisse J and Duncker D (2023) Accuracy and comprehensibility of chat-based artificial intelligence for patient information on atrial fibrillation and cardiac implantable electronic devices, Europace, 10.1093/europace/euad369, 26:1, Online publication date: 28-Dec-2023. July 2023Vol 16, Issue 7 Advertisement Article InformationMetrics © 2023 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.123.012015PMID: 37334705 Originally publishedJune 19, 2023 Keywordsarrhythmiaatrial fibrillationpatientsphysiciansPDF download Advertisement SubjectsAtrial FibrillationMachine Learning and Artificial Intelligence

Purpose of Review Patient education strategies are shown to reduce stroke risk in patients with atrial fibrillation (AF). We describe the most recent evidence-based treatments to reduce stroke risk and outline challenges that exist in empowering patients to be active participants in decision-making. The shared decision-making (SDM) panorama is highlighted due to its benefits, including increased patient participation in decision-making, patient and clinician satisfaction, and improved outcomes.Recent Findings Oral anticoagulation remains the preferred therapy for stroke prevention in AF. Several barriers to stroke risk reduction persist, including both upstream and downstream barriers on the provider and patient front. Appropriate patient education approaches consider health literacy levels, quality of education materials, and SDM concepts. Many distinct approaches to mitigating these barriers exist, but much remains to be done. To overcome the barriers to patient education, providers must consider social determinants of health including access to care, cultural and language barriers, and socioeconomic status. Each of these factors will ultimately interfere with the success of the educational interventions.Summary The current best practice for educating and engaging patients with AF regarding stroke prevention strategies is patient-centered and informed by SDM values. As AF could often be asymptomatic, patients are less likely to adhere to treatment if they do not understand the rationale and the long-term balance of potential benefits and harms. Patient education and engagement tools can assist health care providers when conveying this important message, in a culturally appropriate and adjusted way according to health literacy levels.

Background Atrial fibrillation (AF) affects around 6 million Americans. AF management involves pharmacologic therapy and/or interventional procedures to control rate and rhythm, as well as anticoagulation for stroke prevention. Different populations may respond differently to distinct management strategies. This review will describe disparities in rate and rhythm control and their impact on outcomes among women and historically underrepresented racial and/or ethnic groups. Methods This is a narrative review exploring the topic of sex and racial and/or ethnic disparities in rate and rhythm management of AF. We describe basic terminology, summarize AF epidemiology, discuss diversity in clinical research, and review landmark clinical trials. Results Despite having higher rates of traditional AF risk factors, Black and Hispanic adults have lower risk of AF than non-Hispanic White (NHW) patients, although those with AF experience more severe symptoms and report lower quality-of-life scores than NHW patients with AF. NHW patients receive antiarrhythmic drugs, cardioversions, and invasive therapies more frequently than Black and Hispanic patients. Women have lower rates of AF than men, but experience more severe symptoms, heart failure, stroke, and death after AF diagnosis. Women and people from diverse racial and ethnic backgrounds are inadequately represented in AF trials; prevalence findings may be a result of underdetection. Conclusion Race, ethnicity, and gender are social determinants of health that may impact the prevalence, evolution, and management of AF. This impact reflects differences in biology as well as disparities in treatment and representation in clinical trials.

Introduction: The clinical implications of incidental premature ventricular contractions (PVCs) are poorly understood. Though controversial, athletes often receive electrocardiograms (ECGs) during pre-participation exams. The prevalence and morphologies of PVCs in this cohort have not been widely reported. Recent studies have defined benign PVC morphologic patterns in athlete populations that may guide clinical evaluations. Methods: Digital ECGs were obtained from 10,728 screened athletes aged 14 to 35 at school and professional team screenings in California. Captured PVCs were analyzed using simultaneous frontal and horizontal plane leads, displaying each standard ECG lead in full-length, allowing for morphologic categorization. PVCs were coded for morphology and benign status using recommended criteria outlined in Figure 1. Results: Twenty-six of 10,728 athletes (0.24%) had at least one PVC (Figure 1); 7 of those (27%) had bigeminy and 3 of those (12%) had trigeminy. Overall, participants were 43% female, 62% White, 12% Black, 9% Asian, and 8% Hispanic. Of those with PVCs, 50% were female, 65% were White, 23% were Black, 8% were Asian, and 4% were Hispanic. Twenty-four ECGs (92%) had PVCs with benign patterns, including 17 with right ventricular outflow tract, 5 with left anterior fascicle, and 2 with left posterior fascicle morphology. Two ECGs had non-benign PVCs with left bundle branch patterns and superior axes. Both of these athletes had normal echocardiograms and exercise testing and are being followed closely. Conclusions: We found a low prevalence of PVCs on routine ECG screening of young athletes, although evaluation of PVC prevalence and frequency are limited by the short duration of an ECG. Most incidental PVCs among young athletes had benign patterns. This study also demonstrates the value of digital ECG recorders to display simultaneous frontal and horizontal plane leads for the morphologic categorization of PVCs which may guide further workup.

HomeJournal of the American Heart AssociationVol. 11, No. 5Racial and Ethnic Group Underrepresentation in Studies of Adverse Pregnancy Outcomes and Cardiovascular Risk Open AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toOpen AccessLetterPDF/EPUBRacial and Ethnic Group Underrepresentation in Studies of Adverse Pregnancy Outcomes and Cardiovascular Risk Sofia E. Gomez, MD, Ashish Sarraju, MD and Fatima Rodriguez, MD, MPH Sofia E. GomezSofia E. Gomez https://orcid.org/0000-0002-0900-6519 Department of Medicine, , Stanford University School of Medicine, , Stanford, , CA , Ashish SarrajuAshish Sarraju https://orcid.org/0000-0003-1649-2110 Division of Cardiovascular Medicine and Cardiovascular Institute, , Department of Medicine, , Stanford University School of Medicine, , Stanford, , CA and Fatima RodriguezFatima Rodriguez * Correspondence to: Fatima Rodriguez, MD, MPH, Division of Cardiovascular Medicine, Stanford University, 453 Quarry Road, Center for Academic Medicine, Stanford, CA 94304‐5687. E‐mail: E-mail Address: [email protected] https://orcid.org/0000-0002-5226-0723 Division of Cardiovascular Medicine and Cardiovascular Institute, , Department of Medicine, , Stanford University School of Medicine, , Stanford, , CA Originally published22 Feb 2022https://doi.org/10.1161/JAHA.121.024776Journal of the American Heart Association. 2022;11:e024776Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: February 22, 2022: Ahead of Print Adverse pregnancy outcomes (APOs), including hypertensive disorders of pregnancy, gestational diabetes, and preterm delivery are pathologic adaptations to pregnancy. These events place women at increased risk of peripartum cardiomyopathy, stroke, seizure, and stillbirth in the short term and chronic kidney disease or cardiovascular disease (CVD) in the long term.1, 2 Recent guidelines on APOs have highlighted stark racial and ethnic disparities in cardiovascular risk and outcomes.3 Hypertensive disorders of pregnancy occur more frequently in Black women (including a 3‐fold higher mortality from preeclampsia) compared with White women.3, 4 Asian (especially Indian, Filipina, and Southeast Asian) women experience the highest rates of gestational diabetes of any racial or ethnic group.3, 4 Peripartum cardiomyopathy has a prevalence of ≈11.8 in 10 000 births, disproportionally impacting Black women.4 Given these documented disparities, diverse racial and ethnic representation in studies of APOs and CVD is crucial to ensure generalizability and equity when developing preventive strategies and treatment recommendations.We aimed to evaluate gaps in the reporting and representation of participant‐level race and ethnicity in studies of APOs and CVD informing the most contemporary guidelines, namely those cited in the 2021 American Heart Association's (AHA's) scientific statement on APOs and CVD risk.2Data supporting the findings of this study are available on request from the corresponding author. Two authors (S.E.G. and A.S.) reviewed cited studies in the 2021 AHA statement.2 Original studies and those within cited meta‐analyses were evaluated for study type (trial versus cohort), location (United States versus non–United States), and participant‐level racial and ethnic data. Racial and ethnic representation among pooled US studies was compared with 2010 and 2020 US Census estimates using the two‐proportion z test. Institutional review board approval was not obtained because public articles were reviewed.We reviewed 85 studies published between 2000 and 2019; all were observational studies investigating the correlation between APOs and either composite CVD (coronary artery disease, myocardial infarction, stroke, congestive heart failure), CVD mortality broadly (77 studies), or coronary artery disease and stroke (7 studies). Only 16 (19%) reported participant‐level racial and ethnic information. Only 12 reported White representation, 9 reported Black representation, 8 reported Hispanic representation, 5 reported Asian representation, 2 reported Aboriginal representation, 1 reported Jewish/Bedouin representation, and 7 reported "other" representation. No studies reported Pacific Islander, American Indian, or Alaska Native participation. Only 1 study disaggregated Asian data; none disaggregated Hispanic data. Fourteen (16%) studies included a US cohort, and 11 reported participant‐level race and ethnicity.Among US studies, White representation was 94.7% and 120.4% of expected compared with 2010 and 2020 US Census data, respectively (Figure, studies: 74.2%; 2010 Census: 78.4%; 2020 Census: 61.6%; P<0.001). Black representation was 75.4% and 79.2% of expected compared with 2010 and 2020 Census data, respectively (studies: 9.8%; 2010 Census: 13.0%; 2020 Census: 12.4%; P<0.001). Hispanic and Asian participants were also underrepresented compared with 2010 and 2020 Census estimates, with participation of 82.5% and 72.0% of expected for Hispanic groups and 63.4% and 51.9% for Asian groups, respectively.Contemporary studies of APOs and CVD cited in the 2021 AHA statement on APOs and CVD risk were limited, observational, mostly non‐US studies that underreported racial and ethnic data and lacked disaggreopgated race and ethnicity data. US studies underrepresented Black, Hispanic, and Asian groups compared with US Census population estimates.APOs and CVD heterogeneously and disproportionately affect historically disenfranchised groups.3 Yet, guideline‐informing evidence linking APOs and CVD lacked adequate racial and ethnic reporting and representation. While a small number of studies provided detailed reporting, overall reporting was suboptimal with minimal disaggregation by subgroups. These findings are consistent with disparities seen in cardiovascular trials among major disease states including dyslipidemia.5 Moreover, US studies had no reporting for Pacific Islanders, American Indians, and Alaska Natives despite prior literature suggesting a high burden of adverse cardiovascular outcomes and limited access to prenatal care in these groups. The need to improve study reporting and representation may be most crucial among these underrepresented groups. Concerted scientific and public health efforts focused on APOs and cardiovascular health in these groups are warranted. Finally, limited US‐based data (16% of total studies) further limits generalizability. Overall, inadequate national, racial, and ethnic representation may lead to inequitable study of the APO‐CVD relationship.This study has certain limitations. We included studies cited within the 2021 AHA statement, which have high visibility likely to guide clinical practice but may not be comprehensive. Given inconsistent reporting, we were unable to disaggregate data including for Asian participants and non‐Hispanic versus Hispanic ethnicity. Since the APO‐CVD relationship is understudied, available studies may be low in number. Nevertheless, these findings are crucial indicators of current racial and ethnic disparities in study reporting and representation in women's cardiovascular health.In conclusion, we found significant underreporting and underrepresentation of diverse racial and ethnic groups among guideline‐informing studies of APOs and CVD. Improving diverse participant reporting and representation in studies on APOs and CVD across the life course is necessary to inform CVD prevention for these high‐risk women.Sources of FundingDr Ashish Sarraju received support from the American Heart Association (grant 20SFRN35360178). Dr Fatima Rodriguez received support from the National Heart, Lung, and Blood Institute, National Institutes of Health (1K01HL144607), and the American Heart Association/Robert Wood Johnson Harold Amos Medical Faculty Development Program.DisclosuresNone.Download figureDownload PowerPointFigure 1. Racial and ethnic representation among pooled US study participants per 2010 and 2020 US Census estimates.A, Proportion of studies reporting participant‐level racial and ethnic data. B, Adverse pregnancy outcomes (APOs) by racial and ethnic group, using gestational diabetes prevalence data from Northern California cohort 1995 to 2004 and preeclampsia incidence data from New York City cohort 1993 to 2002.3 GDM indicates gestational diabetes; and PE, preeclampsia.Footnotes* Correspondence to: Fatima Rodriguez, MD, MPH, Division of Cardiovascular Medicine, Stanford University, 453 Quarry Road, Center for Academic Medicine, Stanford, CA 94304‐5687. E‐mail: [email protected]edu*A. Sarraju and F. Rodriguez are co‐senior authors.For Sources of Funding and Disclosures, see page 3.References1 Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, Braun LT, de Ferranti S, Faiella‐Tommasino J, Forman DE, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019; 139:e1082–e1143. doi: 10.1161/CIR.0000000000000625LinkGoogle Scholar2 Parikh NI, Gonzalez JM, Anderson CAM, Judd SE, Rexrode KM, Hlatky MA, Gunderson EP, Stuart JJ, Vaidya D. Adverse pregnancy outcomes and cardiovascular disease risk: unique opportunities for cardiovascular disease prevention in women: a scientific statement from the American Heart Association. Circulation. 2021; 143:e902–e916. doi: 10.1161/cir.0000000000000961LinkGoogle Scholar3 Balla S, Gomez SE, Rodriguez F. Disparities in cardiovascular care and outcomes for women from racial/ethnic minority backgrounds. Curr Treat Options Cardiovasc Med. 2020; 22:75. doi: 10.1007/s11936‐020‐00869‐zCrossrefMedlineGoogle Scholar4 Virani SS, Alonso A, Aparicio HJ, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Cheng S, Delling FN, et al. Heart disease and stroke statistics‐2021 update: a report from the American Heart Association. Circulation. 2021; 143:e254–e743. doi: 10.1161/CIR.0000000000000950LinkGoogle Scholar5 Sarraju A, Valencia A, Knowles JW, Maron DJ, Rodriguez F. Diverse racial/ethnic group underreporting and underrepresentation in high‐impact cholesterol treatment trials. Circulation. 2021; 143:2409–2411. doi: 10.1161/CIRCULATIONAHA.120.050034LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails March 1, 2022Vol 11, Issue 5Article InformationMetrics Copyright © 2022 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley BlackwellThis is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.https://doi.org/10.1161/JAHA.121.024776PMID: 35191322 Manuscript receivedNovember 18, 2021Manuscript acceptedJanuary 5, 2022Originally publishedFebruary 22, 2022 Keywordscardiovascular risk factorsadverse pregnancy outcomesracial and ethnic disparitiesPDF download SubjectsCardiovascular DiseasePregnancyRace and EthnicityRisk FactorsWomen, Sex, and Gender

There is a growing body of literature focusing on the morphology, management, and outcomes of PVCs in athletes. This review summarizes this literature and establishes recommendations on management, treatment, and indications for specialist referral in this patient population. The sports medicine physician's responses and recommendation should be made in conjunction with the athletes wishes. Medications or ablations are not always necessary in all athletes if they are followed with regular evaluations.

This review summarizes contemporary data on unique cardiovascular disease (CVD) risk factors in Hispanic individuals in the USA, and how addressing these factors is important in addressing health equity. Recent studies have shown high rates of traditional CVD risk factors in Hispanic individuals such as obesity, hypertension, diabetes, hyperlipidemia, and emerging CVD risk factors like hypertensive disorders of pregnancy, psychological stress, and occupational exposures. However, most studies fail to consider the significant heterogeneity in risk factor burden and outcomes in atherosclerotic CVD by Hispanic subgroup. Heart failure and rhythm disorders are less well studied in Hispanic adults, making risk assessment for these conditions difficult. High levels of CVD risk factors in Hispanic youth given an aging Hispanic population overall highlight the importance of risk mitigation among these individuals. In brief, these data highlight the significant, unique burden of CVD risk among Hispanic individuals in the USA and predict a rising burden of disease among this growing and aging population. Future CVD research should focus on including robust, diverse Hispanic cohorts as well as specifically delineating results for disaggregated Hispanic groups across CVDs. This will allow for better risk assessment, prevention, and treatment decisions to promote health equity for Hispanic patients.

Background Tyrosine kinase inhibitors (TKIs) have been increasingly used as first-line therapy in hematologic and solid-organ malignancies. Multiple TKIs have been linked with the development of cardiovascular complications, especially atrial arrhythmias, but data on ventricular arrhythmias (VAs) is scarce. Methods Herein we describe five detailed cases of VAs related to TKI use in patients with varied baseline cardiovascular risk factors between 2019 and 2022 at three centers. Individual chart review was conducted retrospectively. Results Patient ages ranged from 43 to 83 years. Three patients were on Bruton's TKI (2 ibrutinib and 1 zanubrutinib) at the time of VAs; other TKIs involved were afatinib and dasatinib. Three patients had a high burden of non-sustained ventricular tachycardia (NSVT) requiring interventions, whereas two patients had sustained VAs. While all patients in our case series had significant improvement in VA burden after TKI cessation, two patients required new long-term antiarrhythmic drug therapy, and one had an implantable defibrillator cardioverter (ICD) placed due to persistent VAs after cessation of TKI therapy. One patient reinitiated TKI therapy after control of arrhythmia was achieved with antiarrhythmic drug therapy. Conclusions Given the expanding long-term use of TKIs among a growing population of cancer patients, it is critical to acknowledge the association of TKIs with cardiovascular complications such as VAs, to characterize those at risk, and deploy preventive and therapeutic measures to avoid such complications and interference with oncologic therapy. Further efforts are warranted to develop monitoring protocols and optimal treatment strategies for TKI-induced VAs.

BACKGROUND:There remains uncertainty regarding optimal primary atherosclerotic cardiovascular disease (ASCVD) prevention practices for older adults. OBJECTIVE:To assess statin treatment patterns and incident ASCVD among older patients for primary prevention across the spectrum of ASCVD risk. DESIGN:Retrospective cohort study of participants without ASCVD aged 65-79 years. Patients were stratified by age (65-69, 70-75, > 75 years) and 10-year ASCVD risk category (low/borderline, intermediate, high) based on the Pooled Cohort Equations. Multivariable logistic regressions were used to identify predictors of moderate- or high-intensity statin prescriptions. Cox proportional models were used to estimate hazard ratios (HRs) for incident ASCVD. PARTICIPANTS:Patients aged 65-79 years without ASCVD from a Northern California health system. MAIN MEASURES:Statin prescriptions and incident ASCVD events. KEY RESULTS:There were 54,066 patients, with 10,288 (19%) aged > 75 years and 57% women. Compared with younger groups, adults > 75 years were less likely to be prescribed moderate- or high-intensity statin prescriptions across ASCVD risk groups (all p < 0.001); this persisted after multivariable adjustment including for ASCVD risk (odds ratio [OR] 0.80, 95% confidence interval [CI] 0.74-0.86). Adults > 75 years were more likely to experience incident ASCVD (HR 1.42, 95% CI 1.23-1.63). Women (OR 0.85, 95% CI 0.81-0.89) and underweight older adults (OR 0.45, 95% CI 0.33-0.61) were also less likely to receive moderate- or high-intensity statins. CONCLUSIONS:Among older adults aged 65-79 years without prior ASCVD, those > 75 years of age were less likely to receive moderate- or high-intensity statins regardless of ASCVD risk compared with their younger counterparts, while experiencing more incident ASCVD. Efforts are warranted to study the reasons for age-based differences in statin use in older adults, particularly those at highest ASCVD risk.