<div><h4>Status of Maternal Cardiovascular Health in American Indian and Alaska Native Individuals: A Scientific Statement From the American Heart Association.</h4><i>Sharma G, Kelliher A, Deen J, Parker T, ... American Heart Association Cardiovascular Disease and Stroke in Women and Underrepresented Populations Committee of the Council on Clinical Cardiology; Council on Hypertension; Council on Cardiovascular and Stroke Nursing; Council on Arteriosclerosis, Thrombosis and Vascular Biology; and Council on Quality of Care and Outcomes Research</i><br /><AbstractText>Cardiovascular disease is the leading cause of pregnancy-related death in the United States. American Indian and Alaska Native individuals have some of the highest maternal death and morbidity rates. Data on the causes of cardiovascular disease-related death in American Indian and Alaska Native individuals are limited, and there are several challenges and opportunities to improve maternal cardiovascular health in this population. This scientific statement provides an overview of the current status of cardiovascular health among American Indian and Alaska Native birthing individuals and causes of maternal death and morbidity and describes a stepwise multidisciplinary framework for addressing cardiovascular disease and cerebrovascular disease during the preconception, pregnancy, and postpartum time frame. This scientific statement highlights the American Heart Association\'s factors for cardiovascular health assessment known collectively as Life\'s Essential 8 as they pertain to American Indian and Alaska Native birthing individuals. It summarizes the impact of substance use, adverse mental health conditions, and lifestyle and cardiovascular disease risk factors, as well as the cascading effects of institutional and structural racism and the historical trauma faced by American Indian and Alaska Native individuals. It recognizes the possible impact of systematic acts of colonization and dominance on their social determinants of health, ultimately translating into worse health care outcomes. It focuses on the underreporting of American Indian and Alaska Native disaggregated data in pregnancy and postpartum outcomes and the importance of engaging key stakeholders, designing culturally appropriate care, building trust among communities and health care professionals, and expanding the American Indian and Alaska Native workforce in biomedical research and health care settings to optimize the cardiovascular health of American Indian and Alaska Native birthing individuals.</AbstractText><br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 31 May 2023:e000117; epub ahead of print</small></div>

<div><h4>Expanding Our Methodological Toolbox to Improve Quality: The Role of Mixed-Methods Evaluations.</h4><i>Chandanabhumma PP, Zhou S, Fetters MD, Likosky DS</i><br /><AbstractText>The care delivered to patients with cardiovascular disease involves coordination among a multitude of clinical team members spanning diverse inpatient and outpatient settings. The majority of quality improvement interventions in cardiovascular care have been developed based on quantitative evidence, which neither fully accounts for multilevel determinants (eg, patient, clinician, and institution) nor contextualization from key informants. The rigor and effectiveness of these interventions would be enhanced by mixed-methods studies whose strengths include (1) the use of qualitative research methodologies (eg, eliciting patient or clinician perspectives on barriers and facilitators of best practices) and (2) integrating qualitative and quantitative data and analyses to understand more fully effective strategies for achieving optimal care and outcomes for these patients across diverse settings. This article illustrates the application of a complex mixed-methods design to advance an evidence-based, customizable infection prevention toolkit for durable left ventricular assist device therapy. The study (1) uses quantitative clinical data merged with Medicare claims to evaluate interhospital variability in the incidence of infection; (2) uses qualitative methods to understand local practice patterns across low- and high-performing centers; and (3) integrates both data sources to gain a comprehensive understanding of the overall findings.</AbstractText><br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 05 May 2023:e009629; epub ahead of print</small></div>

<div><h4>Disability-Adjusted Life Years Due to Pediatric Out-of-Hospital Cardiac Arrest in the United States: A CARES Surveillance Group Study.</h4><i>Coute RA, Nathanson BH, DeMasi S, Mader TJ, Kurz MC, CARES Surveillance Group*</i><br /><b>Background</b><br />Disability-adjusted life years (DALY) are a common public health metric used to estimate disease burden. The DALY due to pediatric out-of-hospital cardiac arrest (OHCA) in the United States is unknown. We aimed to estimate pediatric OHCA DALY and to compare it with the other leading causes of pediatric death and disability in the United States.<br /><b>Methods</b><br />We conducted a retrospective observational analysis of the national Cardiac Arrest Registry to Enhance Survival database. DALY were calculated as the sum of years of life lost and years lived with disability. Years of life lost were calculated using all pediatric (age <18 years) nontraumatic OHCA from the Cardiac Arrest Registry to Enhance Survival from 2016 to 2020. Disability weights based on cerebral performance category scores, an outcome measure of neurologic function, were used to estimate years lived with disability . Data were reported as total, mean, and rate per 100 000 individuals, and were compared with the leading causes of pediatric DALY in the United States published by the Global Burden of Disease study for 2019.<br /><b>Results</b><br />Totally 11 177 OHCA met the study inclusion criteria. A modest increase in total OHCA DALY in the United States was observed from 407 500 (years of life lost = 407 435 and years lived with disability =65) in 2016 to 415 113 (years of life lost = 415 055 and years lived with disability =58) in 2020. The DALY rate increased from 553.3 per 100 000 individuals in 2016 to 568.3 per 100 000 individuals in 2020. For 2019, OHCA was the 10th leading cause of pediatric DALY lost behind neonatal disorders, injuries, mental disorders, premature birth, musculoskeletal disorders, congenital birth defects, skin diseases, chronic respiratory diseases, and asthma.<br /><b>Conclusions</b><br />Nontraumatic OHCA is one of the top 10 leading causes of annual pediatric DALY lost in the United States.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 01 May 2023; 16:e009786</small></div>

<div><h4>Reach Out Emergency Department: A Randomized Factorial Trial to Determine the Optimal Mobile Health Components to Reduce Blood Pressure.</h4><i>Skolarus LE, Dinh M, Kidwell KM, Lin CC, ... Jaggi M, Meurer WJ</i><br /><b>Background</b><br />Mobile health (mHealth) strategies initiated in safety-net Emergency Departments may be one approach to address the US hypertension epidemic, but the optimal mHealth components or dose are unknown.<br /><b>Methods</b><br />Reach Out is an mHealth, health theory-based, 2×2×2 factorial trial among hypertensive patients evaluated in a safety-net Emergency Department in Flint, Michigan. Reach Out consisted of 3 mHealth components, each with 2 doses: (1) healthy behavior text messaging (yes versus no), (2) prompted self-measured blood pressure (BP) monitoring and feedback (weekly versus daily), and (3) facilitated primary care provider appointment scheduling and transportation (yes versus no). The primary outcome was a change in systolic BP from baseline to 12 months. In a complete case analysis, we fit a linear regression model and accounted for age, sex, race, and prior BP medications to explore the association between systolic BP and each mHealth component.<br /><b>Results</b><br />Among 488 randomized participants, 211 (43%) completed follow-up. Mean age was 45.5 years, 61% were women, 54% were Black people, 22% did not have a primary care doctor, 21% lacked transportation, and 51% were not taking antihypertensive medications. Overall, systolic BP declined after 6 months (-9.2 mm Hg [95% CI, -12.2 to -6.3]) and 12 months (-6.6 mm Hg, -9.3 to -3.8), without a difference across the 8 treatment arms. The higher dose of mHealth components were not associated with a greater change in systolic BP; healthy behavior text messages (point estimate, mmHG=-0.5 [95% CI, -6.0 to 5]; <i>P</i>=0.86), daily self-measured BP monitoring (point estimate, mmHG=1.9 [95% CI, -3.7 to 7.5]; <i>P</i>=0.50), and facilitated primary care provider scheduling and transportation (point estimate, mmHG=0 [95% CI, -5.5 to 5.6]; <i>P</i>=0.99).<br /><b>Conclusions</b><br />Among participants with elevated BP recruited from an urban safety-net Emergency Department, BP declined over the 12-month intervention period. There was no difference in change in systolic BP among the 3 mHealth components. Reach Out demonstrated the feasibility of reaching medically underserved people with high BP cared for at a safety-net Emergency Departments, yet the efficacy of the Reach Out mHealth intervention components requires further study.<br /><b>Registration</b><br />URL: https://www.<br /><b>Clinicaltrials</b><br />gov; Unique identifier: NCT03422718.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 01 May 2023; 16:e009606</small></div>

<div><h4>Evaluating the Implementation of Patient-Reported Outcomes in Heart Failure Clinic: A Qualitative Assessment.</h4><i>Brown-Johnson C, Calma J, Amano A, Winget M, ... Sandhu AT, Kalwani NM</i><br /><b>Background</b><br />Patient-reported outcomes (PROs) may improve care for patients with heart failure. The Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) is a patient survey that captures symptom frequency, symptom burden, physical limitations, social limitations, and quality of life. Despite the utility of PROs and the KCCQ-12, the implementation and routine use of these measures can be difficult. We conducted an evaluation of clinician perceptions of the KCCQ-12 to identify barriers and facilitators to implementation into clinical practice.<br /><b>Methods</b><br />We conducted interviews with cardiologists from 4 institutions across the United States and Canada (n=16) and observed clinic visits at 1 institution in Northern California (n=5). Qualitative analysis was conducted in 2 rounds: (1) rapid analysis constructed around major themes related to the aims of the study and (2) content analysis with codes derived from the rapid analysis and implementation science.<br /><b>Results</b><br />Most heart failure physicians and advanced practice clinicians reported that the KCCQ-12 was acceptable, appropriate, and useful in clinical care. Clinician engagement efforts, trialability, and the straightforward design of the KCCQ-12 facilitated its use in clinical care. Further opportunities identified to facilitate implementation include more streamlined integration into the electronic health record and comprehensive staff education on PROs. Participants highlighted that the KCCQ-12 was useful in clinic visits to improve the consistency of patient history taking, focus patient-clinician conversations, collect a more accurate account of patient quality of life, track trends in patient well-being over time, and refine clinical decision-making.<br /><b>Conclusions</b><br />In this qualitative study, clinicians reported that the KCCQ-12 enhanced several aspects of heart failure patient care. Use of the KCCQ-12 was facilitated by a robust clinician engagement campaign and the design of the KCCQ-12 itself. Future implementation of PROs in heart failure clinic should focus on streamlining electronic health record integration and providing additional staff education on the value of PROs.<br /><b>Registration</b><br />URL: https://clinicaltrials.gov; Unique identifier: NCT04164004.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 28 Apr 2023:e009677; epub ahead of print</small></div>

<div><h4>Discrimination Experiences and All-Cause and Cardiovascular Mortality: Multi-Ethnic Study of Atherosclerosis.</h4><i>Lawrence WR, Jones GS, Johnson JA, Ferrell KP, ... Diez Roux AV, Forde AT</i><br /><b>Background</b><br />Epidemiologic studies have documented the associations between experiences of discrimination and adverse health outcomes. However, the relationship between discrimination and mortality, and the factors that may moderate this relationship are not well understood. This study examined whether lifetime and everyday discrimination were associated with all-cause and cardiovascular mortality and whether these associations differed by race and ethnicity, gender, and racial and ethnic residential segregation.<br /><b>Methods</b><br />The study included 1633 Black, 1403 Hispanic/Latino, and 2473 White participants aged 45 to 84 years from the Multi-Ethnic Study of Atherosclerosis, enrolled from 2000 to 2002 and followed across 5 exams (2002-2018). Discrimination was measured using the lifetime discrimination (major experiences of unfair treatment) and everyday discrimination (day-to-day experiences of unfair treatment) scales. Racial and ethnic residential segregation was measured using the <i>Gi*</i> statistic. Cox proportional hazards regression was used to estimate hazard ratios (HRs) and 95% CIs, adjusting for sociodemographic characteristics, health behaviors, and clinical risk factors.<br /><b>Results</b><br />Each increase in reports of lifetime discrimination was associated with increased all-cause (HR, 1.06 [95% CI, 1.00-1.11]) and cardiovascular (HR, 1.15 [95% CI, 1.04-1.27]) mortality, adjusting for sociodemographic factors, health behaviors, and clinical risk factors. Associations between lifetime discrimination and cardiovascular mortality were observed across all racial and ethnic groups but were strongest and only statistically significant among Black participants (HR, 1.18 [95% CI, 1.02-1.37]). Additionally, in the fully adjusted model, each increase in reports of everyday discrimination was strongly associated with increased cardiovascular mortality (HR, 1.21 [95% CI, 1.03-1.43]). Associations for lifetime and everyday discrimination with all-cause and cardiovascular mortality were not modified by race and ethnicity, gender, or racial and ethnic residential segregation.<br /><b>Conclusions</b><br />These findings suggest that experiences of discrimination are associated with increased all-cause and cardiovascular mortality.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 05 Apr 2023:e009697; epub ahead of print</small></div>

<div><h4>Longitudinal Trends in Cardiovascular Risk Factor Profiles and Complications Among Patients Hospitalized for COVID-19 Infection: Results From the American Heart Association COVID-19 Cardiovascular Disease Registry.</h4><i>Hall EJ, Ayers CR, Kolkailah AA, Rutan C, ... Das SR, de Lemos JA</i><br /><b>Background</b><br />The COVID-19 pandemic has evolved through multiple phases characterized by new viral variants, vaccine development, and changes in therapies. It is unknown whether rates of cardiovascular disease (CVD) risk factor profiles and complications have changed over time.<br /><b>Methods</b><br />We analyzed the American Heart Association COVID-19 CVD registry, a national multicenter registry of hospitalized adults with active COVID-19 infection. The time period from April 2020 to December 2021 was divided into 3-month epochs, with March 2020 analyzed separately as a potential outlier. Participating centers varied over the study period. Trends in all-cause in-hospital mortality, CVD risk factors, and in-hospital CVD outcomes, including a composite primary outcome of cardiovascular death, cardiogenic shock, new heart failure, stroke, and myocardial infarction, were evaluated across time epochs. Risk-adjusted analyses were performed using generalized linear mixed-effects models.<br /><b>Results</b><br />A total of 46 007 patient admissions from 134 hospitals were included (mean patient age 61.8 years, 53% male, 22% Black race). Patients admitted later in the pandemic were younger, more likely obese, and less likely to have existing CVD (<i>P</i><sub>trend</sub> ≤0.001 for each). The incidence of the primary outcome increased from 7.0% in March 2020 to 9.8% in October to December 2021 (risk-adjusted <i>P</i><sub>trend</sub>=0.006). This was driven by an increase in the diagnosis of myocardial infarction and stroke (<i>P</i><sub>trend</sub><0.0001 for each). The overall rate of in-hospital mortality was 14.2%, which declined over time (20.8% in March 2020 versus 10.8% in the last epoch; adjusted <i>P</i><sub>trend</sub><0.0001). When the analysis was restricted to July 2020 to December 2021, no temporal change in all-cause mortality was seen (adjusted <i>P</i><sub>trend</sub>=0.63).<br /><b>Conclusions</b><br />Despite a shifting risk factor profile toward a younger population with lower rates of established CVD, the incidence of diagnosed cardiovascular complications of COVID increased from the onset of the pandemic through December 2021. All-cause mortality decreased during the initial months of the pandemic and thereafter remained consistently high through December 2021.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 05 Apr 2023:e009652; epub ahead of print</small></div>

<div><h4>\" A Qualitative Study of Families\' Experiences When a Young Relative Dies of Sudden Cardiac Death.</h4><i>Allan KS, Mason KL, Garner J, Dainty KN, ... Dorian P, Lewis KB</i><br /><b>Background</b><br />Sudden cardiac death (SCD) in younger individuals is frequently caused by heritable cardiac conditions. The unexpected nature of SCD leaves families with many unanswered questions and an insufficient understanding of the cause of death and their own risk for heritable disease. We explored the experiences of families of young SCD victims upon learning about their relative\'s cause of death and how they perceive their own risk for heritable cardiac conditions.<br /><b>Methods</b><br />We conducted a qualitative descriptive study, by interviewing families of young (ages 12-45) SCD victims, who died between 2014 and 2018 from a heritable cardiac condition and were investigated by the Office of the Chief Coroner of Ontario, Canada. We used thematic analysis to analyze the transcripts.<br /><b>Results</b><br />Between 2018 and 2020, we interviewed 19 family members, of which 10 were males and 9 were females, ages ranging from 21 to 65 (average 46.2±13.1). Four main themes were revealed, each representing a distinct time period that families experience along a trajectory: (1) interactions between bereaved family and others, in particular coroners, shaped their search for answers about their relative\'s cause of death, with the types, formats, and timing of communication varying by case; (2) searching for answers and processing the cause of death; (3) incidental implications of the SCD event, such as financial strain and lifestyle changes contributed to cumulative stress; (4) receiving answers (or not) and moving forward.<br /><b>Conclusions</b><br />Families rely on communication with others, yet the type, formats, and timing of information received varies, which can influence families\' experiences of processing the death (and its cause), their perceived risk and their decision to pursue cascade screening. These results may provide key insights for the interprofessional health care team responsible for the delivery and communication of the cause of death to families of SCD victims.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 04 Apr 2023:e009524; epub ahead of print</small></div>

<div><h4>Long-Term Effect of Weight Regain Following Behavioral Weight Management Programs on Cardiometabolic Disease Incidence and Risk: Systematic Review and Meta-Analysis.</h4><i>Hartmann-Boyce J, Theodoulou A, Oke JL, Butler AR, ... Jebb SA, Aveyard P</i><br /><b>Background</b><br />Behavioral weight management programs (BWMPs) enhance weight loss in the short term, but longer term cardiometabolic effects are uncertain as weight is commonly regained. We assessed the impact of weight regain after BWMPs on cardiovascular risk factors, diabetes, and cardiovascular disease.<br /><b>Methods</b><br />Trial registries, 11 databases, and forward-citation searching (latest search, December 19) were used to identify articles published in English, from any geographical region. Randomized trials of BWMPs in adults with overweight/obesity reporting cardiometabolic outcomes at ≥12 months at and after program end were included. Differences between more intensive interventions and comparator groups were synthesized using mixed-effects, meta-regression, and time-to-event models to assess the impact of weight regain on cardiovascular disease incidence and risk.<br /><b>Results</b><br />One hundred twenty-four trials reporting on ≥1 cardiometabolic outcomes with a median follow-up of 28 (range, 11-360) months after program end were included. Median baseline participant body mass index was 33 kg/m<sup>2</sup>; median age was 51 years. Eight and 15 study arms (7889 and 4202 participants, respectively) examined the incidence of cardiovascular disease and type 2 diabetes, respectively, with imprecise evidence of a lower incidence for at least 5 years. Weight regain in BWMPs relative to comparators reduced these differences. One and 5 years after program end, total cholesterol/HDL (high-density lipoprotein) ratio was 1.5 points lower at both times (82 studies; 19 003 participants), systolic blood pressure was 1.5 mm mercury and 0.4 mm lower (84 studies; 30 836 participants), and HbA1c (%) 0.38 lower at both times (94 studies; 28 083 participants). Of the included studies, 22% were judged at high risk of bias; removing these did not meaningfully change results.<br /><b>Conclusions</b><br />Despite weight regain, BWMPs reduce cardiometabolic risk factors with effects lasting at least 5 years after program end and dwindling with weight regain. Evidence that they reduce the incidence of cardiovascular disease or diabetes is less certain. Few studies followed participants for ≥5 years.<br /><b>Registration</b><br />URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42018105744.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 28 Mar 2023:e009348; epub ahead of print</small></div>

<div><h4>Quantifying Blood Pressure Visit-to-Visit Variability in the Real-World Setting: A Retrospective Cohort Study.</h4><i>Lu Y, Linderman GC, Mahajan S, Liu Y, ... Spatz ES, Krumholz HM</i><br /><b>Background</b><br />Visit-to-visit variability (VVV) in blood pressure values has been reported in clinical studies. However, little is known about VVV in clinical practice and whether it is associated with patient characteristics in real-world setting.<br /><b>Methods</b><br />We conducted a retrospective cohort study to quantify VVV in systolic blood pressure (SBP) values in a real-world setting. We included adults (age ≥18 years) with at least 2 outpatient visits between January 1, 2014 and October 31, 2018 from Yale New Haven Health System. Patient-level measures of VVV included SD and coefficient of variation of a given patient\'s SBP across visits. We calculated patient-level VVV overall and by patient subgroups. We further developed a multilevel regression model to assess the extent to which VVV in SBP was explained by patient characteristics.<br /><b>Results</b><br />The study population included 537 218 adults, with a total of 7 721 864 SBP measurements. The mean age was 53.4 (SD 19.0) years, 60.4% were women, 69.4% were non-Hispanic White, and 18.1% were on antihypertensive medications. Patients had a mean body mass index of 28.4 (5.9) kg/m<sup>2</sup> and 22.6%, 8.0%, 9.7%, and 5.6% had a history of hypertension, diabetes, hyperlipidemia, and coronary artery disease, respectively. The mean number of visits per patient was 13.3, over an average period of 2.4 years. The mean (SD) intraindividual SD and coefficient of variation of SBP across visits were 10.6 (5.1) mm Hg and 0.08 (0.04). These measures of blood pressure variation were consistent across patient subgroups defined by demographic characteristics and medical history. In the multivariable linear regression model, only 4% of the variance in absolute standardized difference was attributable to patient characteristics.<br /><b>Conclusions</b><br />The VVV in real-world practice poses challenges for management of patients with hypertension based on blood pressure readings in outpatient settings and suggest the need to go beyond episodic clinic evaluation.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 08 Mar 2023:e009258; epub ahead of print</small></div>

<div><h4>Long-Term Prognosis of Patients With Coexisting Obesity and Malnutrition After Acute Myocardial Infarction: A Cohort Study.</h4><i>Kong G, Zhang A, Chong B, Lim J, ... Loh PH, Chew NWS</i><br /><b>Background</b><br />The double burden of malnutrition, described as the coexistence of malnutrition and obesity, is a growing global health issue. This study examines the combined effects of obesity and malnutrition on patients with acute myocardial infarction (AMI).<br /><b>Methods</b><br />Patients presenting with AMI to a percutaneous coronary intervention-capable hospital in Singapore between January 2014 and March 2021 were retrospectively studied. Patients were stratified into the following: (1) nourished nonobese, (2) malnourished nonobese, (3) nourished obese, and (4) malnourished obese. Obesity and malnutrition were defined according to the World Health Organization definition (body mass index ≥27.5 kg/m<sup>2</sup>) and Controlling Nutritional Status score, respectively. The primary outcome was all-cause mortality. The association between combined obesity and nutritional status with mortality was examined using Cox regression, adjusted for age, sex, AMI type, previous AMI, ejection fraction, and chronic kidney disease. Kaplan-Meier curves for all-cause mortality were constructed.<br /><b>Results</b><br />The study included 1829 AMI patients, of which 75.7% were male and mean age was 66 years. Over 75% of patients were malnourished. Majority were malnourished nonobese (57.7%), followed by malnourished obese (18.8%), nourished nonobese (16.9%), and nourished obese (6.6%). Malnourished nonobese had highest all-cause mortality (38.6%), followed by the malnourished obese (35.8%), nourished nonobese (21.4%), and nourished obese (9.9%, <i>P</i><0.001). Kaplan-Meier curves demonstrated least favorable survival in malnourished nonobese group, followed by malnourished obese, nourished nonobese, and nourished obese. With nourished nonobese group as the reference, malnourished nonobese had higher all-cause mortality (hazard ratio, 1.46 [95% CI, 1.10-1.96], <i>P</i>=0.010), but only a nonsignificant increase in mortality was observed in the malnourished obese (hazard ratio, 1.31 [95% CI, 0.94-1.83], <i>P</i>=0.112).<br /><b>Conclusions</b><br />Among AMI patients, malnutrition is prevalent even in the obese. Compared to nourished patients, malnourished AMI patients have a more unfavorable prognosis especially in those with severe malnutrition regardless of obesity status, but long-term survival is the most favorable among nourished obese patients.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 03 Mar 2023:e009340; epub ahead of print</small></div>