Background: The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). Methods: The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year’s worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year’s edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. Results: Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. Conclusions: The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions. 

Heart Disease and Stroke Statistics—2023 Update: A Report From the American Heart Association

The relation between sodium intake and cardiovascular disease remains controversial, owing in part to inaccurate assessment of sodium intake. Assessing 24-hour urinary excretion over a period of multiple days is considered to be an accurate method.We included individual-participant data from six prospective cohorts of generally healthy adults; sodium and potassium excretion was assessed with the use of at least two 24-hour urine samples per participant. The primary outcome was a cardiovascular event (coronary revascularization or fatal or nonfatal myocardial infarction or stroke). We analyzed each cohort using consistent methods and combined the results using a random-effects meta-analysis.Among 10,709 participants, who had a mean (±SD) age of 51.5±12.6 years and of whom 54.2% were women, 571 cardiovascular events were ascertained during a median study follow-up of 8.8 years (incidence rate, 5.9 per 1000 person-years). The median 24-hour urinary sodium excretion was 3270 mg (10th to 90th percentile, 2099 to 4899). Higher sodium excretion, lower potassium excretion, and a higher sodium-to-potassium ratio were all associated with a higher cardiovascular risk in analyses that were controlled for confounding factors (P≤0.005 for all comparisons). In analyses that compared quartile 4 of the urinary biomarker (highest) with quartile 1 (lowest), the hazard ratios were 1.60 (95% confidence interval [CI], 1.19 to 2.14) for sodium excretion, 0.69 (95% CI, 0.51 to 0.91) for potassium excretion, and 1.62 (95% CI, 1.25 to 2.10) for the sodium-to-potassium ratio. Each daily increment of 1000 mg in sodium excretion was associated with an 18% increase in cardiovascular risk (hazard ratio, 1.18; 95% CI, 1.08 to 1.29), and each daily increment of 1000 mg in potassium excretion was associated with an 18% decrease in risk (hazard ratio, 0.82; 95% CI, 0.72 to 0.94).Higher sodium and lower potassium intakes, as measured in multiple 24-hour urine samples, were associated in a dose-response manner with a higher cardiovascular risk. These findings may support reducing sodium intake and increasing potassium intake from current levels. (Funded by the American Heart Association and the National Institutes of Health.). 

/pdf/24-hour-urinary-sodium-and-potassium-excretion-and-2a1y15mv.pdf

24-Hour Urinary Sodium and Potassium Excretion and Cardiovascular Risk

The Global Burden of Cardiovascular Diseases and Risk: A Compass for Future Health.

There are scarce data on left atrial (LA) enlargement and electrophysiological features in athletes.Multicenter observational study in competitive athletes and controls. LA enlargement was defined as LA volume indexed to body surface area ≥ 34 mL/m2. We analyzed its relationship with atrial electrocardiography parameters.We included 356 participants, 308 athletes (mean age: 36.4 ± 11.6 years) and 48 controls (mean age: 49.3 ± 16.1 years). Compared with controls, athletes had a higher mean LA volume index (29.8 ± 8.6 vs 25.6 ± 8.0 mL/m2, P = .006) and a higher prevalence of LA enlargement (113 [36.7%] vs 5 [10.4%], P < .001), but there were no relevant differences in P-wave duration (106.3 ± 12.5 ms vs 108.2 ± 7.7 ms; P = .31), the prevalence of interatrial block (40 [13.0%] vs 4 [8.3%]; P = .36), or morphology-voltage-P-wave duration score (1.8 ± 0.84 vs 1.5 ± 0.8; P = .71). Competitive training was independently associated with LA enlargement (OR, 14.7; 95%CI, 4.7-44.0; P < .001) but not with P-wave duration (OR, 1.02; 95%CI, 0.99-1.04), IAB (OR, 1.4; 95%CI, 0.7-3.1), or with morphology-voltage-P-wave duration score (OR, 1.4; 95%CI, 0.9-2.2).LA enlargement is common in adult competitive athletes but is not accompanied by a significant modification in electrocardiographic parameters.Existe poca información sobre la dilatación de la aurícula izquierda (AI) y los parámetros electrocardiográficos en deportistas.Estudio observacional multicéntrico en deportistas de competición y controles. La dilatación de la AI se definió como un volumen indexado por área de superficie corporal ≥ 34 ml/m2. Se estudió su relación con parámetros electrocardiográficos auriculares.Se incluyó en total a 356 sujetos: 308 deportistas de competición (media de edad, 36,4 ± 11,6 años) y 48 controles (49,3 ± 16,1 años). Los deportistas de competición tenían un mayor volumen medio indexado de la AI (29,8 ± 8,6 frente a 25,6 ± 8,0 ml/m2; p = 0,006) y una mayor prevalencia de dilatación de la AI (113 [36,7%] frente a 5 [10,4%]; p < 0,001), sin diferencias relevantes en cuanto a la duración de la onda P (106,3 ± 12,5 frente a 108,2 ± 7,7 ms; p = 0,31), la prevalencia de bloqueo interauricular (40 [13,0%] frente a 4 [8,3%]; p = 0,36) ni la puntuación Morphology-Voltage-P-wave duration (1,8 ± 0,84 frente a 1,5 ± 0,8; p = 0,71). El entrenamiento competitivo se asoció de manera independiente con la dilatación de la AI (OR = 14,7; IC95%, 4,7-44,0; p < 0,001), pero no con la duración de la onda P (OR = 1,02; IC95%, 0,99-1,04), el bloqueo interauricular (OR = 1,4; IC95%, 0,7-3,1) o la puntuación Morphology-Voltage-P-wave duration (OR = 1,4; IC95%, 0,9-2,2).La dilatación de la AI es frecuente en deportistas de competición, pero no se acompaña de una modificación relevante en los parámetros electrocardiográficos. 

Comments on the 2021 ESC guidelines on cardiovascular disease prevention in clinical practice.

Background Salt substitutes with reduced sodium levels and increased potassium levels have been shown to lower blood pressure, but their effects on cardiovascular and safety outcomes are u...

https://www.nejm.org/doi/pdf/10.1056/NEJMoa2105675

Effect of Salt Substitution on Cardiovascular Events and Death.

An evidence-based randomized controlled trial for a novel Pharmacy Asthma Service was tested in 3 Australian states. Positive asthma outcomes were achieved after the 12-month intervention, albeit in both the intervention and comparator arms. The current investigation uses a mixed methods approach to 1) qualitatively explore how comparator arm pharmacists implemented the trial protocol and 2) quantitatively examine how this may have impacted patient outcomes in this trial.Post-intervention semi-structured qualitative interviews were conducted with 20 pharmacists, representing 21 of 37 (57%) comparator arm pharmacies that completed the trial. Based on these interviews, pharmacies were classified as 'adherent' to the trial protocol (reporting no interventions other than general practitioner referral) or 'non-adherent' (reporting at least one extra intervention to the trial protocol), or 'inconclusive'. These subgroups were compared descriptively in relation to patient outcomes.Overall, 33% (n = 8/24) of the comparator pharmacies who were interviewed (n = 21) or determined to have monitoring by a project officer to ensure adherence to the protocol (n = 3) were classified as adherent), 58% (n = 14/24) as non-adherent, 8% inconclusive (n = 2/24). While all patients commenced with uncontrolled asthma (Asthma Control Questionnaire score (ACQ) > 1.5), after 12 months the mean ACQ score for patients from adherent comparator pharmacies ('true control') was 1.8 (still uncontrolled asthma) compared to a score of 1.4 (controlled asthma) in the non-adherent comparator group. Quality of life significantly improved in the non-adherent comparator group over the 12 months of the trial.The majority of pharmacists in the comparator arm who were interviewed, introduced their own interventions, which may have influenced the outcomes of the trial. The naturalistic setting of the study was not protective against these confounders. These findings question the feasibility of comparator arms within primary care settings and that alternative study designs should be considered when designing future intervention studies in pharmacy practice. 

Rethinking the gold standard - The feasibility of randomized controlled trials within health services effectiveness research.

Background: Accurate clinical assessment of patient adherence using reliable and valid measures is essential in establishing the presence of adherence issues and support practices for pharmacists. Objective: This investigation aims to conduct a novel assessment of patient adherence to asthma controller therapy by combining 1) patient-specific dosage data found in pharmacy dispensing data with 2) centrally collected administrative claims records, to determine the added value of using both sources of data. Methods: A total of 381 clinically uncontrolled asthma patients, from 95 community pharmacies across three Australian States were recruited and provided consent for the retrieval of their claims records and pharmacy dispensing data. Patients were stratified as multiple or single pharmacy users and adherence scores were calculated via the proportion of days covered (PDC) method using 1) patient claims records, 2) patient pharmacy dispensing data, and 3) combined claims records and pharmacy dispensing data. Cohort and subgroup adherence estimates were then compared. Results: Low levels of adherence were evident amongst the cohort irrespective of the data source used. PDC estimates based on claims records alone or combined claims records and pharmacy dispensing data were significantly higher than estimates based on pharmacy dispensing data for the total cohort (56%, 52%, 42% respectively, p < 0.001) and more noticeably for multiple pharmacy users (67%, 64%, 35% respectively, p < 0.001). PDC estimates based on combined claims records and pharmacy dispensing data were significantly lower than estimates based on claims records alone, indicating that perhaps standard daily dose is not a robust proxy for prescribed dosage to inhaled respiratory devices in adherence approximations. Poorer adherence was found amongst single pharmacy users than multiple pharmacy users when combined claims records and pharmacy dispensing data (46% compared to 64% respectively, p < 0.001) or claims records alone (51% compared to 67% respectively, p < 0.001) were compared. Conclusion: Access to routine collected data increases clinical acuity over patient adherence to asthma controller medications and is a valuable resource for health care professionals. A policy of secure accessibility of such data at the patient-pharmacist or patient-GP interface may allow real-time intervention and assist in decision making across numerous therapeutic areas.

/pdf/integrating-pharmacy-and-registry-data-strengthens-clinical-34xg53sv.pdf

Sana Shan

Papers

Effect of Salt Substitution on Cardiovascular Events and Death.

Rethinking the gold standard - The feasibility of randomized controlled trials within health services effectiveness research.

Integrating Pharmacy and Registry Data Strengthens Clinical Assessments of Patient Adherence

Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial