Overall, 31 percent of cardiologists and 21 percent of FITs did not recall receiving any nutrition education during medical school, while 21 percent of cardiologists and 39 percent of FITs received more extensive nutrition education, consisting of a series of lectures. Additionally, 59 percent of cardiologists did not recall receiving any nutrition lectures, 9 percent recalled only a single lecture, and 6 percent reported receiving a series of nutrition lectures during internal medicine residency training. Ninety percent of cardiologists reported receiving no or minimal nutrition education during fellowship training (57 percent and 33 percent, respectively). Only 8 percent felt they had a “solid nutrition education” that they considered “adequate” and 1 percent reported a “high level of nutrition education that gave me excellent skills for counseling patients.” Following cardiovascular fellowship training, 56 percent of cardiologists described receiving no formal education in nutrition. Cardiologists who ate more servings of fruits and vegetables were more likely to feel their role included provided patients with dietary information.

During an average patient appointment, 4 percent of cardiologists reported not discussing nutrition, 18 percent reported spending one minute or less on nutrition, 40 percent spent two to three minutes per visit, 25 percent estimated five minutes per visit, 8 percent reported 10 minutes per visit and 4 percent spent 15 minutes or more. Female cardiologists spent more time on nutrition counseling than male cardiologists.

While the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults emphasizes the importance of a healthy diet, Devries and colleagues write these findings show that cardiologists may not be effectively implementing them.

“The current report, while highlighting deficiencies in nutrition education and practice, can also be viewed as spotlighting tremendous opportunities to improve cardiovascular care,” the authors write. “The urgency to act quickly is brought to light by the recent plateau in the previous declining trend in cardiovascular mortality – fueled largely by substantial increases in the prevalence of obesity and diabetes. It is hoped that the survey presented in this report will serve as a call to action for much greater emphasis on nutrition in the training and practice of cardiovascular specialists, and serve as a template for similar engagement in a wide range of lifestyle interventions.”

Devries S, Agatston A, Aggarwal M, et al. Am Journal Med May 24:[Epub ahead of print].

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Steven M. Bradley, MD, FACC, et al., assessed the real-world implications of the PEGASUS-TIMI 54 trial using patients from ACC’s ACTION Registry as part of ACC’s Research to Practice initiative – which identifies impactful cardiovascular research and analyzes its implications for contemporary clinical practice using ACC’s NCDR clinical registries.

They found that 41.1 percent of 273,328 MI patients in the registry between Oct. 1, 2010 and April 30, 2013 met the eligibility criteria for the trial. Of the 83,871 eligible patients with pharmacy claims data, only 27.5 percent were on a P2Y12 inhibitor one year post MI. However, its use declined at two and three years post MI (11.5 percent and 6.3 percent, respectively), with the majority (79.2 percent) of these patients on clopidogrel.

Additionally, cost varied greatly by P2Y12 inhibitor type. The estimated cost per ischemic event averted using long-term ticagrelor was 45-times more than generic clopidogrel ($885,000 vs. $19,800).

The authors conclude that “applying PEGASUS trial findings to clinical practice would result in a large increase in P2Y12 inhibitor use. Given the cost implications for different P2Y12 inhibitors, additional study of long-term P2Y12 inhibitors on patient outcomes and cost of care is needed to guide optimal use of this therapy in clinical practice.”

Bradley SM, Hess GP, Stewart P, et al. Open Heart 2017;4:e000580.

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Only 67.5 percent of female patients achieved the target contact-to-device time (≤90 minutes) compared with 75.6 percent of male patients. Furthermore, female patients had longer total ischemic times (161 vs. 145 minutes) and a higher in-hospital mortality rate (4.1 vs. 2.0 percent) compared with male STEMI patients.

While improving patient education about the symptoms of an acute coronary syndrome is necessary to reduce symptom onset to contact time, the authors state that “further investigation is needed to mitigate the sex-specific circumstances that exacerbate the risk of mortality for female STEMI patients.” They add that since the launch of ACC’s Door to Balloon (D2B) initiative in 2006, “D2B times have drastically decreased and sex‐related disparities in D2B times have improved. A similar initiative that is focused on standardizing prehospital assessment would likely improve [contact-to-device] times, mitigate disparities based on sex, and improve survival from STEMI.”

Roswell RO, Kunkes J, Chen AY, et al. J Am Heart Assoc 2017;Jan 11:[Epub ahead of print].

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Cardiovascular disease remains the leading cause of death in the U.S., although mortality rates dropped 50.2 percent between 1980 and 2014. In 2014, cardiovascular disease was the cause of more than 846,000 deaths and 11.7 million years of life lost. Between 1980 and 2014, the difference in cardiovascular mortality rates between counties at the 10th and 90th percentile (accounting for population age differences) dropped 14.6 percent.

In 2014, counties in the 90th percentile for ischemic heart disease mortalities had twice as many deaths as counties in the 10th percentile. Counties in the 90th percentile for cerebrovascular disease mortalities had 1.7-times as many deaths as counties in the 10th percentile.

The greatest concentration of counties with high cardiovascular disease mortality in 2014 spanned southeastern Oklahoma along the Mississippi River Valley, to eastern Kentucky. However, specific cardiovascular disease conditions were clustered elsewhere, including atrial fibrillation in the Northwest, aortic aneurysm in the Midwest and endocarditis in the Mountain West and Alaska. Counties with lower cardiovascular mortality rates were found around San Francisco, California, central Colorado, northern Nebraska, central Minnesota, northeastern Virginia and southern Florida.

The authors conclude these data have health policy implications on the local and national level. They add moving forward, “major efforts are still needed to reduce geographic variation in risk of death due to ischemic heart disease and cerebrovascular diseases.”

In an editorial, George A. Mensah, MD, FACC, et al., add that understanding the primary determinants of these variations can inform the types of multilevel and multisector interventions needed and the level of intensity and dose required for “practices, programs, and policies to have sustained beneficial effects on health.”

Roth GA, Dswyer-Lindgren L, Bertozzi-Villa A, et al. JAMA 2017;317:1976-92.

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Black patients were less likely to have STEMI as compared with white patients (37.7 vs. 42.8 percent), but more likely to experience signs of cardiogenic shock or heart failure once at the hospital (17.8 vs. 15 percent).

The authors found “black patients were more likely to reside in communities with higher proportions of single-person households, unmarried people, and high residence turnover, suggesting greater social isolation.” However, while black patients were more likely to use emergency medical services (49.1 vs. 45.2 percent), they had shorter median driving distances and drive times to a hospital, which was often larger and/or academic. Further, black patients with AMI experienced a 9 percent longer median time from symptom onset to presentation (114 vs. 101 minutes for whites), regardless of socioeconomic factors or transportation.

“Despite significant advances in AMI care as well as the elaboration of quality improvement initiatives designed to reduce or eliminate discrepancies in care, racial differences in both short- and long-term outcomes persist,” the authors conclude.

Miller AL, Simon D, Roe MT, et al. Am J Cardiol 2017;119:1127-34.

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