Publications

OBJECTIVE: Use of glucagon-like peptide 1 receptor agonists (GLP-1 RAs) for diabetes or weight management may affect pregnancy outcomes. We sought to estimate the number of U.S. women of reproductive age eligible for GLP-1 RA therapy.

RESEARCH DESIGN AND METHODS: Using 2017-2023 nationally representative survey data, we identified nonpregnant U.S. women aged 18-44 years who met trial-based eligibility criteria for diabetes, weight management, or secondary cardiovascular prevention.

RESULTS: Among 3,218 participants, 1,447 were eligible for GLP-1 RAs, representing 24.6 million U.S. women. Among GLP-1 RA-eligible women, mean BMI was 34.8 kg/m2, 8.3% had diabetes, and 1.9% had prior cardiovascular disease. Eligibility was primarily for weight management (24.1 million), followed by diabetes (2.0 million) and cardiovascular prevention (0.34 million).

CONCLUSIONS: Nearly half of U.S. reproductive-age women are eligible for GLP-1 RAs. Given limited pregnancy safety data and rising cardiometabolic burden in reproductive-age women, research is needed to guide counseling and coverage of preconception GLP-1 RA use.

UNLABELLED: Video 1.Video abstract4b256fe6-3f25-4d79-adeb-93b3562c7122docm250040video1.

BACKGROUND: COVID-19 hospitalization in the pre-Omicron era was associated with an increased risk of major adverse cardiovascular events, but data from the Omicron era are sparse. We examined the risk of death and major adverse cardiovascular events among older adults hospitalized with COVID-19 during the Omicron era compared with the pre-Omicron era and a historical influenza cohort.

METHODS: Retrospective cohort study of Medicare beneficiaries aged ≥65 years hospitalized for COVID-19 in the Omicron era (November 2021-September2022), COVID-19 in the pre-Omicron era (March 2020-November 2021), and influenza (October 2017-September 2018). The primary outcome was a composite of all-cause death and hospitalization for myocardial infarction, ischemic stroke, transient ischemic attack, pulmonary embolism, deep vein thrombosis, heart failure, and cardiac arrest within 1 year of the index admission. We standardized the cohorts using inverse probability weighting.

RESULTS: We included 1 184 182 patients (mean age 79 years; 51% women):361 382 in the Omicron cohort, 731 455 in the pre-Omicron cohort, and 91 345 in the influenza cohort. The risk of the primary outcome in the Omicron cohort was lower than in the pre-Omicron cohort (48.8% versus 49.3%; standardized risk difference, -0.6% [95% CI, -0.8% to -0.3%]) but higher than in the influenza cohort (48.8% versus 33.4%; risk difference, 15.4% [15.1%-15.6%]). Compared with the pre-Omicron cohort, the Omicron cohort had a significantly lower risk of death (34.2% versus 39.7%; risk difference, -5.5% [-5.7% to -5.3%]) but a higher risk of myocardial infarction, stroke or transient ischemic attack, pulmonary embolism, deep vein thrombosis, and heart failure.

CONCLUSIONS: Among older adults hospitalized with COVID-19, the risk of death within 1 year was lower, and the risk of major adverse cardiovascular event was higher in the Omicron era than the pre-Omicron era; however, the risk of either outcome was higher than after influenza hospitalization. These findings underscore the need for effective cardiovascular prevention strategies after a COVID-19 hospitalization.

BACKGROUND: Guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) reduces mortality rates but remains widely underused. A polypill for HFrEF has been proposed as an implementation strategy to improve GDMT delivery, but little is known about physicians' preferences in the design of HFrEF polypills. Discrete choice experiments (DCEs), in which survey respondents choose among hypothetical products, are a powerful tool in health economics research and can lend insight into key tradeoffs in HFrEF polypill design. However, the process of designing DCEs is complex and often poorly reported.

METHODS: We developed a survey instrument, including a DCE, through a 5-stage mixed-methods process including (1) literature review; (2) physician interviews and surveys; (3) attribute generation; (4) expert review; and (5) pilot testing. We applied a D-efficient design approach using a multinomial logic model to determine the number of choice tasks for the DCE.

RESULTS: We designed a DCE with 4 attributes: HFrEF polypill out-of-pocket cost, inclusion of an angiotensin converting enzyme inhibitor, angiotensin receptor blocker, or sacubitril/valsartan, ancillary support for polypill prescribing, and pharmacy availability. The final survey will be distributed to cardiologists in academic and Veterans Administration medical centers across the United States.

CONCLUSIONS: Through a rigorous multistage design process leveraging mixed methods, we developed a DCE that elicits cardiologists' preferences about HFrEF polypills and key tradeoffs in their design. Results from this DCE study will directly inform future HFrEF polypill cluster-randomized clinical trials.

AIM: The "2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome" retires, replaces, and expands upon the "2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults." The primary intended audience for this guideline is clinicians who care for patients across the spectrum of cardiovascular-kidney-metabolic syndrome, an interrelated condition characterized by the interconnections among metabolic risk factors (including obesity and type 2 diabetes), chronic kidney disease, and cardiovascular disease.

METHODS: A comprehensive literature search was conducted from October 29, 2024, to April 14, 2025, to identify clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human subjects that were published since 2015 in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE: The focus of this clinical practice guideline is to create a living, working document that provides current knowledge in the field of cardiovascular-kidney-metabolic syndrome aimed at all practicing cardiologists, endocrinologists, nephrologists, and primary care and specialty clinicians who manage these patients.

AIM: The "2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome" retires, replaces, and expands upon the "2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults." The primary intended audience for this guideline is clinicians who care for patients across the spectrum of cardiovascular-kidney-metabolic syndrome, an interrelated condition characterized by the interconnections among metabolic risk factors (including obesity and type 2 diabetes), chronic kidney disease, and cardiovascular disease.

METHODS: A comprehensive literature search was conducted from October 29, 2024, to April 14, 2025, to identify clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human subjects that were published since 2015 in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE: The focus of this clinical practice guideline is to create a living, working document that provides current knowledge in the field of cardiovascular-kidney-metabolic syndrome aimed at all practicing cardiologists, endocrinologists, nephrologists, and primary care and specialty clinicians who manage these patients.

BACKGROUND: Although mitral transcatheter edge-to-edge repair (MTEER) was approved for secondary mitral regurgitation after the COAPT trial, findings of other MTEER trials have been mixed, raising questions about the applicability of the COAPT results to contemporary clinical practice.

OBJECTIVES: We used transportability methods to estimate the treatment effects of COAPT trial interventions applied to 2 target populations: 1) trial-eligible patients representative of U.S. clinical practice; and 2) treatment-candidate patients with secondary mitral regurgitation representative of U.S. clinical practice, regardless of trial eligibility.

METHODS: We identified patients from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy (TVT) Registry who were treated with MTEER for secondary mitral regurgitation from March 14, 2019 to September 30, 2023. To select trial-eligible individuals, we applied COAPT trial eligibility criteria to the TVT Registry sample. We used inverse odds of participation weighting to standardize patient-level COAPT data to the data distribution of each target population sample and estimated treatment-specific outcomes. The primary outcome was heart failure hospitalization at 2 years. We also examined 10 secondary outcomes, including all-cause death.

RESULTS: Our analyses included 614 COAPT trial patients and 15,275 TVT Registry patients, of which 7,289 were COAPT trial-eligible. Trial-eligible TVT Registry patients were less likely to have ischemic cardiomyopathy (34.1% vs 60.8%) and more likely to have 4+ mitral regurgitation (79.4% vs 47.9%) compared with trial patients. We estimated that compared with medical therapy alone, MTEER in conjunction with other COAPT interventions (eg, optimization of medical therapy) in the trial-eligible population would result in 2-year absolute risk reductions of 17.0% for heart failure hospitalizations (95% CI: -28.7% to -5.7%) and 15.4% for all-cause death (95% CI: -26.6% to -5.2%), effect sizes similar to those estimated in the trial (P for difference between the trial and target populations >0.05 for both outcomes). The estimated treatment effect for heart failure hospitalizations in the broader treatment-candidate target population was also similar to that in the COAPT trial (P for difference = 0.90).

CONCLUSIONS: Although COAPT trial patients had different baseline characteristics than patients undergoing MTEER in contemporary U.S. practice, we estimated that treatment effects would be similar had real-world patients received COAPT trial interventions, under the assumptions required for transportability (eg, conditional exchangeability across data sources, positivity of trial participation).

BACKGROUND: Sodium-glucose co-transporter 2 (SGLT2) inhibitors and angiotensin receptor-neprilysin inhibitors (ARNI) are heart failure (HF) therapies selected for price negotiations under the Inflation Reduction Act. This study aimed to summarize the cost-effectiveness of SGLT2 inhibitors and ARNIs for HF, examine how cost-effectiveness varies by ejection fraction (EF) and drug price, and estimate the effect of negotiated prices on cost-effectiveness.

METHODS: A systematic literature search identified cost-effectiveness analyses of SGLT2 inhibitors and ARNIs versus standard of care for the treatment of HF from a US perspective, published through 2025. Analyses were stratified by HF with reduced EF (<40%, HFrEF), moderately reduced EF (40% to 49%, HFmrEF), and preserved EF (≥50%, HFpEF). Incremental cost-effectiveness ratios were estimated at negotiated drug prices from base-case, threshold, and sensitivity analyses of drug pricing. Key drivers of cost-effectiveness were identified from the top 3 variables in 1-way sensitivity analyses.

RESULTS: Of 821 studies identified, 16 were included: 11 HFrEF, 2 HFrEF/HFmrEF/HFpEF, and 3 HFmrEF/HFpEF. Across all EF categories, incremental cost-effectiveness ratios (2024 US dollars) versus standard of care ranged from $59 600 to $187 100/quality-adjusted life year (QALY) gained with SGLT2 inhibitors, $24 400 to $92 300 with ARNIs, and $69 300 to $91 500 with SGLT2 inhibitors + ARNIs. Incremental cost-effectiveness ratios in studies of HFrEF were <$120 000/QALY gained and all but 1 were ≥$120 000/QALY gained in studies of HFmrEF/HFpEF. At negotiated drug prices across all EF categories, the incremental cost-effectiveness ratio was estimated to be $47 800/QALY gained with SGLT2 inhibitors, $39 900/QALY gained with ARNIs, and $44 400/QALY gained with SGLT2 inhibitors+ARNIs. The key drivers of cost-effectiveness included drug price (17 studies), cardiovascular death risk with SGLT2 inhibitors and ARNIs (15 studies), and duration of intervention effectiveness (5 studies).

CONCLUSIONS: At negotiated prices resulting from the Inflation Reduction Act, SGLT2 inhibitors and ARNIs seem cost-effective in HFrEF, with projected cost-effectiveness in HFmrEF/HFpEF dependent on price reductions and less certain treatment-effect estimates.

It has long been accepted that observational analyses have an important role in evaluating use patterns and assessing the safety of different treatments, including cardiovascular devices, in clinical practice. With the proliferation of large electronic databases, there has been increasing interest in using observational analyses to also examine the comparative effectiveness of devices. However, these analyses are often met with skepticism because of concerns about whether they can generate credible evidence about causal effects. This is in part a result of the difficulty in meeting the assumptions necessary to interpret observational associations as causal effects and of the wide variability in analytic rigor. In this review, we outline frameworks and review methods for using observational analyses to answer questions about the effectiveness and safety of cardiovascular devices. We highlight the target trial framework as a practical tool for guiding observational comparative effectiveness analyses. We illustrate how the framework allows investigators planning and conducting observational analyses to organize their activities as responses to 3 prompting questions. First, what is the research question of the study (ie, "What do we want?")? Second, what are the resources-including background knowledge, research concepts, principles and methods, and available data-that can be brought to bear on the research question (ie, "What do we have?")? And third, what specific steps should be taken to use the available resources to answer the research question (ie, "What do we do?")? We focus our exposition on the evaluation of cardiovascular devices, for which randomized trial data are often limited and there is a strong need for real-world evidence. In this setting, real-world evidence is usually derived from observational comparisons of the treatment of interest with relevant comparator groups using data captured during routine care. A principled approach to the planning and conduct of observational analyses can improve the quality of real-world evidence generation and ensure that the results of observational studies on medical devices can support meaningful conclusions about the risks and benefits of new devices.

The United States is facing a growing health care affordability crisis. In 2024, national health expenditures totalled $5.3 trillion, or $15 474 per person, accounting for 18.0% of the U.S. economy. Spending on health care continues to rise, propelled by high prices for services, drugs, and devices; growing administrative complexity; chronic underinvestment in prevention, primary care, and public health; and the mounting burden of chronic conditions such as cardiovascular disease. Patients, even those with insurance, frequently face financial hardship, delayed or foregone care, and medical debt because of gaps in coverage and inadequate consumer protections. Addressing this crisis will require coordinated action across the health care system, guided by evidence and a commitment to shared responsibility among key stakeholders. This Presidential Advisory from the American Heart Association draws on interviews and listening sessions with patients, clinicians, payers, employers, health system leaders, and public health experts to examine the many dimensions of affordability and offer a practical framework for action. The Advisory presents 5 core principles to guide efforts to address the affordability crisis: ensuring access to high-quality care without financial hardship; minimizing cost sharing for high-value services; creating shared accountability across the health care system; investing in the workforce, infrastructure, and data systems needed to support progress; and addressing the social and structural factors that make care less affordable for many communities. The evidence, tools, and expertise to combat the health care affordability crisis already exist. What is needed now is the collective will to act.

BACKGROUND: Conduction system pacing (CSP) has emerged as an alternative to biventricular pacing (BVP) for cardiac resynchronization therapy (CRT), with potential clinical benefits and lower costs. PhysioSync-HF is a multicenter, randomized trial comparing these strategies from both clinical and economic perspectives in patients with heart failure with reduced ejection fraction (HFrEF).

OBJECTIVE: To describe the rationale and design of the trial-based economic evaluation embedded within the PhysioSync-HF trial.

METHODS: The PhysioSync-HF trial enrolled 179 patients with 1-year follow-up. Procedural cost data will be collected using a time-driven activity-based costing approach. Costs associated with the device, adverse clinical events, and ambulatory care during follow-up will be estimated using resource-based accounting methods. Appropriate methods will address missing data, and statistical analyses will account for the skewed distribution of cost variables.

RESULTS: The primary economic outcome is the between-group difference in total direct medical costs per patient over the 1-year follow-up (CSP vs BVP). Secondary outcomes include component-level cost breakdowns of direct medical expenses and a budget impact analysis estimating the annual effect on Brazil's health care system if all eligible patients received CSP instead of BVP.

CONCLUSION: By leveraging a multicenter cardiovascular trial to measure costs of CSP versus BVP, this economic evaluation aims to identify cost-saving opportunities that could expand equitable access to CRT for individuals with HFrEF in Brazil, while providing insights relevant to other health care settings worldwide.

TRIAL REGISTRATION: NCT05572736.

BACKGROUND: Veterans are at an increased cardiovascular risk compared to age- and sex-matched non-Veterans. Cardiac rehabilitation (CR) can improve outcomes in cardiovascular disease, but its use in men and women Veterans is not well understood.

OBJECTIVES: This study aimed to examine CR participation by sex and socioeconomic status among Veterans.

METHODS: The authors conducted a retrospective cohort study from January 1, 2021, to December 31, 2023, using a national electronic health record database. The primary outcome was participation in at least 1 CR session among patients within 1 year of myocardial infarction, percutaneous coronary intervention, or coronary artery bypass surgery. Multivariable logistic regression models accounted for patient-level (demographics, medical/psychiatric comorbidities) and community-level factors. Area deprivation indices (ADIs) (analyzed as quartiles) assessed socioeconomic status.

RESULTS: Among 82,496 CR-eligible Veterans (3.6% women), CR participation was low (10.4%) and similar by sex (women = 10.2%, men = 10.4%). Women Veterans did not differ significantly in CR participation compared to men Veterans after adjusting for patient-level and community-level characteristics, including age, race, cardiac and comorbidities, mental health risk factors, rural-urban status, and ADI (adjusted OR: 0.90; 95% CI: 0.79-1.03; P = 0.121). Veterans in the most deprived ADI quartile were less likely to participate vs the least deprived quartile (adjusted OR: 0.82; 95% CI: 0.75-0.89; P < 0.001).

CONCLUSIONS: CR participation among U.S. Veterans remains low, far below that of the Medicare population (10.4% vs 28%), with no significant differences in initiation by sex. However, low socioeconomic status is associated with decreased uptake. Further research is needed to explore innovative, Veteran-specific CR delivery models.

IMPORTANCE: Semaglutide reduces the risk of major adverse cardiovascular events (MACE) in adults with overweight or obesity and cardiovascular disease (CVD) but without diabetes. The cost-effectiveness and budget impact of semaglutide therapy could inform ongoing Medicare price negotiations but are uncertain.

OBJECTIVE: To evaluate the cost-effectiveness of semaglutide for secondary prevention of CVD and potential effect on US health care spending.

DESIGN, SETTING, AND PARTICIPANTS: This population-based cohort simulation study used the CVD Policy Model, a validated simulation model of CVD outcomes and costs in the US, to evaluate lifetime cost-effectiveness of semaglutide. The addition of lifetime treatment with weekly subcutaneous semaglutide to usual care compared with usual care alone in US adults age 45 years or older, with a body mass index (calculated as weight in kilograms divided by height in meters squared) of 27 or higher, and history of myocardial infarction or stroke, without diabetes were evaluated. The model incorporated annual semaglutide cost of $8604 (2023 US price net of rebates and discounts) and adopted a health-system perspective. Sensitivity analyses explored uncertainty. These data were analyzed from January 2024 and June 2025.

EXPOSURE: Semaglutide and usual care compared with usual care alone.

MAIN OUTCOMES AND MEASURES: Main outcomes were lifetime MACE (cardiovascular death, myocardial infarction, or stroke), incremental cost per quality-adjusted life-year (QALY), and change in annual US health care spending.

RESULTS: Adding semaglutide to usual care in the estimated 4 million US adults without diabetes eligible for secondary prevention of CVD is projected to avert 358 400 MACE at a cost of $148 100 per QALY gained (95% uncertainty interval, $127 100-$173 400). The mean age of this cohort was 66 years and 55% were male and 45% were female. Treatment with semaglutide was projected to increase annual health care spending by $23 billion. Semaglutide would be cost-effective at a threshold of $120 000 per QALY gained if the annual cost were lowered an additional 18% to $7055. Semaglutide is cost-effective for this indication at the cash price currently available to self-paying customers ($5988; incremental cost-effectiveness ratio, $99 600 per QALY gained).

CONCLUSIONS AND RELEVANCE: Semaglutide for secondary prevention of CVD in US adults with overweight or obesity but without diabetes is projected to yield meaningful health benefits. Lowering annual drug costs by 18% from $8604 to $7055-or making the current cash price available to all patients-would make semaglutide cost-effective at $120 000 per QALY gained.

IMPORTANCE: The prevalence of obesity and cardiovascular-kidney-metabolic (CKM) syndrome continues to rise. Indications for novel CKM therapies, including glucagonlike peptide 1 receptor agonists (GLP-1RAs), sodium-glucose cotransporter-2 inhibitors (SGLT2is), and nonsteroidal mineralocorticoid antagonists (nsMRAs) continue to expand, yet the proportion of adults meeting expanded indications, including for multiple medications remains unclear.

OBJECTIVE: To examine proportion of adults meeting US Food and Drug Administration (FDA)-approved indications for GLP1-RAs, SGLT2is, and nsMRAs across national survey, community-based, and ambulatory health care samples.

DESIGN, SETTING, AND PARTICIPANTS: This study used a representative cross-sectional survey of US adults (National Health and Nutrition Examination Survey [NHANES], weighted 245 million; mean [SD] age, 47 [18] years; 126.8 million [52%] female), 5 pooled community-based cohort studies (the Framingham Heart Study, the Multi-Ethnic Study of Atherosclerosis, the Prevention of Renal and Vascular Endstage Disease Study, the Atherosclerosis Risk in Communities Study, and the Cardiovascular Health Study; n = 30 929; mean [SD] age, 63 [14] years; 16 749 [54%] female), and 2 ambulatory health care samples (the Beth Israel Deaconess Medical Center cohort [BIDMC], n = 84 714; mean [SD] age, 46 [17] years; 51 113 [60%] female] and the Mass General Brigham cohort [MGB], n = 362 485; mean [SD] age, 48 [17] years; 227 206 [61%] female). Data were analyzed from November 2024 to November 2025.

EXPOSURES: FDA-approved indications for GLP-1RAs, SGLT2is, and nsMRAs.

MAIN OUTCOMES AND MEASURES: Medication class eligibility within each study sample.

RESULTS: The proportion of individuals who met current FDA-approved indications for 1 or more CKM medication was 60% in NHANES (representing 148 million US adults), 61% in the pooled cohorts, 42% in the BIDMC ambulatory cohort, and 46% in the MGB ambulatory cohort. Eligibility for GLP-1RA therapy was most common, with 56% (representing 137.1 million US adults) in NHANES, 49% in the pooled cohorts, 41% in the BIDMC cohort, and 46% in the MGB cohort. This was followed by SGLT2i therapy (24% [57.9 million] in NHANES, 33% in the pooled cohorts, 14% for both BIDMC and MGB) and nsMRA (5% [11.7 million] in NHANES, 5% in the pooled cohorts, and 1% to 2% in ambulatory samples). Overlapping eligibility for multiple classes was common, with 12% to 17% for GLP1-RA and SGLT2i therapies and 1% to 5% for all 3 classes (an estimated 11.7 million US adults in NHANES).

CONCLUSIONS AND RELEVANCE: This study found that up to 61% of adults met FDA-approved indications for at least 1 of 3 novel CKM therapy classes. This represents an estimated 148 million US adults, including 11.7 million US adults with potential FDA indications for triple therapy, highlighting the urgent need to optimize implementation and utilization of CKM syndrome therapies.

BACKGROUND: Prior authorizations could hinder the filling of life-saving heart failure (HF) medications, such as angiotensin receptor neprilysin inhibitors (ARNIs) and sodium glucose cotransporter 2 inhibitors (SGLT2is).

OBJECTIVES: The aim of the study was to determine whether prior authorizations were associated with delayed or decreased filling for ARNI and SGLT2i.

METHODS: This was a retrospective cohort study using electronic health record, pharmacy fill, and neighborhood-level data from a large, academic health system. We included patients with HF and a new prescription for ARNI or SGLT2i between April 1, 2021, and April 30, 2023, and assessed for presence of prior authorization requirement. Outcomes included days to first fill and never filling the prescription. Analyses were conducted using inverse probability weighting methods.

RESULTS: Among 2,183 patients, 12.2% (152/1,243) and 14.3% (165/1,150) had a prior authorization requirement for ARNI or SGLT2i, respectively. Patients requiring prior authorization tended to be younger, identify as non-Hispanic Black or Hispanic, have non-Medicare insurance, and have fewer comorbidities. In weighted models, patients requiring prior authorization took 3.03 (95% CI: 2.16-4.25) times longer to fill ARNI, 6.75 (95% CI: 4.44-10.3) times longer to fill SGLT2i, and were 2.23 (95% CI: 1.37-3.65) times more likely to never fill SGLT2i prescriptions (all P < 0.001).

CONCLUSIONS: Prior authorization requirements were more common for patients identifying as Black or Hispanic and were associated with decreased and delayed filling of ARNI and SGLT2i. Our findings highlight an important barrier to mortality-reducing, guideline-recommended medications for HF.

BACKGROUND: The American Heart Association annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and cardiovascular-kidney-metabolic syndrome) that contribute to cardiovascular health. The 2026 Heart Disease and Stroke Statistics Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, 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 and globally to provide the most current information available in the annual Statistics Update with review of published literature through the year before writing. The 2026 Statistics Update is the product of a full year's worth of effort in 2025 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes a new chapter on cardiovascular-kidney-metabolic syndrome, as well as an expanded chapter on tobacco and nicotine use and exposure.

RESULTS: Each of the chapters in the Statistics Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS: The Statistics 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.

OBJECTIVE: Identifying social and economic factors associated with initiation of semaglutide or tirzepatide may inform strategies to support equitable uptake.

RESEARCH DESIGN AND METHODS: A cross-sectional study was conducted using 100% of Medicare claims of patients ≥65 years with type 2 diabetes mellitus (T2DM). The outcome was initiation of semaglutide or tirzepatide. We calculated adjusted odds ratios (aORs) for each exposure (self-reported race and ethnicity, dual enrollment in Medicare and Medicaid, rurality, and social vulnerability index), accounting for demographic and clinical characteristics.

RESULTS: Among 13,922,387 patients with T2DM, 673,776 (4.8%) initiated semaglutide or tirzepatide in 2023. Minoritized racial and ethnic identity (e.g., non-Hispanic Black compared with White; aOR 0.72; 95% CI 0.71-0.72), dual enrollment (aOR 0.90; 0.89-0.91), and residence in the most versus least vulnerable socially vulnerable neighborhoods (aOR 0.93; 0.92-0.93) were associated with lower initiation.

CONCLUSIONS: Minoritized racial and ethnic identity and adverse socioeconomic factors were associated with lower odds of initiation among Medicare beneficiaries with T2DM.

IMPORTANCE: Heterozygous familial hypercholesterolemia (FH), a genetic condition, results in lifelong increased low-density lipoprotein cholesterol (LDL-C) and increases lifetime cardiovascular disease (CVD) risk. Most individuals with FH remain undiagnosed, so early FH identification and treatment could lower CVD burden.

OBJECTIVE: To evaluate the projected cost-effectiveness of population sequential FH screening (lipid testing followed by genetic testing after a high LDL-C measurement) at 10 or 18 years of age.

DESIGN, SETTING, AND PARTICIPANTS: The CVD Policy Model, a validated discrete event simulation of CVD risk factor management and CVD outcomes in National Health and Nutrition Examination Survey participants, was used to simulate lifetime health and economic outcomes from a health care sector perspective for a hypothetical cohort of 4.2 million US 10-year-olds. Individual characteristics and health care processes informed CVD events (coronary heart disease or stroke) and survival probabilities. Model inputs included national data sources, clinical trials, pooled longitudinal cohort studies, and published literature.

INTERVENTIONS: Usual care assumed only opportunistic lipid testing and LDL-C and CVD risk-guided treatment. When added to usual care, sequential FH screening strategies examined combinations of childhood (age 10 years) or early adulthood (age 18 years) screening with 3 LDL-C thresholds (≥130 mg/dL, ≥160 mg/dL, or ≥190 mg/dL) to select patients for genetic testing.

MAIN OUTCOMES AND MEASURES: Primary outcomes were direct health care costs (2021 US dollars), quality-adjusted life-years (QALYs), and an incremental cost-effectiveness ratio (ICER). Future costs and QALYs were discounted 3% annually. Strategies with an ICER of less than $100 000 per QALY gained were considered cost-effective.

RESULTS: For the simulated cohort, usual care would lead to 3 118 000 (95% uncertainty interval, 3 061 000-3 192 000) total lifetime CVD events, with 16 182 (95% uncertainty interval, 15 683-16 827) among those with FH. Childhood FH screening could avert between 1385 and 1820 CVD events (<0.1% reduction in overall population), and early adulthood FH screening could avert between 1154 and 1448 CVD events (<0.1% reduction). While effective, no FH screening strategies were cost-effective relative to usual care; screening at age 18 years using an LDL-C threshold of 190 mg/dL or greater had the lowest ICER, at $289 700 per QALY gained. Sequential FH screening could become cost-effective vs usual care if lifetime lipid monitoring plus lifestyle therapy increased after a high screening LDL-C result, including for patients with non-FH dyslipidemias.

CONCLUSIONS AND RELEVANCE: Sequential FH screening in childhood or early adulthood could be effective but not cost-effective vs usual care. However, sequential FH screening could become cost-effective under highly optimistic assumptions about increased lifestyle therapy and increased lifetime lipid monitoring for patients with non-FH dyslipidemias.

INTRODUCTION: Self-measured blood pressure (SMBP) monitoring with clinical support is an evidence-based practice to improve hypertension control. However, it can be challenging to implement in safety-net systems that disproportionately serve low-income and/or racial/ethnic minority populations at risk of worse hypertension outcomes. We therefore propose a hybrid effectiveness-implementation trial to evaluate the effectiveness of multi-level implementation strategies to increase the use of SMBP monitoring in two urban safety-net systems.

METHODS: We will conduct a patient-level randomized controlled trial with 330 English-, Spanish-, and Chinese (Cantonese)-speaking patients with uncontrolled hypertension across six study sites with patients randomized to a low-intensity (SMBP education, text message education and reminders) vs high-intensity intervention (adds group classes and engagement of identified caregivers). To support increased use of SMBP data by the clinical team, we will concurrently deliver a staggered roll-out of a clinic-level implementation strategy (clinic education, shadowing, auditing with feedback, and optimization of electronic health record [EHR] use).

RESULTS: The primary outcomes will be clinic-measured systolic BP (SBP) among enrolled participants for the patient-level intervention and among all patients assigned to the clinic for the clinic-level intervention. We will additionally collect secondary clinical outcomes (BP control, home SBP), implementation outcomes (adoption, reach, and costs), and patient-reported outcomes (patient activation).

DISCUSSION: The results of this trial will address gaps in identifying cost-conscious implementation strategies for increasing adoption of SMBP in safety-net systems with the overarching goal of improving blood pressure control in low-income, diverse patient populations. Trial registration NCT, NCT06871462. Registered 4 March 2025, https://clinicaltrials.gov/study/NCT06871462.