Faculty Bibliography

The implementation of guideline-recommended care is associated with improved clinical outcomes for patients with cardiovascular disease. It is well documented that people living in low socioeconomic position have a high burden of cardiovascular disease and higher mortality rates. In this state-of-the-art review, the association of socioeconomic deprivation and guideline implementation is outlined, showing that across a range of settings, countries and clinical scenarios people with low socioeconomic position are further disadvantaged by sub-optimal provision of guideline recommended care. Reducing cardiovascular health inequality and improving population education should be priorities for governments. Greater attention to the provision of guideline-indicated care is recommended by tackling modifiable barriers to care. Broadly, the prioritization of use of advocacy, workforce, broader policy responses, data, randomized clinical trial re-design, quality indicators, and risk scores are recommended to reduce health inequalities for those who live in socioeconomic deprivation. A renewed focus on the provision of high-quality guideline-recommended cardiovascular care has the potential to reduce healthcare inequalities as well as improve clinical outcomes amongst our most socioeconomically deprived populations.

OBJECTIVES/OBJECTIVE:To identify stakeholder perceived challenges and facilitators for implementing a clean fuel and clean stove intervention to reduce household air pollution and hypertension in Lagos, Nigeria. DESIGN/METHODS:Qualitative study guided by the Exploration and Preparation phases of the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework, using focus group discussions and in-depth semi-structured interviews with inductive and deductive thematic analysis. SETTING/METHODS:Peri-urban communities across the five administrative divisions of Lagos State, Nigeria. PARTICIPANTS/METHODS:128 stakeholders from 32 communities, including community, religious, market and youth leaders, primary healthcare staff, and household decision makers. Approximately half were female. INTERVENTIONS/METHODS:This was a pre-implementation needs assessment that included demonstrations of the clean stove and fuel. PRIMARY AND SECONDARY OUTCOME MEASURES/METHODS:Thematic domains describing barriers and enablers to adoption and implementation, mapped to EPIS inner, outer, and bridging factors. RESULTS:Stakeholders reported barriers that included stove stacking, upfront stove cost, concerns about long-term fuel price and availability, equipment durability and maintenance, safety, mistrust of new technology, and uncertainty about stove performance for dishes requiring high heat and long cooking times. Reported facilitators included payment flexibility and subsidies, opportunities to test the stove, perceived benefits of cleaner and faster cooking with less soot, endorsement by community leaders, and interest in local retail and distribution to improve access. CONCLUSIONS:Implementation planning for clean fuel and clean stove programmes should address affordability, reliable fuel supply chains, durability and service, culturally relevant cooking needs, and trust building through community leadership. These findings inform adaptation strategies for scale-up in similar low-resource settings. TRIAL REGISTRATION NUMBER/BACKGROUND:NCT05048147.

The impact of COVID-19-related mental health effects on health behaviors among people living with HIV (PLWH) remains unknown. Our qualitative study explored the relationship between the mental health consequences of the COVID-19 pandemic and self-management of HIV and cardiovascular disease (CVD) among PLWH in the United States. Twenty-four PLWH enrolled in a multicenter, cardiovascular, clinical trial completed one-on-one semistructured interviews to assess changes in mood, health behaviors, and comorbid CVD management during the COVID-19 pandemic. The majority of participants (ages 43-70 years) were male (n = 17, 70.8%) and Black (n = 19, 79.2%). Participants reported increased mental distress during the COVID-19 pandemic, which they perceived to negatively affect heart-healthy behaviors. Despite mental health stressors, this population continued to adhere to medications, including antiretroviral therapy. Future initiatives should focus on improving mental health outcomes and promotion of healthy lifestyle choices among PLWH to mitigate adverse CVD outcomes.

BACKGROUND:The COVID-19 pandemic had a significant impact on healthcare delivery. Older adults with multimorbidities were at risk of healthcare disruptions for the management of their chronic conditions. OBJECTIVE:To characterize healthcare disruptions during the COVID-19 healthcare shutdown and recovery period (March 7, 2020-October 6, 2020) and their effects on disease management among older adults with multimorbidities who were patients of NYC Health + Hospitals (H + H), the largest municipal safety-net system in the United States. DESIGN/METHODS:Observational. PATIENTS/METHODS:Patients aged 50 + with hypertension or diabetes and at least one other comorbidity, at least one H + H ambulatory visit in the six months before COVID-19 pandemic onset (March 6, 2020), and at least one visit in the post-acute shutdown period (October 7, 2020 to December 31, 2023). MAIN MEASURES/METHODS:We characterized disruption in care (defined as no ambulatory or telehealth visits during the acute shutdown) and estimated the effect of disruption on blood pressure control, hemoglobin A1c (HbA1c), and low-density lipoprotein (LDL) cholesterol using difference-in-differences models. KEY RESULTS/RESULTS:Out of 73,889 individuals in the study population, 12.5% (n = 9,202) received no ambulatory or telehealth care at H + H during the acute shutdown. Low pre-pandemic healthcare utilization, Medicaid insurance, and self-pay were independent predictors of care disruption. In adjusted analyses, the disruption group had a 3.0-percentage point (95% CI: 1.2-4.8) greater decrease in blood pressure control compared to those who received care. Disruption did not have a significant impact on mean HbA1c or LDL. CONCLUSIONS:Care disruption was associated with declines in blood pressure control, which while clinically modest, could impact risk of cardiovascular outcomes if sustained. Disruption did not affect HbA1c or LDL. Telehealth mitigated impacts of the pandemic on care disruption and subsequent disease management. Targeted outreach to those at risk of care disruption is needed during future crises.

People with HIV are at increased risk of cardiovascular events; thus, care delivery strategies that increase access to comprehensive cardiovascular disease (CVD) risk management are a priority. We report the results of a multi-component telemedicine-based strategy to improve blood pressure control among people with HIV-Assess and Adapt to the Impact of COVID-19 on CVD Self-Management and Prevention Care in Adults Living with HIV (AAIM-High). The AAIM High strategy is a virtual adaptation of our previously published EXTRA-CVD strategy and consisted of hypertension education and six components: nurse-led care coordination (delivered by teleconference or telephone), home systolic blood pressure (SBP) monitoring, evidence-based treatment algorithms, electronic health records tools, technology coach, and communication preferences assessment. People with HIV (n = 74) with comorbid hypertension at three academic medical centers were enrolled in a single arm implementation study from January 2021 to December 2022. Over 12 months, the average patient-performed home SBP decreased by 7.7 mmHg (95% CI -11.5, -3.9). The percentage of patients at treatment goal, defined as average SBP <130 mmHg, increased from 46.0% to 72.5% at 12 months. By adapting to the growing use of telemedicine in healthcare delivery, our study effectively improved hypertension control in people with HIV through a virtual, nurse-led intervention.

BACKGROUND:In Nigeria, cardiovascular diseases, especially hypertension, are on the rise. This increase in hypertension correlates with more strokes, significantly impacting mortality. Since hypertension often persists into adulthood, early interventions are crucial to prevent its complications. Non-invasive methods, such as music and creative activities, can effectively improve blood pressure and reduce stroke risk. This study aims to improve intergenerational awareness of hypertension and promote sustainable preventive practices by involving youth and caregivers within families and communities. METHODS:We employed a participatory, observational design, incorporating a five-month crowdsourcing open call followed by a designathon event. Participatory social and health innovations were combined and implemented as part of a larger study titled "Innovative Tool to Expand Music-Inspired Strategies for Blood Pressure and Stroke Prevention" (I-TEST BP/Stroke). Our study targeted youths aged 14 to 24, a critical period for shaping health behaviors and attitudes toward diseases. The 20 finalist textual entries were categorized into themes using the PEN-3 cultural model. The PLAN framework analyzed the effectiveness of participants' entries in conveying public health messages. RESULTS:The crowdsourced open call for musical ideas received 85 submissions between October 2023 and March 2024. More males (74.3%) than females, mainly aged 22-24, and mostly undergraduates (44.3%), participated in the open call, with 88.65% having heard of hypertension. Qualitative analysis with PEN-3 highlighted themes regarding Perceptions and Enablers, such as monitoring blood pressure, engaging in physical activity, and avoiding alcohol and smoking. The use of Pidgin English and Nigerian languages in songs represents Positive Cultural Empowerment. The Negative Cultural Empowerment domain addresses misconceptions about hypertension, including the belief that hypertension is a curse. Utilizing the PLAN framework, the submissions demonstrated an effective blend of catchy, memorable tunes with health education messages. CONCLUSION/CONCLUSIONS:The designathon produced various music genres, including afrobeats, rap, and R&B, with lyrics deemed feasible and socio-culturally appropriate. This suggests that music interventions tailored to Nigeria could enhance public awareness of hypertension and stroke prevention if scaled up.

INTRODUCTION/BACKGROUND:In Africa, 75% of households are exposed to household air pollution (HAP), a key contributor to cardiovascular disease (CVD). In Nigeria, 90 million households rely on solid fuels for cooking, and 40% of adults have hypertension. Though clean fuel and clean stove (CF-CS) technologies can reduce HAP and CVD risk, their adoption in Africa remains limited. METHODS AND ANALYSIS/METHODS:Using the Exploration, Preparation, Implementation and Sustainment framework, this cluster-randomised controlled trial evaluates the implementation and effectiveness of a community mobilisation (CM) strategy versus a self-directed condition (i.e., receipt of information on CF-CS use without CM) on adoption of CF-CS technologies and systolic blood pressure (SBP) reduction among 1248 adults from 624 households across 32 peri-urban communities in Lagos, Nigeria. The primary outcome is CF-CS adoption at 12 months; secondary outcomes are SBP reduction at 12 months and sustainability of CF-CS use at 24 months. Adoption is assessed via objective monitoring of stove usage with temperature-triggered iButton sensors. SBP is assessed in 2 adults per household using validated automated blood pressure monitor. Generalised linear mixed-effects regression models will be used to assess study outcomes, accounting for clustering at the level of the peri-urban communities (unit of randomisation) and households. To date, randomisation is completed, and a total of 1248 households have enrolled in the study. The final completion of the study is expected in June 2026. ETHICS AND DISSEMINATION/BACKGROUND:The study was approved by the Institutional Review Boards (IRB) of NYU Grossman School of Medicine (primary IRB of record; protocol ID: i21-00586; Version 6.0 approved on 4 June 2024), and Lagos State University Teaching Hospital (protocol ID: LREC 06/10/1621). Written consent was obtained from all participants. Findings will inform scalable and culturally appropriate strategies for reducing HAP and CVD risk in low-resource settings. Results will be disseminated through peer-reviewed publications, conference presentations and stakeholder engagements. TRIAL REGISTRATION NUMBER/BACKGROUND:NCT05048147.

Wildfires continue to increase in size, intensity, and duration. There is growing evidence that wildfire smoke adversely impacts clinical outcomes; however, few studies have assessed the impact of wildfires on household air quality and subclinical cardiovascular health indicators. We measured continuous indoor and outdoor fine particulate matter (PM_2.5) concentrations from July-October 2022 at 20 residences in the rural, mountainous state of Montana in the United States. We used a combination of satellite-derived smoke plume data from the National Oceanic and Atmospheric Administration's Hazard Mapping System and household-level daily mean PM_2.5 concentrations to classify wildfire-impacted days. One participant from each household self-reported in-home blood pressure (BP) on weekly electronic surveys. We used linear mixed-effects regression models to assess associations between air pollution exposures (PM_2.5 concentrations; number of wildfire-impacted days) and systolic BP (SBP) and diastolic BP (DBP). Models were adjusted for potential time-variant confounders including temperature, humidity, and self-reported exercise. Compared to survey periods with 0 wildfire days, SBP was 3.83 mmHg higher (95% Confidence Interval [95% CI]: 0.22, 7.44) and DBP was 2.36 mmHg higher (95% CI: -0.06, 4.78) during periods with 4+ wildfire days. Across the entire study period, a 10 µg m^-3 increase in indoor PM_2.5 was associated with 1.34 mmHg higher SBP (95%CI: 0.39, 2.29) and 0.71 mmHg higher DBP (95% CI: 0.07, 1.35). We observed that wildfire-impacted days and increasing household-level PM_2.5 concentrations are associated with higher in-home BP. Our results support growing literature which indicates that wildfires adversely impact subclinical cardiovascular health. Clinical and public health messaging should emphasize the cardiovascular health impacts of wildfire smoke and educate on exposure-reduction strategies such as indoor air filtration.

BACKGROUND:Advances in antiretroviral therapy have enabled people living with HIV (PLHIV) to live longer and healthier lives. However, aging with HIV infection is accompanied by an increased risk of non-communicable diseases (NCDs), highlighting the need to integrate care services. The Academic Model Providing Access to Healthcare (AMPATH) in Eldoret, Kenyahas, which has been providing care for PLHIV for over 30 years, is seeing an increase in NCDs, particularly hypertension and diabetes, especially among older patients. It is unclear how healthcare providers manage the complex healthcare needs of older adults living with HIV (OALWH) and comorbid NCDs, or how they perceive the integration of hypertension and diabetes care within the HIV care platform. METHODS:We conducted in-depth interviews at an AMPATH facility in Eldoret, Kenya. Ten healthcare providers (three nurses and seven clinical officers) were interviewed to explore the facilitators and barriers to integrating HIV and NCD care services for OALWH. Audio records were transcribed verbatim, content analysis was performed, and the capabilities (C), opportunities (O), and motivation (M) models for behavior change (COM-B model) were used to comprehensively map the drivers and barriers that shape healthcare providers' acceptance, adoption, and implementation of integrated HIV and NCD care services. RESULTS:The majority of participants had worked for more than five years, offering care for people living with HIV. All participants had experience managing older adults living with HIV and expressed challenges with the lack of coordinated care delivery for HIV and NCDs. The participants highlighted the potential challenges of optimal adherence to antiretroviral therapy (ART) among OALWH in the presence of multiple chronic conditions. Based on these challenges, participants perceived the integration of hypertension and diabetes care into the HIV care platform as beneficial to clients and the overall healthcare system. Factors such as the availability of physical resources and infrastructure (C), availability of training opportunities for NCD care (O), leadership support (M), and motivation to provide person-centered care (M) were perceived as facilitators of HIV/NCD integrated care delivery. Impeding factors such as lack of guidelines for integration (O), siloed healthcare service delivery (O), inadequate resource allocation for NCDs (O), and perceived increased workload (M) were also highlighted by healthcare providers. CONCLUSION/CONCLUSIONS:The findings of this study highlight healthcare providers' perceived facilitators and barriers to the integration of NCD care into HIV care platforms. The insights gained from this study hold the potential to inform tailored interventions, policy decisions, and capacity-building initiatives aimed at fostering successful integration and improving overall health care delivery to meet the needs of OALWH in resource-constrained settings.

BACKGROUND/UNASSIGNED:Systematic screening individuals with non-invasive devices may improve diagnosis of atrial fibrillation (AF) and reduce adverse clinical events. We systematically reviewed the existing literature to determine the yield of new AF diagnosis associated with systematic AF screening, the relative increase in yield of new AF diagnosis with systematic screening compared to usual care, and the effect of systematic AF screening on clinical outcomes compared with usual care. METHODS/UNASSIGNED:The Medline, Embase, Web of Science and Cochrane Library databases were searched from inception through 1st February 2025 for prospective cohort studies or randomised clinical trials (RCTs) of systematic AF screening with the outcome of incidence of previously undiagnosed AF from screening. Incidence rates (IR) and relative risks were calculated and random effects meta-analysis performed to synthesise rates of AF in prospective cohort studies and RCTs, as well as outcomes in RCTs. FINDINGS/UNASSIGNED:From 3806 unique records we included 32 studies representing 735,542 participants from 8 RCTs and 24 prospective cohorts. The diagnosis rate for incident AF in prospective cohorts was 2.75% (95% CI 1.87-3.62), and the pooled relative risk in RCTs was 2.22 (95% CI 1.41-3.50). The use of age and NT-proBNP (IR 4.36%, 95% CI 3.77-5.08) or AF risk score classification (4.79%, 95% CI 3.62-6.29) led to higher new AF diagnosis yields than age alone (0.93%, 95% CI 0.28-2.99). Pooled data from RCTs did not demonstrate an effect of screening on death (RR 1.01, 95% CI 0.97-1.05), cardiovascular hospitalisation (1.00, 95% CI 0.97-1.03), stroke (0.95, 95% CI 0.87-1.04) or bleeding (1.08, 95% CI 0.91-1.29). INTERPRETATION/UNASSIGNED:Systematic screening for AF using non-invasive devices is associated with increased diagnosis of AF, but not reduced adverse clinical events. Screening studies of AF utilising alternative risk stratifications and outcome measures are required. FUNDING/UNASSIGNED:British Heart Foundation (grant reference CC/22/250026) and National Institute for Health and Care Research.