Faculty Bibliography

OBJECTIVE/UNASSIGNED:This study examined decade-long trends and differences in sodium-glucose cotransporter 2 inhibitor (SGLT2i) and glucagon-like peptide-1 receptor agonist (GLP-1 RA) prescriptions among adults with type 2 diabetes using real-world data from Epic Cosmos. RESEARCH DESIGN AND METHODS/UNASSIGNED:We analyzed electronic health records of 1 517 594 adults with type 2 diabetes without end-stage renal disease from 2014 to 2024. Annual prescribing trends were evaluated by patient race and insurance type using negative binomial regression. Medication exposure was defined using active prescriptions/orders recorded in Epic Cosmos during the calendar year. In pooled descriptive analyses, we also characterized patients prescribed these medications by clinical characteristics, neighborhood-level social vulnerability, and prescriber specialty. RESULTS/UNASSIGNED:From 2014 to 2024, SGLT2i use rose from 0.5% to 12.1% and GLP-1 RA use increased from 0.9% to 15.9%. Black patients had consistently lower prescription rates than White patients across insurance groups. Primary care physicians prescribed about one-third of these medications. In pooled descriptive analyses, endocrinology was associated with higher observed prescribing rates than primary care or cardiology. Patients from neighborhoods with lower social vulnerability were more likely to receive these therapies. CONCLUSIONS/UNASSIGNED:Use of SGLT2i and GLP-1 RA increased substantially over the past decade, significant racial, socioeconomic, and insurance-related differences persist in prescribing these therapies.

IMPORTANCE/UNASSIGNED:Ischemic heart disease (IHD), the leading cause of death in the US, is predominantly due to modifiable risk factors. Estimates of IHD mortality attributable to risk factors provide evidence for health policy decision-making. OBJECTIVE/UNASSIGNED:To estimate the burden of IHD death attributable to risk factors in the US from 1990-2023. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:The Global Burden of Disease Study 2023 (GBD 2023) used vital records and a broad set of epidemiologic data to estimate IHD death rates, risk factor exposure, and relative risk curves for risk-outcome pairs for 1990-2023 for the general population. Data analysis was performed from October 2024 to December 2025. EXPOSURE/UNASSIGNED:Twelve metabolic, behavioral, and environmental risk factors. MAIN OUTCOMES AND MEASURES/UNASSIGNED:The primary outcomes were IHD death rates per 100 000 persons, counts, and attributable risks from 1990-2023 by age, sex, and US state. Estimates include 95% uncertainty intervals (UI). IHD death rates were estimated using ensemble modeling methods. Risk exposures were estimated using bayesian meta-regression methods. Relative risks were estimated following the Burden of Proof framework. RESULTS/UNASSIGNED:In 2023, there were 473 000 IHD deaths (95% UI, 414 000-510 000) in the US, a decrease of 58.7% (95% UI, 56.8%-61.0%) in age-standardized rate since 1990. Between 2010 and 2023, there was a 19.0% decrease (95% UI, 15.0%-22.9%) for males and a 24.5% decrease (95% UI, 20.3%-29.7%) for females in IHD death rates. High systolic blood pressure (SBP), dietary risks, and high low-density lipoprotein cholesterol (LDL-C) were the leading risk factors for IHD deaths in 2023, accounting for 47.2% (95% UI, 36.4%-57.0%), 38.6% (95% UI, 17.2%-56.8%), and 28.5% (95% UI, 19.3%-39.6%) of IHD deaths, respectively. Increased exposure to several risk factors substantially increased their attributable burden for IHD deaths in 2023, with high fasting plasma glucose (FPG) increasing 38.8% (95% UI, 11.5%-81.1%) and high body mass index (BMI) increasing 54.5% (95% UI, 41.8%-66.3%) since 1990. Smoking and particulate matter pollution had the greatest decrease in attributable IHD mortality since 1990, at 33.3% (95% UI, 23.6%-41.7%) and 74.9% (95% UI, 46.7%-88.8%), respectively. CONCLUSION AND RELEVANCE/UNASSIGNED:Per the results of this systematic analysis of GBD 2023, a total of 88.7% (95% UI, 83.4%-92.5%) of IHD deaths were attributable to modifiable risk factors in the US in 2023, with high SBP, dietary risks, and high LDL-C being the greatest contributors. High BMI and high FPG showed the largest attribution increases, while exposure to other risks did not increase significantly for the population.

IMPORTANCE/UNASSIGNED:In patients with asymptomatic severe aortic stenosis (AS), exercise stress testing is recommended to unmask symptoms and guide the timing of intervention, yet it is infrequently used in clinical practice. This registry-based follow-up of the Evaluation of TAVR Compared to Surveillance for Patients With Asymptomatic Severe Aortic Stenosis (EARLY TAVR) trial evaluates how treadmill stress testing (TST), used during screening for EARLY TAVR to confirm asymptomatic status, informed subsequent aortic valve replacement and clinical outcomes. OBJECTIVE/UNASSIGNED:To evaluate clinical outcomes in patients with asymptomatic severe AS and a positive TST result and to identify predictors of a positive TST result. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This prespecified TST registry of the EARLY TAVR trial involved 75 clinical sites across the US. Between July 2017 and December 2021, apparently asymptomatic patients with severe AS underwent standardized TST. Those with normal TST results were randomized to transcatheter aortic valve replacement or clinical surveillance, whereas those with positive TST results were invited to enroll in a prospective registry and were followed up with through 2 years. Of 1250 patients screened, 962 met trial criteria. Of these, 816 (84.8%) had a normal TST result and 146 (15.2%) had a positive TST result. Of these, 105 consented to enroll in the EARLY TAVR Treadmill Registry. Data were analyzed from August 2025 to January 2026. EXPOSURE/UNASSIGNED:Positive TST result. MAIN OUTCOMES AND MEASURES/UNASSIGNED:TST-related safety, 2-year all-cause mortality, and rates of subsequent aortic valve replacement (AVR). Baseline predictors of a positive TST result were identified using multivariable logistic regression models. RESULTS/UNASSIGNED:Of the 105 patients included in the present analysis, the mean (SD) age was 76.1 (6.5) years, and 80 participants (76.2%) were male. TST was found to be safe, with no reported deaths, syncope, or cardioversions. Multivariable baseline predictors of a positive TST included higher peak velocity, lower ejection fraction, prior coronary artery bypass, and prior stroke. The 2-year Kaplan-Meier rate for all-cause mortality was 5.7%. Among patients with positive TST results, the rates of AVR at 1 and 2 years were 79.9% and 85.9%, respectively. Rates of mortality and AVR were similar for patients who had a class I indication for AVR (symptoms during testing) and those with a class IIa indication (drop in systolic blood pressure). CONCLUSIONS AND RELEVANCE/UNASSIGNED:In patients with asymptomatic severe AS, TST was found to be safe and identified symptoms and AVR indication in approximately 15% of patients. However, 20% of those patients remained untreated at 1 year, despite having an indication for prompt treatment. TRIAL REGISTRATION/UNASSIGNED:ClinicalTrials.gov Identifier: NCT03042104.

PURPOSE/OBJECTIVE:To develop expert-consensus recommendations for patient selection, technique and clinical management in genicular artery embolization (GAE) using a Delphi process. MATERIALS AND METHODS/METHODS:A working group developed a 75-statement questionnaire. A panel of musculoskeletal and interventional radiologists (IRs), selected based on clinical experience, scientific expertise and geographic diversity, scored each response using a 10-point Likert-scale across three rounds. Consensus was predefined as ≥ 75% of ratings ≥ 7/10. RESULTS:Twenty-nine IRs completed all three rounds. Consensus inclusion criteria for GAE include knee pain refractory to conservative treatment for ≥ 3 months due to osteoarthritis, tendinopathies or prior knee surgery and recurrent hemarthrosis (median 9[IQR 7-10]; 86% ≥ 7). Pre-procedural assessment should include standardized outcome measures, clinical examination and knee radiographs. Contrast-enhanced MRI is optional for osteoarthritis phenotyping and grading of synovitis, differential diagnosis and outcome prediction (8[7-10]; 79% ≥ 7). Via an ipsilateral antegrade transfemoral access, all visible genicular arteries should be catheterized and embolized upon detection of a hypervascular blush (9[7-10]; 76% ≥ 7). No evidence of superiority of either temporary or permanent embolic agents in terms of safety or efficacy has been demonstrated (10[8-10]; 86% ≥ 7). Structured long-term follow-up is recommended, with clinical success defined as achievement of the minimal clinically important difference or individual patient satisfaction (9[7-10]; 83% ≥ 7). Contralateral or repeat GAE may be considered for bilateral knee pain, insufficient response or pain recurrence (8[7-10]; 76% ≥ 7). CONCLUSION/CONCLUSIONS:This Delphi study establishes expert-derived consensus recommendations for GAE, emphasizing broad indications, patient-tailored technique and an active role of the IR in multidisciplinary longitudinal care.

IMPORTANCE/UNASSIGNED:In patients with asymptomatic severe aortic stenosis (AS), exercise stress testing is recommended to unmask symptoms and guide the timing of intervention, yet it is infrequently used in clinical practice. This registry-based follow-up of the Evaluation of TAVR Compared to Surveillance for Patients With Asymptomatic Severe Aortic Stenosis (EARLY TAVR) trial evaluates how treadmill stress testing (TST), used during screening for EARLY TAVR to confirm asymptomatic status, informed subsequent aortic valve replacement and clinical outcomes. OBJECTIVE/UNASSIGNED:To evaluate clinical outcomes in patients with asymptomatic severe AS and a positive TST result and to identify predictors of a positive TST result. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This prespecified TST registry of the EARLY TAVR trial involved 75 clinical sites across the US. Between July 2017 and December 2021, apparently asymptomatic patients with severe AS underwent standardized TST. Those with normal TST results were randomized to transcatheter aortic valve replacement or clinical surveillance, whereas those with positive TST results were invited to enroll in a prospective registry and were followed up with through 2 years. Of 1250 patients screened, 962 met trial criteria. Of these, 816 (84.8%) had a normal TST result and 146 (15.2%) had a positive TST result. Of these, 105 consented to enroll in the EARLY TAVR Treadmill Registry. Data were analyzed from August 2025 to January 2026. EXPOSURE/UNASSIGNED:Positive TST result. MAIN OUTCOMES AND MEASURES/UNASSIGNED:TST-related safety, 2-year all-cause mortality, and rates of subsequent aortic valve replacement (AVR). Baseline predictors of a positive TST result were identified using multivariable logistic regression models. RESULTS/UNASSIGNED:Of the 105 patients included in the present analysis, the mean (SD) age was 76.1 (6.5) years, and 80 participants (76.2%) were male. TST was found to be safe, with no reported deaths, syncope, or cardioversions. Multivariable baseline predictors of a positive TST included higher peak velocity, lower ejection fraction, prior coronary artery bypass, and prior stroke. The 2-year Kaplan-Meier rate for all-cause mortality was 5.7%. Among patients with positive TST results, the rates of AVR at 1 and 2 years were 79.9% and 85.9%, respectively. Rates of mortality and AVR were similar for patients who had a class I indication for AVR (symptoms during testing) and those with a class IIa indication (drop in systolic blood pressure). CONCLUSIONS AND RELEVANCE/UNASSIGNED:In patients with asymptomatic severe AS, TST was found to be safe and identified symptoms and AVR indication in approximately 15% of patients. However, 20% of those patients remained untreated at 1 year, despite having an indication for prompt treatment. TRIAL REGISTRATION/UNASSIGNED:ClinicalTrials.gov Identifier: NCT03042104.

BACKGROUND:The risk of intracerebral hemorrhage (ICH) hematoma expansion (HE) is highest in the first hours after onset, and coagulopathy is believed to further increase this risk. However, there is a paucity of data comparing the risk of HE over time for various antithrombotic agents. METHODS:We conducted a retrospective study of spontaneous ICH patients enrolled at a comprehensive stroke center between December 2016 and May 2022, excluding those who underwent surgical evacuation. ICH volumes were calculated using ABC/2 methodology and HE was coded for a ≥ 33% and/or ≥ 6-mL increase in ICH volume. Multivariable logistic regression and Cox proportional hazards models were constructed to evaluate risk of HE among patients exposed to the following antithrombotics: aspirin, P2Y12 inhibitors, aspirin + P2Y12 inhibitors, warfarin, oral factor Xa inhibitors, direct thrombin inhibitors, full dose heparinoids, and combined antiplatelet + anticoagulant. RESULTS:Of 319 patients with ICH, 141 (44%) were on an antithrombotic at the time of ICH and 65 (20%) had HE in a median of 10 h (interquartile range (IQR) 7-21) from last known normal (LKN). In multivariable logistic regression analyses, the odds of HE decreased by 2% for every hour from LKN (adjusted odds ratio (aOR) 0.98, 95% CI 0.97-0.99, P = 0.038), and HE occurred significantly more often in patients taking combined antiplatelet + anticoagulant (9/24, 38%) compared with those who were not (56/295, 19%, aOR 2.71, 95% CI 1.09-6.73, P = 0.032). No other antithrombotic was significantly associated with HE. In multivariable Cox analysis adjusting for admission National Institutes of Health Stroke Scale (NIHSS), only antiplatelet + anticoagulant use was associated with significantly increased rates of HE (adjusted HR (aHR) 2.33, 95% CI 1.14-4.75, P = 0.020), with the highest probability of HE occurring immediately after ICH onset. CONCLUSIONS:Use of combined antiplatelet + anticoagulant was associated with a twofold increased hazard of HE, with the highest probability of expansion occurring early after ICH onset. No increased rate of HE was observed for other antithrombotics.

PURPOSE/OBJECTIVE:To develop expert-consensus recommendations for patient selection, technique and clinical management in genicular artery embolization (GAE) using a Delphi process. MATERIALS AND METHODS/METHODS:A working group developed a 75-statement questionnaire. A panel of musculoskeletal and interventional radiologists (IRs), selected based on clinical experience, scientific expertise and geographic diversity, scored each response using a 10-point Likert-scale across three rounds. Consensus was predefined as ≥ 75% of ratings ≥ 7/10. RESULTS:Twenty-nine IRs completed all three rounds. Consensus inclusion criteria for GAE include knee pain refractory to conservative treatment for ≥ 3 months due to osteoarthritis, tendinopathies or prior knee surgery and recurrent hemarthrosis (median 9[IQR 7-10]; 86% ≥ 7). Pre-procedural assessment should include standardized outcome measures, clinical examination and knee radiographs. Contrast-enhanced MRI is optional for osteoarthritis phenotyping and grading of synovitis, differential diagnosis and outcome prediction (8[7-10]; 79% ≥ 7). Via an ipsilateral antegrade transfemoral access, all visible genicular arteries should be catheterized and embolized upon detection of a hypervascular blush (9[7-10]; 76% ≥ 7). No evidence of superiority of either temporary or permanent embolic agents in terms of safety or efficacy has been demonstrated (10[8-10]; 86% ≥ 7). Structured long-term follow-up is recommended, with clinical success defined as achievement of the minimal clinically important difference or individual patient satisfaction (9[7-10]; 83% ≥ 7). Contralateral or repeat GAE may be considered for bilateral knee pain, insufficient response or pain recurrence (8[7-10]; 76% ≥ 7). CONCLUSION/CONCLUSIONS:This Delphi study establishes expert-derived consensus recommendations for GAE, emphasizing broad indications, patient-tailored technique and an active role of the IR in multidisciplinary longitudinal care.

BACKGROUND:The risk of intracerebral hemorrhage (ICH) hematoma expansion (HE) is highest in the first hours after onset, and coagulopathy is believed to further increase this risk. However, there is a paucity of data comparing the risk of HE over time for various antithrombotic agents. METHODS:We conducted a retrospective study of spontaneous ICH patients enrolled at a comprehensive stroke center between December 2016 and May 2022, excluding those who underwent surgical evacuation. ICH volumes were calculated using ABC/2 methodology and HE was coded for a ≥ 33% and/or ≥ 6-mL increase in ICH volume. Multivariable logistic regression and Cox proportional hazards models were constructed to evaluate risk of HE among patients exposed to the following antithrombotics: aspirin, P2Y12 inhibitors, aspirin + P2Y12 inhibitors, warfarin, oral factor Xa inhibitors, direct thrombin inhibitors, full dose heparinoids, and combined antiplatelet + anticoagulant. RESULTS:Of 319 patients with ICH, 141 (44%) were on an antithrombotic at the time of ICH and 65 (20%) had HE in a median of 10 h (interquartile range (IQR) 7-21) from last known normal (LKN). In multivariable logistic regression analyses, the odds of HE decreased by 2% for every hour from LKN (adjusted odds ratio (aOR) 0.98, 95% CI 0.97-0.99, P = 0.038), and HE occurred significantly more often in patients taking combined antiplatelet + anticoagulant (9/24, 38%) compared with those who were not (56/295, 19%, aOR 2.71, 95% CI 1.09-6.73, P = 0.032). No other antithrombotic was significantly associated with HE. In multivariable Cox analysis adjusting for admission National Institutes of Health Stroke Scale (NIHSS), only antiplatelet + anticoagulant use was associated with significantly increased rates of HE (adjusted HR (aHR) 2.33, 95% CI 1.14-4.75, P = 0.020), with the highest probability of HE occurring immediately after ICH onset. CONCLUSIONS:Use of combined antiplatelet + anticoagulant was associated with a twofold increased hazard of HE, with the highest probability of expansion occurring early after ICH onset. No increased rate of HE was observed for other antithrombotics.

OBJECTIVE/UNASSIGNED:Timely use of sodium-glucose cotransporter-2 inhibitors (SGLT2is) is vital for managing type 2 diabetes (T2DM) and preventing cardiovascular and renal complications. However, socioeconomic barriers and prescribing inertia may disproportionately affect disadvantaged populations. We examined racial and ethnic differences in the initiation of SGLT2i among Medicaid patients with T2DM. METHODS/UNASSIGNED:Adult participants 18-64 with T2DM and prescribed with metformin were drawn from MarketScan Multistate Medicaid Database (2015-2022) for this retrospective cohort study. We used a Cox proportional hazards model, adjusted for age, sex, type of Medicaid coverage, and comorbidities, to assess time to SGLT2i initiation. RESULTS/UNASSIGNED:Among 13 744 Medicaid patients, non-Hispanic Black patients had an 18% lower rate of SGLT2i initiation compared with non-Hispanic White patients (hazard ratio [HR] = 0.82; 95%CI: 0.75-0.90). This disparity was most pronounced among patients without pre-existing atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease (HR = 0.79; 95%CI: 0.71-0.87). No significant racial/ethnic differences were observed among patients with these conditions. CONCLUSIONS/UNASSIGNED:Significant delays in SGLT2i initiation among Black Medicaid patients-particularly in early stage of diabetes-may increase their risk for long-term complications. Addressing structural barriers through targeted interventions is essential to promote equity in diabetes care.

OBJECTIVE/UNASSIGNED:This study examined decade-long trends and differences in sodium-glucose cotransporter 2 inhibitor (SGLT2i) and glucagon-like peptide-1 receptor agonist (GLP-1 RA) prescriptions among adults with type 2 diabetes using real-world data from Epic Cosmos. RESEARCH DESIGN AND METHODS/UNASSIGNED:We analyzed electronic health records of 1 517 594 adults with type 2 diabetes without end-stage renal disease from 2014 to 2024. Annual prescribing trends were evaluated by patient race and insurance type using negative binomial regression. Medication exposure was defined using active prescriptions/orders recorded in Epic Cosmos during the calendar year. In pooled descriptive analyses, we also characterized patients prescribed these medications by clinical characteristics, neighborhood-level social vulnerability, and prescriber specialty. RESULTS/UNASSIGNED:From 2014 to 2024, SGLT2i use rose from 0.5% to 12.1% and GLP-1 RA use increased from 0.9% to 15.9%. Black patients had consistently lower prescription rates than White patients across insurance groups. Primary care physicians prescribed about one-third of these medications. In pooled descriptive analyses, endocrinology was associated with higher observed prescribing rates than primary care or cardiology. Patients from neighborhoods with lower social vulnerability were more likely to receive these therapies. CONCLUSIONS/UNASSIGNED:Use of SGLT2i and GLP-1 RA increased substantially over the past decade, significant racial, socioeconomic, and insurance-related differences persist in prescribing these therapies.