Background Prior studies have reported disparities by race in the management of acute myocardial infarction (MI), with many studies having limited covariates or now dated. We examined racial and ethnic differences in the management of MI, specifically non–ST‐segment‐elevation MI (NSTEMI), in a large, socially diverse cohort of insured patients. We hypothesized that the racial and ethnic disparities in the receipt of coronary angiography or percutaneous coronary intervention would persist in contemporary data. Methods and Results We identified individuals presenting with incident, type I NSTEMI from 2017 to 2019 captured by a health claims database. Race and ethnicity were categorized by the database as Asian, Black, Hispanic, or White. Covariates included demographics (age, sex, race, and ethnicity); Elixhauser variables, including cardiovascular risk factors and other comorbid conditions; and social factors of estimated annual household income and educational attainment. We examined rates of coronary angiography and percutaneous coronary intervention by race and ethnicity and income categories and in multivariable‐adjusted models. We identified 87 094 individuals (age 73.8±11.6 years; 55.6% male; 2.6% Asian, 13.4% Black, 11.2% Hispanic, 72.7% White) with incident NSTEMI events from 2017 to 2019. Individuals of Black race were less likely to undergo coronary angiography (odds ratio [OR], 0.93; [95% CI, 0.89–0.98]) and percutaneous coronary intervention (OR, 0.86; [95% CI, 0.81–0.90]) than those of White race. Hispanic individuals were less likely (OR, 0.88; [95% CI, 0.84–0.93]) to undergo coronary angiography and percutaneous coronary intervention (OR, 0.85; [95% CI, 0.81–0.89]) than those of White race. Higher annual household income attenuated differences in the receipt of coronary angiography across all racial and ethnic groups. Conclusions We identified significant racial and ethnic differences in the management of individuals presenting with NSTEMI that were marginally attenuated by higher household income. Our findings suggest continued evidence of health inequities in contemporary NSTEMI treatment.

Background Cardiac rehabilitation (CR) is associated with improved cardiovascular outcomes. Racial and ethnic differences in CR have been identified, but whether income may attenuate these disparities remains unknown. We evaluated (1) racial/ethnic differences in CR participation in a contemporary sample of insured US adults, and (2) assessed how household income modifies associations between race or ethnicity and CR participation. Methods and Results We identified 107 199 individuals with a CR‐qualifying diagnosis between January 1, 2016 and December 31, 2018 in Optum’s de‐identified Clinformatics database. We evaluated associations between race or ethnicity and participation in CR, and assessed interaction between race or ethnicity and annual household income. The mean±SD age of all participants was 70.4±11.6 years; 37.4% were female and 76.0% were White race. Overall, 28 443 (26.5%) attended ≥1 CR sessions. After adjustment, compared with White individuals, the probability of attending CR was 31% lower for Asian individuals (95% CI, 27%–36%), 19% lower for Black individuals (95% CI, 16%–22%), and 43% lower for Hispanic individuals (95% CI, 40%–45%), all P <0.0001. The time to CR attendance was also significantly longer for Asian, Black, and Hispanic individuals. Associations between race or ethnicity and attendance at CR differed significantly across household income categories ( P interaction=0.0005); however, Asian, Black, and Hispanic individuals were less likely to attend CR at all incomes. Conclusions In a geographically and racially diverse cohort, participation in CR was low overall, and was lowest among Asian, Black, and Hispanic candidates. Household income may impact the link between race or ethnicity and attendance at CR, but substantial racial and ethnic disparities exist across incomes.

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Background: Outcomes in heart failure with reduced ejection fraction (HFrEF), are influenced by access and adherence to guideline-directed medical therapy. Our objective was to study the association between annual household income and: (1) the odds of having a claim for sacubitril/valsartan among insured patients with HFrEF and (2) medication adherence (measured as the proportion of days covered [PDC]). We hypothesized that lower annual household income is associated with decreased odds of having a claim for and adhering to sacubitril/valsartan. Methods: Using the Optum de-identified Clinformatics® Data Mart, patients with HFrEF and ≥6 months of enrollment for follow up (2016-2020) were included. Covariates included age, sex, race, ethnicity, educational attainment, US region, number of prescribed medications, and Elixhauser Comorbidity Index. Prescription for sacubitril/valsartan was defined by the presence of a claim within 6 months of HFrEF diagnosis. Adherence was defined as PDC≥80%. We fit multivariable-adjusted logistic regression models and hierarchical logistic regression accounting for covariates. Results: Among 322,007 individuals with incident HFrEF, 135,282 had complete data for analysis. Of the patients eligible for sacubitril/valsartan, 4.7% (6,372) had a claim within 6 months of HFrEF diagnosis. Following multivariable adjustment, individuals in the lowest annual income category (<$40,000) were significantly less likely (OR=0.83, 95% CI [0.76, 0.90]) to have a sacubitril/valsartan claim within 6 months of HFrEF diagnosis than those in the highest annual income category (≥$100,000). Annual income <$40,000 was associated with lower odds of PDC≥80% compared with income ≥$100,000 (OR=0.70, 95% CI [0.59, 0.83]). Conclusions: Lower household income is associated with decreased likelihood of a sacubitril/valsartan claim and medication adherence within 6 months of HFrEF diagnosis, even after adjusting for sociodemographic and clinical factors. Future analyses are needed to identify additional social factors associated with delays in sacubitril/valsartan initiation and long-term adherence.

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Objective: Studies suggest a reversal in the protective association of high-density lipoprotein cholesterol (HDL-C) and cardiovascular disease in women traversing menopause. Decreasing estrogen levels during the transition, as well as inflammation, may explain this reversal. We tested whether either estradiol or C-reactive protein (CRP) concentrations modified the association of HDL-C with aortic (AC) or coronary artery calcification (CAC). Methods: A total of 478 participants between ages 46 to 59 from the Study of Women's Health Across the Nation Heart baseline visit were included. AC and CAC presence were defined as Agatston score of 100 or higher and 10 or higher, respectively. Logistic regression was used for analysis. Results: A total of 112 (23.53%) participants had AC 100 or higher and 104 (21.76%) had CAC 10 or higher. In unadjusted models, a 1-mg/dL higher in HDL-C was associated with 3% lower odds of AC (95% CI: 0.95-0.99) and 4% lower odds of CAC (95% CI: 0.95-0.98). In adjusted models, a significant interaction between HDL-C and estradiol with respect to AC but not CAC was detected, such that higher HDL-C level was protective at the highest estradiol quartile (odds ratio: 0.91, 95% CI: 0.84-0.99 per 1 mg/dL higher HDL-C, P = 0.03) but tended to associate with greater risk at the lowest quartile (odds ratio: 1.04, 95% CI: 0.98-1.10 per 1 mg/dL higher HDL-C, P = 0.16). CRP did not modify any association. Conclusions: The protective cardiovascular association of higher HDL-C levels on AC was modified by estradiol but not CRP concentrations. The pathways through which estradiol might influence this association should be further investigated. Video Summary: http://links.lww.com/MENO/A689.

Background Atrial fibrillation (AF) is associated with a five-fold increased risk of stroke and a two-fold increased risk of death. We aimed to quantify changes in new diagnoses of AF following the onset of the COVID-19 pandemic. Investigating changes in new diagnoses of AF is of relevance because delayed diagnosis interferes with timely treatment to prevent stroke, heart failure, and death. Methods Using De-identified Optum’s Clinformatics® Data Mart, we identified 19,500,401 beneficiaries continuously enrolled for 12 months in 2016-Q3 2020 with no history of AF. The primary outcome was new AF diagnoses per 30-day interval. Secondary outcomes included AF diagnosis in the inpatient setting, AF diagnosis in the outpatient setting, and ischemic stroke as initial manifestation of AF. We constructed seasonal autoregressive integrated moving average models to quantify changes in new AF diagnoses after the onset of the COVID-19 pandemic (3/11/2020, date of pandemic declaration). We tested whether changes in the new AF diagnoses differed by race and ethnicity. Results The average age of study participants was 51.0±18.5 years, and 52% of the sample was female. During the study period, 2.7% of the study sample had newly-diagnosed AF. New AF diagnoses decreased by 35% (95% CI, 21%-48%) after the onset of the COVID-19 pandemic, from 1.14 per 1000 individuals (95% CI, 1.05–1.24) to 0.74 per 1000 (95% CI, 0.64 to 0.83, p-value<0.001). New AF diagnoses decreased by 37% (95% CI, 13%- 55%) in the outpatient setting and by 29% (95% CI, 14%-43%) in the inpatient setting. The decrease in new AF diagnoses was similar across racial and ethnic subgroups. Conclusion In a nationwide cohort of 19.5 million individuals, new diagnoses of AF decreased substantially following the onset of the COVID-19 pandemic. Our findings evidence pandemic disruptions in access to care for AF, which are concerning because delayed diagnosis interferes with timely treatment to prevent complications.