Background: Social and environmental factors play an important role in the rising health care burden of cardiovascular disease. The Centers for Disease Control and Prevention developed the Social Vulnerability Index (SVI) from US census data as a tool for public health officials to identify communities in need of support in the setting of a hazardous event. SVI (ranging from a least vulnerable score of 0 to a most vulnerable score of 1) ranks communities on 15 social factors including unemployment, minoritized groups status, and disability, and groups them under 4 broad themes: socioeconomic status, housing and transportation, minoritized groups, and household composition. We sought to assess the association of SVI with self‐reported prevalent cardiovascular comorbidities and atherosclerotic cardiovascular disease (ASCVD). Methods and Results: We performed a retrospective cohort analysis of adults (≥18 years) in the Behavioral Risk Factor Surveillance System 2016 to 2019. Data regarding self‐reported prevalent cardiovascular comorbidities (including diabetes, hypertension, hyperlipidemia, smoking, substance use), and ASCVD was captured using participants' response to a structured telephonic interview. We divided states on the basis of the tertile of SVI (first—participant lives in the least vulnerable group of states, 0–0.32; to third—participant lives in the most vulnerable group of states, 0.54–1.0). Multivariable logistic regression models adjusting for age, race and ethnicity, sex, employment, income, health care coverage, and association with federal poverty line were constructed to assess the association of SVI with cardiovascular comorbidities. Our study sample consisted of 1 745 999 participants ≥18 years of age. States in the highest (third) tertile of social vulnerability had predominantly Black and Hispanic adults, lower levels of education, lower income, higher rates of unemployment, and higher rates of prevalent comorbidities including hypertension, diabetes, chronic kidney disease, hyperlipidemia, substance use, and ASCVD. In multivariable logistic regression models, individuals living in states in the third tertile of SVI had higher odds of having hypertension (odds ratio (OR), 1.14 [95% CI, 1.11–1.17]), diabetes (OR, 1.12 [95% CI, 1.09–1.15]), hyperlipidemia (OR, 1.09 [95% CI, 1.06–1.12]), chronic kidney disease (OR, 1.17 [95% CI, 1.12–1.23]), smoking (OR, 1.05 [95% CI, 1.03–1.07]), and ASCVD (OR, 1.15 [95% CI, 1.12–1.19]), compared with those living in the first tertile of SVI. Conclusions: SVI varies across the US states and is associated with prevalent cardiovascular comorbidities and ASCVD, independent of age, race and ethnicity, sex, employment, income, and health care coverage. SVI may be a useful assessment tool for health policy makers and health systems researchers examining multilevel influences on cardiovascular‐related health behaviors and identifying communities for targeted interventions pertaining to social determinants of health.

Introduction: Recent years have brought significant developments in lipid and atherosclerosis research. Although statins are a cornerstone in hyperlipidemia management, new non-statin therapies have had an impact. The reduction of low-density lipoprotein cholesterol (LDL-C) further translates into the lowering of cardiovascular mortality. Additionally, lipid research has progressed beyond LDL-C reduction and this has brought triglyceride (TG) and apoprotein-B containing lipids into focus. Areas covered: Inclisiran and pemafibrate, with expected approval soon, come under the spotlight. We discuss other therapeutics such as lomitapide, mipomersen, volanesorsen and evinacumab and newly approved non statin-based therapies such as ezetimibe, icosapent ethyl (IPE) and bempedoic acid. Expert Opinion: New options now exist for the prevention of atherosclerosis in patients that are not optimized on statin therapy. Multiple guidelines endorse ezetimibe, PCSK9 inhibitors, bempedoic and IPE as add-on therapy. Recently approved bempedoic acid/ezetimibe combination might gain popularity among clinicians. Inclisiran and pemafibrate show promise in the reduction of LDL-C and TG, respectively and results are pending in cardiovascular outcome trials. Combination strategies could improve outcomes, but the challenge will be balancing cost and selecting the correct patient population for each treatment modality to maximize benefit with the fewest medications.

To compare the efficacy and safety of P2Y₁₂ inhibitor or aspirin monotherapy for secondary prevention in patients with atherosclerotic cardiovascular disease (ASCVD). Medline, Embase, and Cochrane Central databases were searched to identify randomized trials comparing monotherapy with a P2Y₁₂ inhibitor versus aspirin for secondary prevention in patients with ASCVD (cardiovascular, cerebrovascular, or peripheral artery disease). The primary outcome was major adverse cardiac events (MACE). Secondary outcomes were myocardial infarction (MI), stroke, all-cause mortality, and major bleeding. A random-effects model was used to calculate risk ratios (RR) and the corresponding 95% confidence interval (CI) and heterogeneity among studies was assessed using the Higgins I² value. A total of 9 eligible trials (5 with clopidogrel and 4 with ticagrelor) with 61 623 patients were included in our analyses. Monotherapy with P2Y₁₂ inhibitors significantly reduced the risk of MACE by 11% (0.89, 95% CI 0.84–0.95, I² = 0%) and MI by 19% (0.81, 95% CI 0.71–0.92, I2 = 0%) compared with aspirin monotherapy. There was no significant difference in the risk of stroke (0.85, 95% CI 0.73–1.01), or all-cause mortality (1.01, 95% CI 0.92–1.11). There was also no significant difference in the risk of major bleeding with P2Y₁₂ inhibitor monotherapy compared with aspirin (0.94, 95% CI 0.72–1.22, I² = 42.6%). Results were consistent irrespective of the P2Y₁₂ inhibitor used. P2Y₁₂ inhibitor monotherapy for secondary prevention is associated with a significant reduction in atherothrombotic events compared with aspirin alone without an increased risk of major bleeding. A meta-analysis of 9 randomized trials (61 623 patients) was conducted to compare P2Y₁₂ inhibitor monotherapy versus aspirin monotherapy for secondary prevention of cardiovascular events in patients with established atherosclerotic cardiovascular disease (coronary, cerebrovascular, or peripheral artery disease). The included studies had follow-up periods between 3 and 36 months. Monotherapy with P2Y₁₂ inhibitors (clopidogrel or ticagrelor) significantly reduced the risk of MACE by 11% (0.89, 95% CI 0.84–0.95, I² = 0%) and MI by 19% (0.81, 95% CI 0.71–0.92, I² = 0%) compared with aspirin monotherapy. There was no significant difference in the risk of stroke, all-cause mortality, or major bleeding. Subgroup analysis revealed that the reduction in MACE with P2Y₁₂ inhibitors was driven by a reduction in recurrence of the qualifying event. CI = confidence interval, P2Y12i = P2Y₁₂ inhibitor, RR = risk ratio.