Closing the gaps in cardiovascular prevention: nutrition, coronary calcium, and equitable implementation

Structured Abstract Importance Atherosclerotic cardiovascular disease (ASCVD) prevention remains deeply inequitable due to structural barriers, variable regional resource availability, and out-of-pocket healthcare costs. While guideline-directed preventive tools exist, their localized implementation is often dictated by structural socioeconomic disparities. Observations Traditional, clinic-centered preventive frameworks frequently fail marginalized urban populations. To bridge this gap, the community-embedded H.E.A.R.T. (Helping Everyone Address Risk Today) initiative was established, transitioning from race-based risk calculators to the PREVENT framework to deploy decentralized screening, health navigation, and culturally grounded nutrition resources in under-resourced neighborhoods. A key structural obstacle identified within this continuum is the underutilization of coronary artery calcium (CAC) scoring. While contemporary lipid guidelines place CAC at the center of shared clinical decision-making, the test remains highly restricted. Statewide legislative mandates for insurer coverage of CAC are currently limited to only four states, and traditional Medicare explicitly excludes stand-alone asymptomatic CAC screening. This systemic landscape translates directly into severe regional clinical disparities. In Louisville, Kentucky, a legacy of historical redlining manifests as a profound economic polarization and a severe life-expectancy deficit in the predominantly Black West End compared with the affluent East End. Hospital billing data from the Kentucky Hospital Association across the region reveal CAC imaging volumes are concentrated almost exclusively within high-income ZIP codes, while West End communities remain underrepresented, despite an elevated baseline burden of cardiovascular risk factors. Conclusions and Relevance Realizing equitable cardiovascular prevention requires shifting from passive clinic models to active, community-partnered networks. Mitigating disparities demands policy-level reforms, including legislation expanding insurance mandates for dedicated CAC scoring, and maximizing opportunistic automated screening via existing non-gated lung cancer CT scans.