Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association

The three members of the Vav family proteins form complexes that concur to foam cell formation and atherosclerosis

During foam cell formation and atherosclerosis development, the scavenger receptor CD36 plays critical roles in lipid uptake and triggering of atherogenicity via the activation of Vav molecules. The Vav family includes three highly conserved members known as Vav1, Vav2, and Vav3. As Vav1 and Vav3 were found to exert function in atherosclerosis development, it remains thus to decipher whether Vav2 also plays a role in the development of atherosclerosis. In this study we found that Vav2 deficiency in RAW264.7 macrophages significantly diminished oxidized LDL uptake and CD36 signaling, demonstrating that each Vav protein family member was required for foam cell formation. Genetic disruption of Vav2 in ApoE-deficient C57BL/6 mice significantly inhibited the severity of atherosclerosis. Strikingly, we further found that the genetic deletion of each member of the Vav protein family by CRISPR/Cas9 resulted in a similar alteration of transcriptomic profiles of macrophages. The three members of the Vav proteins were found to form complexes, and genetic ablation of each single Vav molecule was sufficient to prevent endocytosis of CD36. The functional interdependence of the three Vav family members in foam cell formation was due to their indispensable roles in transcriptomic programing, lipid uptake, and activation of the JNK kinase in macrophages.

Weekday Versus Weekend Presentation in the Acute Management of Ischemic Stroke Through Telemedicine

A "weekend effect" resulting in higher mortality rates for patients with stroke admitted on weekends has been reported. We examine this phenomenon for patients with acute ischemic stroke (AIS) presenting to telestroke (TS) sites to determine its effect on stroke alert process times and outcomes. From October 2015 to June 2017, we reviewed patients with AIS receiving intravenous alteplase within our TS network. We compared patients presenting to TS sites on weekdays (Monday 07:00 to Friday 18:59) to those presenting on weekends (Friday 19:00 to Monday 06:59). We analyzed door-to-alert activation, alert activation-to-TS evaluation, door-to-imaging, and door-to-needle times. Rates of favorable outcome (modified Rankin Scale score ≤2) and death at 90 days were compared. We identified 89 (54 weekday and 35 weekend) patients (mean age: 71.8 ± 13.3 years, 47.2% women) during the study period. Median door-to-alert activation (P = .01) and door-to-needle (P = .004) times were significantly longer for patients presenting on weekends compared to weekdays. There were no significant differences in median door-to-imaging (P = .1) and alert activation-to-TS evaluation (P = .07) times. Rates of favorable outcome (P = .19) and death (P = .56) at 90 days did not differ. While there were no significant differences in outcomes, patients presenting on weekends had longer door-to-alert activation and door-to-needle times. Efforts to improve methods in efficiency of care on weekends should be considered.

Posttraumatic Stress Disorder and Risk for Early Incident Atrial Fibrillation: A Prospective Cohort Study of 1.1 Million Young Adults

Background Acute psychological stress and negative emotions are known risk factors for atrial fibrillation (AF). Whether exposure to chronic stress syndromes, such as posttraumatic stress disorder (PTSD), also increases susceptibility to AF is unknown. Methods and Results We prospectively assessed the incidence of AF over a 13-year period among 988 090 young and middle-aged veterans (mean age, 30.29±9.19 years; 87.8% men, 64.5% white) who first accessed care through the Veterans Health Administration from October 2001 to November 2014 and were free of AF, atrial flutter, or atrial tachycardia at baseline. Time-varying, multivariate Cox proportional hazard models were used to examine the independent contribution of PTSD to new AF. We also tested for effect modification by sex and controlled for healthcare use. During a mean follow-up of 4.8 years, 2491 patients were diagnosed with AF. Patients with PTSD had a higher overall incidence of AF (P<0.0001) and were more likely to develop AF at a younger age than those without PTSD (P=0.004). PTSD was significantly associated with incident AF in unadjusted models (hazard ratio, 1.31; 95% CI, 1.19-1.43) and models that adjusted for demographics, lifestyle factors, cardiovascular risk factors, and depression (hazard ratio, 1.13; 95% CI, 1.02-1.24). The interaction with sex was nonsignificant (P=0.93). Conclusions PTSD was associated increased risk for early incident AF after adjustment for established AF risk factors and depression in this cohort of young and middle-aged veterans. Findings from this study require validation in more diverse populations to determine their generalizability.

Percutaneous coronary intervention outcomes in patients with stable coronary disease and left ventricular systolic dysfunction

AIMS

We sought to better understand the role of percutaneous coronary intervention (PCI) in patients with stable coronary artery disease (CAD) and moderate or severe left ventricular systolic dysfunction.

METHODS AND RESULTS

Using data from the Duke Databank for Cardiovascular Disease, we analysed patients who underwent coronary angiography at Duke University Medical Center (1995-2012) that had stable CAD amenable to PCI and left ventricular ejection fraction ≤35%. Patients with acute coronary syndrome or Canadian Cardiovascular Society class III or IV angina were excluded. We used propensity-matched Cox proportional hazards to evaluate the association of PCI with mortality and hospitalizations. Of 901 patients, 259 were treated with PCI and 642 with medical therapy. PCI propensity scores created from 24 variables were used to assemble a matched cohort of 444 patients (222 pairs) receiving PCI or medical therapy alone. Over a median follow-up of 7 years, 128 (58%) PCI and 125 (56%) medical therapy alone patients died [hazard ratio 0.87 (95% confidence interval 0.68, 1.10)]; there was also no difference in the rate of a composite endpoint of all-cause mortality or cardiovascular hospitalization [hazard ratio 1.18 (95% confidence interval 0.96, 1.44)] between the two groups.

CONCLUSIONS

In this well-profiled, propensity-matched cohort of patients with stable CAD amenable to PCI and moderate or severe left ventricular systolic dysfunction, the addition of PCI to medical therapy did not improve long-term mortality, or the composite of mortality or cardiovascular hospitalization. The impact of PCI on other outcomes in these high-risk patients requires further study.

Zebrafish heart regeneration: Factors that stimulate cardiomyocyte proliferation

Myocardial infarctions (MI) remain a leading cause of global morbidity and mortality, and a reason for this is the inability of adult, mammalian cardiomyocytes to divide post-MI. Recent studies demonstrate a limited population of cardiomyocytes retain their proliferative capacity and understanding how endogenous cardiomyocytes can be stimulated to re-enter the cell cycle is a focus of current research. In this review we discuss the history of zebrafish cardiac regeneration and highlight how different models reveal the molecular pathways important in driving cardiomyocyte proliferation after injury. Understanding the molecules that regulate cell cycle re-entry can provide insights into promoting cardiac repair in humans.

Trends in Blood Pressure and High-Sensitivity Cardiac Troponin-T With Cardiovascular Disease: The Cardiovascular Health Study

BACKGROUND

High-sensitivity cardiac troponin T (hs-cTnT) is individually associated with incident hypertension (HTN) and cardiovascular disease (CVD) events. We hypothesize that the increases in hs-cTnT with increases in blood pressure will be related to higher incidence of CVD.

METHODS

The Cardiovascular Health Study is a longitudinal cohort of older adults. Those with hs-cTnT data and CVD risk factors at baseline and follow-up (2-3 years later) were stratified based on systolic blood pressure (SBP; optimal: <120 mm Hg, intermediate: 120-139 mm Hg, elevated: ≥140 mm Hg) and hs-cTnT (undetectable: <5 ng/l, detectable: 5-13 ng/l, elevated: ≥14 ng/l) categories. SBP and hs-cTnT were classified as increased or decreased if they changed categories between exams, and stable if they did not. Cox regression evaluated incident CVD events over an average 9-year follow-up.

RESULTS

Among 2,219 adults, 510 (23.0 %) had decreased hs-cTnT, 1,279 (57.6 %) had stable hs-cTnT, and 430 (19.4 %) had increased hs-cTnT. Those with increased hs-cTnT had a higher CVD risk with stable SBP (hazard ratio [HR]: 1.28 [1.04-1.57], P = 0.02) or decreased SBP (HR: 1.57 [1.08-2.28], P = 0.02) compared to those within the same SBP group but a stable hs-cTnT. In those with lower SBP at follow-up, there was an inverse relation between diastolic blood pressure (DBP) and risk of CVD events in those with increased hs-cTnT (HR: 0.44 per 10 mm Hg increase, P < 0.01).

CONCLUSION

An increase in hs-cTnT over time is associated with a higher risk of CVD even when the blood pressure is stable or decreases over time.

Gender Disparities in Cardiac Rehabilitation Among Older Women: Key Opportunities to Improve Care

Older women with cardiovascular disease experience lower referral, participation, and completion rates of cardiac rehabilitation (CR), despite its well-established benefits (improved morbidity, mortality, quality of life, and functional capacity). Multiple social and health care system barriers affect participation of this population, including limitations in accessibility and transportation, competing responsibilities as caregivers, and lack of insight among patients and provider regarding the value of CR. With continued advances in technology and the ubiquity of smartphones, alternative CR programs may be able to better overcome barriers that affect older women.

Mechanisms by Which Glucagon-Like-Peptide-1 Receptor Agonists and Sodium-Glucose Cotransporter-2 Inhibitors Reduce Cardiovascular Risk in Adults With Type 2 Diabetes Mellitus

The growing global burden of type 2 diabetes mellitus confers significant morbidity and mortality in addition to significant cost to local health-care systems. In recent years, 2 classes of therapies have shown some promise in reducing the risk of adverse cardiovascular (CV) events: 1) glucagon-like-peptide-1 (GLP-1) receptor agonists and 2) sodium-glucose cotransporter-2 (SGLT-2) inhibitors. The mechanisms whereby these therapies reduce the risk of adverse CV outcomes are emerging. Both classes of therapies have overlapping yet distinct mechanisms of action. GLP-1 receptor agonists appear to target the incretin axis, inhibit gastric mobility pathways, modify CV risk factors through weight reduction, induce protection of ischemia/reperfusion injury and improve endothelial dysfunction. In comparison, SGLT-2 inhibitors appear to improve ventricular loading conditions, reduce sympathetic nervous system activation, reduce cardiac fibrosis, reduce renal hypoxia and renal-cardiac signalling, reduce left ventricular mass and improve cardiac energetics. In this review, we summarize the potential mechanisms whereby GLP-1 receptor agonists and SGLT-2 inhibitors improve CV outcomes in patients with type 2 diabetes and highlight evidence for their use in populations without diabetes.

Nanoparticle-Hydrogel System for Post-myocardial Infarction Delivery of MicroRNA

Effective therapies for cardiac repair and regeneration after myocardial infarction (MI) are rather limited. Although microRNAs (miRs) are known to play an important role in improving cardiac function after MI at a cellular level, delivering and retaining miRs at the target site has been challenging. To address this dilemma, several miR carriers have been developed, but these face their own limitations such as immunogenicity and poor targeting to the infarct site. In this Perspective, we summarize different mechanisms for miR administration and localization to cardiac tissue, with a specific focus on the clinically relevant injectable hydrogel and nanoparticle system developed by Yang et al. and reported in this issue of ACS Nano. We also highlight future directions for this field and outline the remaining unanswered questions.

Trends in Survival After Pediatric In-Hospital Cardiac Arrest in the United States

BACKGROUND

Cardiac arrest in hospitalized children is associated with poor outcomes, but no contemporary study has reported whether the trends in survival have changed over time. In this study, we examined temporal trends in survival for pediatric patients with an in-hospital pulseless cardiac arrest and pediatric patients with a nonpulseless cardiopulmonary resuscitation event from 2000 to 2018.

METHODS

This was an observational study of hospitalized pediatric patients (≤18 years of age) who received cardiopulmonary resuscitation from January 2000 to December 2018 and were included in the Get With The Guidelines-Resuscitation registry, a United States-based in-hospital cardiac arrest registry. The primary outcome was survival to hospital discharge, and the secondary outcome was return of spontaneous circulation (binary outcomes). Generalized estimation equations were used to obtain unadjusted trends in outcomes over time. Separate analyses were performed for patients with a pulseless cardiac arrest and patients with a nonpulseless event (bradycardia with poor perfusion) requiring cardiopulmonary resuscitation. A subgroup analysis was conducted for shockable versus nonshockable initial rhythms in pulseless events.

RESULTS

A total of 7433 patients with a pulseless cardiac arrest and 5751 patients with a nonpulseless event were included for the analyses. For pulseless cardiac arrests, survival was 19% (95% CI, 11%-29%) in 2000 and 38% (95% CI, 34%-43%) in 2018, with an absolute change of 0.67% (95% CI, 0.40%-0.95%; P<0.001) per year, although the increase in survival appeared to stagnate following 2010. Return of spontaneous circulation also increased over time, with an absolute change of 0.83% (95% CI, 0.53%-1.14%; P<0.001) per year. We found no interaction between survival to hospital discharge and the initial rhythm. For nonpulseless events, survival was 57% (95% CI, 39%-75%) in 2000 and 66% (95% CI, 61%-72%) in 2018, with an absolute change of 0.80% (95% CI, 0.32%-1.27%; P=0.001) per year.

CONCLUSIONS

Survival has improved for pediatric events requiring cardiopulmonary resuscitation in the United States, with a 19% absolute increase in survival for in-hospital pulseless cardiac arrests and a 9% absolute increase in survival for nonpulseless events between 2000 and 2018. However, survival from pulseless cardiac arrests appeared to have reached a plateau following 2010.

Association between long-term adherence to class-I recommended medications and risk for potentially preventable heart failure hospitalizations among younger adults

Background

Five guideline-recommended medication categories are available to treat patients who have heart failure (HF) with reduced ejection fraction. However, adherence to these medications is often suboptimal, which places patients at increased risk for poor health outcomes, including hospitalization. We aimed to examine the association between adherence to these medications and potentially preventable HF hospitalizations among younger insured adults with newly diagnosed HF.

Methods and results

Using the 2008–2012 IBM MarketScan Commercial database, we followed 26,439 individuals aged 18–64 years with newly diagnosed HF and calculated their adherence (using the proportion of days covered (PDC) algorithm) to the five guideline-recommended medication categories: angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers; beta blockers; aldosterone receptor antagonists; hydralazine; and isosorbide dinitrate. We determined the association between PDC and long-term preventable HF hospitalizations (observation years 3–5) as defined by the United States (U.S.) Agency for Healthcare Research and Quality. Overall, 49.0% of enrollees had good adherence (PDC≥80%), which was more common among enrollees who were older, male, residing in higher income counties, initially diagnosed with HF in an outpatient setting, and who filled prescriptions for fewer medication categories assessed. Adherence differed by medication category and was lowest for isosorbide dinitrate (PDC = 60.7%). In total, 7.6% of enrollees had preventable HF hospitalizations. Good adherers, compared to poor adherers (PDC<40%), were 15% less likely to have a preventable hospitalization (HR 0.85, 95% confidence interval, 0.75–0.96).

Conclusion

We found that approximately half of insured U.S. adults aged 18–64 years with newly diagnosed HF had good adherence to their HF medications. Patients with good adherence, compared to those with poor adherence, were less likely to have a potentially preventable HF hospitalization 3–5 years after their initial diagnosis. Because HF is a chronic condition that requires long-term management, future studies may want to assess the effectiveness of interventions in sustaining adherence.

Quantification of regional right ventricular strain in healthy rats using 3D spiral cine dense MRI

Statistical data from clinical studies suggests that right ventricular (RV) circumferential strain (Ecc) and longitudinal strain (Ell) are significant biomarkers for many cardiovascular diseases. However, a detailed and regional characterization of these strains in the RV is very limited. In the current study, RV images were obtained with 3D spiral cine DENSE MRI in healthy rats. An algorithm for surface growing was proposed in order to fit irregular topology. Specifically, a new custom plugin for the DENSEanalysis program, called 3D DENSE Plugin for Crescent Organ, was developed for surface reconstruction and precise segmentation of organs with sharp curvature, such as the murine RV. The RV free wall (RVFW) was divided into three longitudinal thirds (i.e., basal, middle, and apical) with each one partitioned into circumferential fourths (i.e., anterior, anteriorlateral, inferiorlateral and inferior). Peak systolic strains were quantified for each segment and comparisons were performed statistically. The inclusion of a new plugin was able to generate global values for Ecc and Ell that are in good agreement with previous findings using MRI. Despite no regional variation found in the peak Ecc, the peak Ell exhibited regional variation at the anterior side of the RV, which is potentially due to differences in biventricular torsion at the RV insertion point and fiber architecture. These results provide fundamental insights into the regional contractile function of the RV in healthy rat and could act as a normative baseline for future studies on regional changes induced by disease or treatment.

Shengmai Injection Suppresses Angiotensin II-Induced Cardiomyocyte Hypertrophy and Apoptosis via Activation of the AMPK Signaling Pathway Through Energy-Dependent Mechanisms

Shengmai injection (SMI), a traditional Chinese herbal medicine extracted from Panax ginseng C.A. Mey., Ophiopogon japonicus (Thunb.) Ker Gawl., and Schisandra chinensis (Turcz.) Baill., has been used to treat acute and chronic heart failure. This study aimed to further clarify the effects of SMI on energy metabolism. SMI could improve cell-survival rate and also reduce myocardial cell hypertrophy and apoptosis. Mitochondria are important sites of cellular energy metabolism, and SMI protects mitochondrial function which was evaluated by mitochondrial ultrastructure, mitochondrial respiratory control ratio (RCR), and mitochondrial membrane potential (ΔΨm) in this study. The expression levels of adenosine triphosphate (ATP), adenosine diphosphate (ADP), and phosphocreatine (PCr) increased. The expression levels of free fatty acid oxidation [carnitine palmitoyltransferase-1 (CPT-1)], glucose oxidation [glucose transporter-4 (GLUT-4)], and mitochondrial biogenesis-related genes (peroxisome proliferator-activated receptor-γ coactivator-1α [PGC-1α]) were upregulated after SMI treatment. AMP-activated protein kinase (AMPK) is an important signaling pathway regulating energy metabolism and also can regulate the above-mentioned indicators. In the present study, SMI was found to promote phosphorylation of AMPK. However, the effects of SMI on fatty acid, glucose oxidation, mitochondrial biogenesis, as well as inhibiting apoptosis of hypertrophic cardiomyocytes were partly blocked by AMPK inhibitor–compound C. Moreover, decreased myocardial hypertrophy and apoptosis treated by SMI were inhibited by AMPK knockdown with shAMPK to a certain degree and AMPK knockdown almost abolished the SMI-induced increase in the expression of GLUT-4, CPT-1, and PGC-1α. These data suggest that SMI suppressed Ang II–induced cardiomyocyte hypertrophy and apoptosis via activation of the AMPK signaling pathway through energy-dependent mechanisms.

25-Hydroxyvitamin D level, vitamin D intake, and risk of stroke: A dose-response meta-analysis

BACKGROUND & AIMS

A growing number of studies have shown that vitamin D are related to the risk of stroke, however, the dose-response association between vitamin D and the risk of stroke is still unclear. Accordingly, we conducted a dose-response meta-analysis to evaluate the relationships between 25-hydroxyvitamin D [25(OH)D] level, vitamin D intake, and the risk of stroke by summarizing cohort studies.

METHODS

PubMed, Embase, Cochrane and the Web of Science database were searched for related studies. Cohort studies examining the influence of 25(OH)D level and vitamin D intake on stroke risk were summarized. Dose-response relationships were determined using a random-effect model.

RESULTS

Twenty cohort studies involving 217,235 participants were included. The pooled relative risk for the high-versus-low categories was 0.74 (95% CI: 0.66-0.83) for 25(OH)D level, and 0.75 (95% CI: 0.57-0.98) for vitamin D intake. In addition, there were non-linear relationships between 25(OH)D level, vitamin D intake, and stroke risk. The incidence of stroke was reduced to its lowest point, with a reduction of about 20%, when 25(OH)D level was about 50 nmol/L or vitamin D intake was about 12 μg/day.

CONCLUSION

25(OH)D level and vitamin D intake were both inversely related to stroke risk, with a non-linear dose-response relationship.

Cardiorespiratory Fitness, Different Measures of Adiposity, and Cardiovascular Disease Mortality Risk in Women

Background: Associations among cardiorespiratory fitness (CRF), different adiposity exposures, and cardiovascular disease (CVD) mortality in women are not well defined. Materials and Methods: A total of 19,838 women completed a baseline examination between 1971 and 2013. Measures included body mass index (BMI), waist circumference (WC), waist-to-height (W:HT) ratio, skinfold-derived percent body fat (% Fat), and CRF estimated from a maximal treadmill test. CRF categories were low (quintile 1), moderate (quintiles 2-3), and high (quintiles 4-5); standard cut points were used for adiposity exposures. Hazard ratios (HRs) were estimated using Cox regression. Results: During a mean follow-up period of 19.2 ± 10.3 years, 391 cardiovascular deaths occurred. HRs (95% confidence interval) for CVD in moderate and low CRF groups, using high CRF as the referent, were 1.87 (1.46-2.38) and 2.54 (1.93-3.35), respectively (p trend <0.001). HRs of obese women within each adiposity exposure were higher when compared with normal-weight women (p ≤ 0.03). Joint associations of CRF × adiposity showed a positive trend in CVD mortality across decreasing categories of CRF within each category of W:HT and % Fat, as well as within the normal and overweight BMI categories and the normal WC category (p ≤ 0.03 for each). Conclusion: Higher levels of CRF are associated with lower CVD mortality risk in women, and predict lower risk of CVD mortality in normal-weight women and in obese women. Using different measures of adiposity to predict CVD mortality risk in women may be misleading unless CRF is taken into account. These results support the American Heart Association (AHA) recommendation for including CRF as a clinical vital sign.

MicroRNA-122 promotes cardiomyocyte hypertrophy via targeting FoxO3

OBJECTIVE

-microRNAs (miRNAs) have emerged as novel regulators for cardiac hypertrophy. MiR-122 is well recognized as a promising therapeutic target in liver disease, whereas recently plays important roles in cardiovascular diseases. The current study aimed to explore the effect of miR-122 on the pathogenesis of cardiomyocyte hypertrophy.

METHODS AND RESULTS

-The cardiomyocytes isolated from the neonatal rat ventricular cardiomyocytes (NRVMs) were collected and performed to Angiotensin II (Ang II) administration. We observed a dramatically increased miR-122 expression in hypertrophic cardiomyocytes. The NRVMs transfected with miR-122 mimic or negative control were utilized for the functional analysis. Overexpression of miR-122 increased the morphology size of cardiomyocytes and promoted the pro-hypertrophic genes expression, whereas downregulated the anti-hypertrophic genes upon Ang II stimulation. The bioinformatics analysis and luciferase reporter assays exhibited that miR-122 directly targeted FoxO3 and attenuated its gene level in hypertrophic cardiomyocytes. Moreover, miR-122 negatively regulated FoxO3 but promoted calcineurin signaling pathway activation. Importantly, FoxO3 overexpression significantly reversed the effect of miR-122 on cardiomyocyte hypertrophy.

CONCLUSION

-Collected, our finding demonstrated that miR-122 accelerated the development of cardiomyocytes hypertrophy partially via directly regulation of FoxO3-calcineurin pathway.

Stroke and thromboembolism prevention in atrial fibrillation

Prevention of stroke and systemic thromboembolism remains the cornerstone for management of atrial fibrillation (AF) and flutter. Multiple risk assessment models for stroke and systemic thromboembolism are currently available. The score, with its known limitations, remains as the recommended risk stratification tool in most major guidelines. Once at-risk patients are identified, vitamin K antagonists (VKAs) and, more recently, direct oral anticoagulants (DOACs) are the primary medical therapy for stroke prevention. In those with contraindication for long-term anticoagulation, left atrial appendage occluding devices are developing as a possible alternative therapy. Some controversy exists regarding anticoagulation management for cardioversion of acute AF (<48 hours); however, systemic anticoagulation precardioversion and postcardioversion is recommended for those with longer duration of AF. Anticoagulation management peri-AF ablation is also evolving. Uninterrupted VKA and DOAC therapy has been shown to reduce perioperative thromboembolic risk with no significant escalation in major bleeding. Currently, under investigation is a minimally interrupted approach to anticoagulation with DOACs periablation. Questions remain, especially regarding the delivery of anticoagulation care and integration of wearable rhythm monitors in AF management.

Prehospital advanced airway management for paediatric patients with out-of-hospital cardiac arrest: A nationwide cohort study

BACKGROUND

Although prehospital advanced airway management (AAM) (i.e., endotracheal intubation [ETI] and insertion of supraglottic airways [SGA]) has been performed for paediatric out-of-hospital cardiac arrest (OHCA), the effect of AAM has not been fully studied. We evaluated the association between prehospital AAM for paediatric OHCA and patient outcomes.

METHODS

We conducted an observational cohort study, using the All-Japan Utstein Registry between 2014 and 2016. We included paediatric patients (age <18 years) with OHCA. We calculated time-dependent propensity score at each minute after initiation of cardiopulmonary resuscitation by EMS providers, using a Fine-Gray regression model. We sequentially matched patients who received AAM during cardiac arrest to patients at risk of receiving AAM within the same minute (risk-set matching). The primary outcome was 1-month survival. Secondary outcome was 1-month survival with favourable functional status, defined as Cerebral Performance Category score of 1 or 2.

RESULTS

We analysed 3801 paediatric patients with OHCA. 481 patients (12.7%) received AAM and 3320 (87.3%) did not. Among the 3801 analysed patients, 912 patients underwent risk-set matching. In the matched cohort, AAM was not associated with 1-month survival (AAM: 52/456 [11.4%] vs. no AAM: 44/456 [9.6%]; risk ratio [RR], 1.15 [95% CI, 0.76-1.73]; risk difference [RD], 1.5% [-3.0 to 6.1%]) or favourable functional status (AAM: 9/456 [2.0%] vs. no AAM: 10/456 [2.2%]; RR, 0.69 [95% CI, 0.26-1.79]; RD, -0.8% [-2.9 to 1.3%]).

CONCLUSION

Among paediatric patients with OHCA, we found that prehospital AAM was not associated with 1-month survival or favourable functional status.

Internal Jugular Vein as Alternative Access for Implantation of a Wireless Pulmonary Artery Pressure Sensor

BACKGROUND

A wireless pulmonary artery pressure sensor (CardioMEMS) is approved for implantation via the femoral vein. The internal jugular vein (IJ) is an attractive alternative access route commonly used in pulmonary artery catheterization.

METHODS AND RESULTS

Retrospective chart review was performed for all sensor implants from 10 providers at 4 centers from September 2016 to June 2018. To compare procedural outcomes and discharge efficiency between groups, multivariate analyses incorporating potential confounders were performed. Seventy-three (28%) patients had femoral access, and 189 (72%) had IJ access; demographics were similar between the groups. Complications, including one case of hematoma and 4 cases of mild hemoptysis, and 30-day mortality (2%-3%) did not differ between groups. Provider preference for IJ access substantially increased over time, with IJ accounting for 90% of cases in 2018. After risk-adjustment, IJ cases had 20% (5%-33%) shorter fluoroscopy time (P=0.01) and 24% (7%-38%) lower contrast volume (P=0.008). Compared with outpatient femoral cases, outpatient IJ cases had 62% (52%-69%) faster needle-to-door time and were 34 times (6-235) more likely to have same-day discharge (P<0.001 for both).

CONCLUSIONS

IJ access for CardioMEMS implant is a safe alternative associated with superior procedural and discharge outcomes. Implanters at 4 high-volume centers adopted IJ access as the preferred implant approach.

Association of Long-Term Risk Factor Levels With Carotid Atherosclerosis: The Chicago Healthy Aging Magnetic Resonance Imaging Plaque Study (CHAMPS)

BACKGROUND

Absence of cardiovascular risk factors (RF) in young adulthood is associated with a lower risk for cardiovascular disease. However, it is unclear if low RF burden in young adulthood decreases the quantitative burden and qualitative features of atherosclerosis.

METHODS

Multi-contrast carotid magnetic resonance imaging was performed on 440 Chicago Healthy Aging Study participants in 2009 to 2011, whose RF (total cholesterol, blood pressure, diabetes mellitus, and smoking) were measured in 1967 to 1973. Participants were divided into 4 groups: low-risk (with total cholesterol <200 mg/dL and no treatment, blood pressure <120/80 mm Hg and no treatment, no smoking, and no diabetes mellitus), 0 high RF but some RF unfavorable (≥1 RF above low-risk threshold but below high-risk threshold), 1 high RF (total cholesterol ≥240 mg/dL or treated, blood pressure ≥140/90 or treated, diabetes mellitus, or smoking), and 2 or more high RF. Association of baseline RF status with carotid atherosclerosis (overall mean carotid wall thickness and lipid-rich necrotic core) at follow-up was assessed.

RESULTS

Among 424 participants with evaluable carotid magnetic resonance images, the mean age was 32 years at baseline and 73 years at follow-up; 67% were male, 86% white, and 36% were low-risk at baseline. Two or more high RF status was associated with higher carotid wall thickness (0.99±0.11 mm) and lipid-rich necrotic core prevalence (30%), as compared with low-risk group (0.94±0.09 mm and 17%, respectively). Each increment in baseline RF status was associated with higher carotid wall thickness (β-coefficient, 0.015; 95% CI, 0.004-0.026) and with higher lipid-rich necrotic core prevalence at older age (odds ratio, 1.26; 95% CI, 1.00-1.58) in models adjusted for baseline RF and demographics.

CONCLUSIONS

RF status in young adulthood is associated with the burden and quality of carotid atherosclerosis in older age suggesting that the decades-long protective effect of low-risk status might be mediated through a lower burden of quantitative and qualitative features of atherosclerotic plaque.

Dapagliflozin Effects on Biomarkers, Symptoms, and Functional Status in Patients With Heart Failure With Reduced Ejection Fraction: The DEFINE-HF Trial

BACKGROUND

Outcome trials in patients with type 2 diabetes mellitus have demonstrated reduced hospitalizations for heart failure (HF) with sodium-glucose co-transporter-2 inhibitors. However, few of these patients had HF, and those that did were not well-characterized. Thus, the effects of sodium-glucose co-transporter-2 inhibitors in patients with established HF with reduced ejection fraction, including those with and without type 2 diabetes mellitus, remain unknown.

METHODS

DEFINE-HF (Dapagliflozin Effects on Biomarkers, Symptoms and Functional Status in Patients with HF with Reduced Ejection Fraction) was an investigator-initiated, multi-center, randomized controlled trial of HF patients with left ventricular ejection fraction ≤40%, New York Heart Association (NYHA) class II-III, estimated glomerular filtration rate ≥30 mL/min/1.73m², and elevated natriuretic peptides. In total, 263 patients were randomized to dapagliflozin 10 mg daily or placebo for 12 weeks. Dual primary outcomes were (1) mean NT-proBNP (N-terminal pro b-type natriuretic peptide) and (2) proportion of patients with ≥5-point increase in HF disease-specific health status on the Kansas City Cardiomyopathy Questionnaire overall summary score, or a ≥20% decrease in NT-proBNP.

RESULTS

Patient characteristics reflected stable, chronic HF with reduced ejection fraction with high use of optimal medical therapy. There was no significant difference in average 6- and 12-week adjusted NT-proBNP with dapagliflozin versus placebo (1133 pg/dL (95% CI 1036-1238) vs 1191 pg/dL (95% CI 1089-1304), P=0.43). For the second dual-primary outcome of a meaningful improvement in Kansas City Cardiomyopathy Questionnaire overall summary score or NT-proBNP, 61.5% of dapagliflozin-treated patients met this end point versus 50.4% with placebo (adjusted OR 1.8, 95% CI 1.03-3.06, nominal P=0.039). This was attributable to both higher proportions of patients with ≥5-point improvement in Kansas City Cardiomyopathy Questionnaire overall summary score (42.9 vs 32.5%, adjusted OR 1.73, 95% CI 0.98-3.05), and ≥20% reduction in NT-proBNP (44.0 vs 29.4%, adjusted OR 1.9, 95% CI 1.1-3.3) by 12 weeks. Results were consistent among patients with or without type 2 diabetes mellitus, and other prespecified subgroups (all P values for interaction=NS).

CONCLUSIONS

In patients with heart failure and reduced ejection fraction, use of dapagliflozin over 12 weeks did not affect mean NT-proBNP but increased the proportion of patients experiencing clinically meaningful improvements in HF-related health status or natriuretic peptides. Benefits of dapagliflozin on clinically meaningful HF measures appear to extend to patients without type 2 diabetes mellitus.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT02653482.

GDMT for heart failure and the clinician's conundrum

Therapeutic advances in management of CHF have decreased mortality and have impacted progression in patients with mild to moderate heart failure. Aggressive campaigns by cardiology societies aimed at increasing implementation of these measures in routine practices have almost generalized the treatment of heart failure irrespective of individual variations of clinical status of patients and stages of heart failure. This explains why morbidity compression and quality of life improvement have not been realized fully particularly in patients with advanced disease. To examine whether GDMT for CHF is backed by unambiguous evidence of clinical efficacy for its global implementation in every patient at all stages of the syndrome. ACC/AHA, ESC Guidelines for CHF, and their updates were reviewed. Clinical trial cited in the guideline documents and other pertaining published literatures were analyzed.

Findings

Many of the recommended GDMT for CHF lack unequivocal evidence of clinical efficacy in patients with diverge etiology of heart failure and concomitant comorbid conditions Some of the recommendations which are useful in early stages, lack evidence of efficacy in more advanced stages of heart failure. Application of results of research trials in patients beyond their inclusion and exclusion criteria, appears mere extrapolation, Clinicians are faced with the conundrum of implementing the recommendations without indubitable evidence of their efficacy in every patient of their practice.

Conclusion

A reappraisal of Guidelines is needed to address outstanding questions pertaining to the efficacy of recommendations and plug the knowledge gaps without assumption and extrapolation of results of RCTs beyond their inclusion and exclusion criteria.

Social Network Mapping and Functional Recovery Within 6 Months of Ischemic Stroke

Objective. Stroke recovery is a multidimensional process influenced by biological and psychosocial factors. To understand the latter, we mapped the social networks of stroke patients, analyzing their changes and effects on physical function at 3 and 6 months after stroke. Methods. We used a quantitative social network assessment tool to map the structure and health habits embedded in patients' personal social networks. The physical function outcome was determined using the National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Scale (0-100, mean 50 for US general population). We used mixed-effects models to assess changes in social network metrics. We used multivariable models to test the association between social networks and physical function, independent of demographics, socioeconomic status, clinical characteristics, comorbidities, cognition, and depression. Results. The cohort consisted of 172 patients, with mostly mild motor-predominant stroke (median NIH Stroke Scale of 2) with retention of 149 at 3 months and 139 at 6 months. An average patient's network over 6 months contracted by 1.25 people and became denser and family oriented. Network composition also became healthier with pruning of ties with people who smoked or did not exercise. The baseline network size, and not density or health habits in the network, was independently associated with 3- and 6-month physical function PROMIS scores. Patients embedded in small kin-based networks reported more negative social interactions. Conclusions. Despite social networks becoming smaller and close-knit after stroke, they also become healthier. Larger baseline social networks are independently associated with better patient-reported physical function after stroke.

Can Acupuncture Treatment of Hypertension Improve Brain Health? A Mini Review

With age, cerebrovascular and neurodegenerative diseases (e.g., dementia and Alzheimer’s) are some of the leading causes of death in the United States. Related to these outcomes is the increased prevalence of hypertension, which independently increases the development of cerebrovascular and neurodegenerative diseases. While a direct mechanistic link between hypertension and poor brain health is unknown, many hypothesize that the etiology stems from poor blood pressure (BP) and cerebrovascular regulation. This dysfunction fosters hypoperfusion of the brain, causing stress to the tissue through a nutrient mismatch, subtly damaging the brain over many years. Current Western medical treatment relies on pharmacological treatment (mainly beta-blockers, angiotensin-converting enzyme inhibitors, or a combination of the two). However, Western treatments have not been successful in mitigating brain health outcomes and are burdened with unwanted side effects and non-adherence issues. Alternatively, traditional East Asia medicine has used acupuncture as a treatment for hypertension and may offer a promising approach in response to the limitations of conventional therapy. While detailed clinical and mechanistic experimental evidence is lacking, acupuncture has been observed to reduce BP and improve endothelial function in hypertensive adults. Further, acupuncture has been shown to have specific cerebrovascular effects, increasing cerebrovascular reactivity in healthy adults, highlighting possible neuroprotective properties. Therefore, our review is aimed at evaluating acupuncture as a treatment for hypertension and the potential impact on brain health. We will interrogate the current literature as well as discuss the proposed neural and vascular mechanisms by which acupuncture acts.

Intervenciones adaptadas en personas con enfermedad cardiovascular: hacia un abordaje de enfermería para el cuidado individualizado

A nivel mundial, las enfermedades cardiovasculares (ECV) constituyen la primera causa de morbimortalidad, lo que genera pérdida de años de vida productivos, discapacidad y muerte prematura, además de los costos sociales y para los sistemas de salud derivados de su atención1. Para el adecuado control de los factores de riesgo y el manejo de las ECV, se requiere que la persona modifique su estilo de vida, asuma hábitos saludables y se adhiera al tratamiento farmacológico. En este contexto, resulta indispensable no solamente lograr la participación activa del paciente en el mantenimiento de su propia salud2, sino también que los profesionales de la salud reconozcan al individuo como un ser activo, con habilidades para gestionar su salud, capaz de discernir y tomar decisiones dirigidas al logro de los objetivos terapéuticos. 

Effects of thymosin β4 on neuronal apoptosis in a rat model of cerebral ischemia‑reperfusion injury

The aim of the present study was to investigate the protective effects of thymosin β4 (Tβ4) on neuronal apoptosis in rat middle cerebral artery occlusion ischemia/reperfusion (MCAO I/R) injury, and determine the mechanisms involved in this process. Forty-eight adult male Sprague-Dawley rats were randomly divided into three groups (n=16 per group): A sham control group, an ischemia/reperfusion group (I/R group), and a Tβ4 group. The focal cerebral I/R model was established by blocking the right MCA for 2 h, followed by reperfusion for 24 h. The Zea-Longa method was used to assess neurological deficits. Cerebral infarct volume was assessed using 2,3,5-triphenyltetrazolium chloride staining, and pathological changes were observed via hematoxylin and eosin staining. The terminal dexynucleotidyl transferase (TdT)-mediated dUTP nick end labeling (TUNEL) assay was used to detect apoptosis. The expression of glucose-regulated protein 78 (GRP78), C/EBP homologous protein (CHOP), and caspase-12 (CASP12) protein was assessed using immunohistochemistry and western blotting 24 h after reperfusion. Infarct volume and neuronal damage in the I/R and Tβ4 groups were significantly greater than those observed in the sham group. The Zea-Longa score, neuronal apoptosis, and expression of GRP78, CHOP, and CASP12 in the I/R and Tβ4 groups were significantly higher than those reported in the sham group. However, the Longa score and neuronal apoptosis were lower in the Tβ4 group compared to the I/R group. The expression of GRP78 was significantly increased, whereas that of CHOP and CASP12 was significantly decreased in the Tβ4 group compared to the I/R group. The present data revealed that Tβ4 can inhibit neuronal apoptosis by upregulating GRP78 and downregulating CHOP and CASP12, thereby reducing cerebral I/R injury.

Invasive Management of Out of Hospital Cardiac Arrest

Out of hospital cardiac arrest (OHCA) is a major cause of morbidity and mortality worldwide. Clinical decision making is extremely difficult in this understudied patient population with high prevalence of neurological injury and inexorable shock states. As such, there are uncertain benefits from therapies available in the cardiac catheterization laboratory. Fear of futility and public reporting often affects decision making and can result in risk aversion. This review focuses on invasive management in OHCA care, with particular focus on coronary angiography, coronary revascularization, and mechanical support. Guidelines recommend emergency coronary angiography in patients with ST-segment elevations on ECG after OHCA, while the role of coronary angiography in patients without ST-segment elevations is less clear. Similar uncertainty remains in the appropriate revascularization strategy in these patients. As in other areas of cardiology, there is a growing interest in the role of mechanical circulatory support after OHCA, though the available literature shows mixed results. The many uncertainties associated with treating the patient with OHCA highlight the importance of clinical decision support tools and treatment algorithms in the care of this population. This review focuses on invasive management in OHCA care, with particular focus on coronary angiography, coronary revascularization, and mechanical support.

Myocardial delayed enhancement on dual-energy computed tomography: The prevalence and related factors in patients with suspicion of coronary artery disease

BACKGROUND

We aimed to assess the prevalence of myocardial delayed enhancement (MDE) in patients with suspected obstructive coronary artery disease (CAD), and to investigate factors related to the presence or absence of MDE.

METHODS

We retrospectively evaluated 191 consecutive patients who underwent coronary computed tomography angiography (CCTA) with MDE imaging for clinical suspicion of CAD from December 2014 to December 2016. The presence of MDE on iodine-density images using dual-energy CT was assessed by two independent readers. Multivariable logistic regression analyses were used to determine factors associated with the presence of MDE.

RESULTS

MDE was detected in 58 (30%) patients. Male gender, hypertension, prior heart failure (HF) hospitalization, and CCTA-detected CAD were independent factors related to the presence of MDE. When CCTA-detected CAD was excluded to narrow down the analysis to factors obtainable before CCTA, interventricular septum thickness (IVST) ≥12 mm was added as another independent factor. The combination of the following four factors: female gender, no history of hypertension, no history of prior HF hospitalization, and IVST < 12 mm demonstrated high specificity (98.3%) and positive predictive value (96.2%) for predicting the absence of MDE.

CONCLUSIONS

Male gender, hypertension, prior HF hospitalization, and CAD were independently associated with the presence of MDE in patients with suspected CAD. The combination of female gender, no history of hypertension, no history of prior HF hospitalization, and IVST < 12 mm is likely to be a helpful predictor in discriminating patients without MDE before CCTA.

Promoting Cardiovascular Health for African American Women: An Integrative Review of Interventions

Background: African American (AA) women bear a disproportionate burden of cardiovascular disease. Promoting ideal cardiovascular health is one strategy to promote health equity for this disparate population. The goal of this integrative review was to summarize and evaluate the research evidence for cardiovascular risk reduction interventions specifically targeting, tailored, or adapted for AA women. Materials and Methods: A review of the literature was conducted using the EBSCOHost platform. Study elements from articles in the final analysis were extracted. Results: Fourteen interventions were included in the final analysis (16 peer-reviewed articles). Most studies targeted two or more areas of cardiovascular health with the most common areas being physical activity and diet. Primary and secondary outcome measures varied; the most common measures were self-reported dietary intake, physical activity, and knowledge-related measures. Eleven studies reported health outcomes; only five reported long-term intervention effects. Most studies employed at least one cultural tailoring or adaptation strategy for AA women. The most common strategies included incorporating feedback from the target population before implementation and tailoring intervention material to reflect the target population. Conclusions: There is a need to develop and evaluate tailored or adapted evidence-based interventions for AA women. Additional research is needed to design interventions for subgroups of the population such as low-income or rural AA women.

Self-rated health after stroke: a systematic review of the literature

BACKGROUND

Self-rated health (SRH) allows for comparison and identification of the health status of various populations. The aim of this study was to conduct a systematic review of the literature to expand the understanding of SRH after stroke.

METHODS

This systematic review was registered with PROSPERO (CRD42017056194) and conducted according to PRISMA guidelines. Studies published until December 2018 that evaluated the SRH of adults with stroke were included.

RESULTS

Of the 2132 identified studies, 51 were included. Only four studies had experimental designs (7.8%). In 60.7% of the studies, SRH was assessed by variations on direct questions (i.e., general and comparative SRH). Analog visual scales and quality of life instruments were also used to evaluate SRH, but there is no consensus regarding whether they are appropriate for this purpose. The results of cross-sectional and longitudinal studies revealed significant associations between poor SRH and stroke as well as between SRH, function, and disability. The power of SRH to predict stroke mortality is still uncertain. Two interventions (a home-based psychoeducational program concerning stroke health care and family involvement in functional rehabilitation) effectively improved SRH.

CONCLUSIONS

Direct questions are the most common method of evaluating SRH after stroke. Studies reported significant associations between the SRH of individuals with stroke and several relevant health outcomes. However, few experimental studies have evaluated SRH after stroke. Interventions involving health education and family involvement had a significant impact on SRH.

Exosomes in Coronary Artery Disease

Exosomes, the nanosized vesicles released from various cell types, contain many bioactive molecules, such as proteins, lipids, and nucleic acids, which can participate in intercellular communication in a paracrine manner or an endocrine manner, in order to maintain the homeostasis and respond to stress adaptively. Currently, exosomes have already been utilized as diagnostic biomarkers and therapeutic tools in cancer clinical trials. There has also been great progress in cell and animal exosomes studies of coronary artery disease (CAD). Emerging evidence suggests that exosomes released from endothelial cells, smooth muscle cells, adipose cells, platelets, cardiomyocytes, and stem cells have been reported to play crucial roles in the development and progression of CAD. Moreover, it has been showed that exosomes released from different cell types exhibit diverse biological functions, either detrimental or protective, depending on the cell state and the microenvironment. However, the systematic knowledge of exosomes in CAD at the patient level has not been well established, which are far away from clinical application. This review summarizes the basic information about exosomes and provides an update of the recent findings on exosome-mediated intercellular communication in the development and progression of CAD, which could be helpful for understanding the pathophysiology of CAD and promoting the further potential clinical translation.

Cardiovascular Risk/Benefit Profile of MHT

Background and Objectives: Data emerging from the Women’s Health Initiative (WHI) study point toward an association between menopausal hormone therapy (MHT) and cardiovascular (CV) risk. However, post hoc subgroup analyses stratifying participants according to their age and time since menopause, have opened the way to a better understanding of the relationship between estrogen and CV risk. The aim of this review was to revise the current literature and evaluate the CV risk or benefit following administration of MHT considering several factors such as MHT timing, dose, route of administration, and formulation. Materials and Methods: An electronic databases search of MEDLINE (PubMed), Cochrane Central Register of Controlled Trials, Web of Science, SCOPUS, congress abstracts, and Grey literature (Google Scholar; British Library) was performed, with the date range from each database’s inception until June 2019. All the studies evaluating MHT and cardiovascular risk, including thromboembolism or stroke, were selected. Results: Timing of MHT initiation was shown to be a critical factor in CV risk assessment. In concordance with the “timing hypothesis”, healthy symptomatic women who initiated MHT when aged younger than 60 years, or who were within 10 years of menopause onset, have demonstrated a reduction in both coronary heart disease (CHD) risk and all-cause mortality. In particular, MHT therapy was associated with improvement of subclinical signs of atherosclerosis. Venous thromboembolism (VTE) risk is reduced when low doses of oral estrogen are used. Moreover, transdermal hormonal application significantly reduces CV risk compared with oral administration. MHT impact on the CV system is influenced by either factors inherent to the specific regimen, or factors inherent to the specific patient. Hence, individualization of care is necessary. Conclusion: CV risk calculation should be considered by clinicians in order to exclude patients with high CV risk, in whom MHT is contraindicated. Assessing risks and benefits in a patient-centered approach according to individual’s features, health status, and personal preferences is important in order to realize a safe and effective treatment.

Oxidative Stress in Cardiovascular Diseases: Still a Therapeutic Target?

Cardiovascular diseases (CVD) are complex entities with heterogenous pathophysiologic mechanisms and increased oxidative stress has been viewed as one of the potential common etiologies. A fine balance between the presence of reactive oxygen species (ROS) and antioxidants is essential for the proper normal functioning of the cell. A basal concentration of ROS is indispensable for the manifestation of cellular functions, whereas excessive levels of ROS cause damage to cellular macromolecules such as DNA, lipids and proteins, eventually leading to necrosis and apoptotic cell death. CVD is the main cause of death worldwide with several conditions being affected by oxidative stress. Increased ROS lead to decreased nitric oxide availability and vasoconstriction, promoting arterial hypertension. ROS also negatively influence myocardial calcium handling, causing arrhythmia, and augment cardiac remodeling by inducing hypertrophic signaling and apoptosis. Finally, ROS have also been shown to promote atherosclerotic plaque formation. This review aims at giving an introduction into oxidative stress in CVD, with special focus on endothelial dysfunction, and then examining in detail the role of oxidative stress in the most prevalent of these diseases. Finally, potential nutraceuticals and diets that might be beneficial in diminishing the burden of oxidative stress in CVD are presented.

Predictors for early motor improvement in patients with ischemic stroke

Disability as a stroke consequence is reported by 3% males and 2% females in general population. Motor deficits are common in stroke patients, but their complete recovery is seen only in a minority of cases. Assessment of motor deficits uses clinical methods, especially standardized scales, but also electrophysiological and imagistic methods. The motor recovery is a continuous process, maximal in the first month after stroke, decreasing gradually over the first 6 months. Most powerful predictors for motor recovery are clinical parameters: severity of motor deficit, onset of first voluntary movements after stroke in the first 48-72 hours, a continuous improvement in motor function during the first 8 weeks, a good postural control during the first month, young age, male sex, left hemispheric stroke and absence of other neurological impairments are strong positive predictors. Presence of motor-evoked potentials in paretic muscles and imagistic parameters as location, stroke volume and motor pathways integrity are paraclinical predictors for recovery. There are no specific biomarker which is efficient in predicting recovery. In patients with poor chances for recovery according to actual predictors, the development of more precise algorithms to assess functional outcome is needed, in order to support the choice of appropriate methods and intensity of rehabilitation treatment. Key words: ischemic stroke rehabilitation, functional assessment, motor improvement, recovery predictors, prognostic factors,

Stem Cell-Derived Exosomes Protect Astrocyte Cultures From in vitro Ischemia and Decrease Injury as Post-stroke Intravenous Therapy

In the present study, we assessed efficacy of exosomes harvested from human and mouse stem cell cultures in protection of mouse primary astrocyte and neuronal cell cultures following in vitro ischemia, and against ischemic stroke in vivo. Cell media was collected from primary mouse neural stem cell (NSC) cultures or from human induced pluripotent stem cell-derived cardiomyocyte (iCM) cultures. Exosomes were extracted and purified by polyethylene glycol complexing and centrifugation, and exosome size and concentration were determined with a NanoSite^TM particle analyzer. Exosomes were applied to primary mouse cortical astrocyte or neuronal cultures prior to, and/or during, combined oxygen-glucose deprivation (OGD) injury. Cell death was assessed via lactate dehydrogenase (LHD) and propidium iodide staining 24 h after injury. NSC-derived exosomes afforded marked protection to astrocytes following OGD. A more modest (but significant) level of protection was observed with human iCM-derived exosomes applied to astrocytes, and with NSC-derived exosomes applied to primary neuronal cultures. In subsequent experiments, NSC-derived exosomes were injected intravenously into adult male mice 2 h after transient (1 h) middle cerebral artery occlusion (MCAO). Gross motor function was assessed 1 day after reperfusion and infarct volume was assessed 4 days after reperfusion. Mice treated post-stroke with intravenous NSC-derived exosomes exhibited significantly reduced infarct volumes. Together, these results suggest that exosomes isolated from mouse NSCs provide neuroprotection against experimental stroke possibly via preservation of astrocyte function. Intravenous NSC-derived exosome treatment may therefore provide a novel clinical adjuvant for stroke in the immediate post-injury period.

Dexmedetomidine protects H9c2 cardiomyocytes against oxygen-glucose deprivation/reoxygenation-induced intracellular calcium overload and apoptosis through regulating FKBP12.6/RyR2 signaling

Purpose

Intracellular calcium ([Ca²⁺]i) overload is a major cause of cell injury during myocardial ischemia/reperfusion (I/R). Dexmedetomidine (DEX) has been shown to exert anti-inflammatory and organ protective effects. This study aimed to investigate whether pretreatment with DEX could protect H9c2 cardiomyocytes against oxygen-glucose deprivation/reoxygenation (OGD/R) injury through regulating the Ca²⁺ signaling.

Methods

H9c2 cardiomyocytes were subjected to OGD for 12 h, followed by 3 h of reoxygenation. DEX was administered 1 h prior to OGD/R. Cell viability, lactate dehydrogenase (LDH) release, level of [Ca²⁺]i, cell apoptosis, and the expression of 12.6-kd FK506-binding protein/ryanodine receptor 2 (FKBP12.6/RyR2) and caspase-3 were assessed.

Results

Cells exposed to OGD/R had decreased cell viability, increased LDH release, elevated [Ca²⁺]i level and apoptosis rate, down-regulated expression of FKBP12.6, and up-regulated expression of phosphorylated-Ser2814-RyR2 and cleaved caspase-3. Pretreatment with DEX significantly blocked the above-mentioned changes, alleviating the OGD/R-induced injury in H9c2 cells. Moreover, knockdown of FKBP12.6 by small interfering RNA abolished the protective effects of DEX.

Conclusion

This study indicates that DEX pretreatment protects the cardiomyocytes against OGD/R-induced injury by inhibiting [Ca²⁺]i overload and cell apoptosis via regulating the FKBP12.6/RyR2 signaling. DEX may be used for preventing cardiac I/R injury in the clinical settings.

Cardiac regenerative therapy: Many paths to repair

Cardiovascular disease remains the primary cause of death in the United States and in most nations worldwide, despite ongoing intensive efforts to promote cardiac health and treat heart failure. Replacing damaged myocardium represents perhaps the most promising treatment strategy, but also the most challenging given that the adult mammalian heart is notoriously resistant to endogenous repair. Cardiac regeneration following pathologic challenge would require proliferation of surviving tissue, expansion and differentiation of resident progenitors, or transdifferentiation of exogenously applied progenitor cells into functioning myocardium. Adult cardiomyocyte proliferation has been the focus of investigation for decades, recently enjoying a renaissance of interest as a therapeutic strategy for reversing cardiomyocyte loss due in large part to ongoing controversies and frustrations with myocardial cell therapy outcomes. The promise of cardiac cell therapy originated with reports of resident adult cardiac stem cells that could be isolated, expanded and reintroduced into damaged myocardium, producing beneficial effects in preclinical animal models. Despite modest functional improvements, Phase I clinical trials using autologous cardiac derived cells have proven safe and effective, setting the stage for an ongoing multi-center Phase II trial combining autologous cardiac stem cell types to enhance beneficial effects. This overview will examine the history of these two approaches for promoting cardiac repair and attempt to provide context for current and future directions in cardiac regenerative research.

Toward a unified theory of aging and regeneration

Growing evidence supports the antagonistic pleiotropy theory of mammalian aging. Accordingly, changes in gene expression following the pluripotency transition, and subsequent transitions such as the embryonic–fetal transition, while providing tumor suppressive and antiviral survival benefits also result in a loss of regenerative potential leading to age-related fibrosis and degenerative diseases. However, reprogramming somatic cells to pluripotency demonstrates the possibility of restoring telomerase and embryonic regeneration pathways and thus reversing the age-related decline in regenerative capacity. A unified model of aging and loss of regenerative potential is emerging that may ultimately be translated into new therapeutic approaches for establishing induced tissue regeneration and modulation of the embryo-onco phenotype of cancer.

Assessment of Age-related Oxygenation Changes in Calf Skeletal Muscle by Photoacoustic Imaging: A Potential Tool for Peripheral Arterial Disease

Peripheral artery disease is often asymptomatic, and various imaging and nonimaging techniques have been used for assessment and monitoring treatments. This study is designed to demonstrate the ability of photoacoustic imaging to noninvasively determine changes in tissue oxygenation that occur in mice's hind limb skeletal muscle as they age. Mice from two age cohorts were scanned bilaterally with a pulsed laser. The photoacoustic signal was unmixed to generate a parametric map of estimated oxygen saturation and then overlaid on grayscale ultrasound images. Tissue oxygenation measured in young and old mice was compared. Photoacoustic imaging visually and quantitatively showed the decrease in skeletal muscle oxygenation that occurs with age. Percent tissue oxygenation decreased from 30.2% to 3.5% (p < 0.05). This reduction corresponded to reduced fractional area of oxygenation, which decreased from 60.6% to 6.0% (p < 0.05). The change in oxygenation capacity of the still active vascular regions was insignificant (p > 0.05). Intrasubject, intra-, and interobserver comparisons showed low variability in measurements, exhibited by high regression and intraclass correlations exceeding 0.81 for all ages. The decrease in oxygenation detected by photoacoustic imaging paralleled the known oxygenation decrease observed in aging tissues, demonstrating that photoacoustic imaging can assess age-related changes in a mouse calf muscle. These intramuscular changes could potentially act as a strong diagnostic marker for peripheral artery disease. This study thus opens the doors for a novel, affordable, noninvasive method of evaluation free of radiation or exogenous material.

α-Tocopherol preserves cardiac function by reducing oxidative stress and inflammation in ischemia/reperfusion injury

OBJECTIVE

Myocardial infarction (MI) is a leading cause of mortality and morbidity worldwide and new treatment strategies are highly sought-after. Paradoxically, reperfusion of the ischemic myocardium, as achieved with early percutaneous intervention, results in substantial damage to the heart (ischemia/reperfusion injury) caused by cell death due to aggravated inflammatory and oxidative stress responses. Chronic therapy with vitamin E is not effective in reducing the cardiovascular event rate, presumably through failing to reduce atherosclerotic plaque instability. Notably, acute treatment with vitamin E in patients suffering a MI has not been systematically investigated.

METHODS AND RESULTS

We applied alpha-tocopherol (α-TOH), the strongest anti-oxidant form of vitamin E, in murine cardiac ischemia/reperfusion injury induced by ligation of the left anterior descending coronary artery for 60 min. α-TOH significantly reduced infarct size, restored cardiac function as measured by ejection fraction, fractional shortening, cardiac output, and stroke volume, and prevented pathological changes as assessed by state-of-the-art strain and strain-rate analysis. Cardioprotective mechanisms identified, include a decreased infiltration of neutrophils into cardiac tissue and a systemic anti-inflammatory shift from Ly6Chigh to Ly6Clow monocytes. Furthermore, we found a reduction in myeloperoxidase expression and activity, as well as a decrease in reactive oxygen species and the lipid peroxidation markers phosphatidylcholine (PC) (16:0)-9-hydroxyoctadecadienoic acid (HODE) and PC(16:0)-13-HODE) within the infarcted tissue.

CONCLUSION

Overall, α-TOH inhibits ischemia/reperfusion injury-induced oxidative and inflammatory responses, and ultimately preserves cardiac function. Therefore, our study provides a strong incentive to test vitamin E as an acute therapy in patients suffering a MI.