Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association

Efficacy and Safety of Armolipid Plus®: An Updated PRISMA Compliant Systematic Review and Meta-Analysis of Randomized Controlled Clinical Trials

Armolipid Plus® is a multi-constituent nutraceutical that claims to improve lipid profiles. The aim of this PRISMA compliant systematic review and meta-analysis was to globally evaluate the efficacy and safety of Armolipid Plus® on the basis of the available randomized, blinded, controlled clinical trials (RCTs). A systematic literature search in several databases was conducted in order to identify RCTs assessing the efficacy and safety of dietary supplementation with Armolipid Plus®. Two review authors independently identified 12 eligible studies (1050 included subjects overall) and extracted data on study characteristics, methods, and outcomes. Meta-analysis of the data suggested that dietary supplementation with Armolipid Plus® exerted a significant effect on body mass index (mean difference (MD) = -0.25 kg/m2, p = 0.008) and serum levels of total cholesterol (MD = -25.07 mg/dL, p < 0.001), triglycerides (MD = -11.47 mg/dL, p < 0.001), high-density lipoprotein cholesterol (MD = 1.84 mg/dL, p < 0.001), low-density lipoprotein cholesterol (MD = -26.67 mg/dL, p < 0.001), high sensitivity C reactive protein (hs-CRP, MD = -0.61 mg/L, p = 0.022), and fasting glucose (MD = -3.52 mg/dL, p < 0.001). Armolipid Plus® was well tolerated. This meta-analysis demonstrates that dietary supplementation with Armolipid Plus® is associated with clinically meaningful improvements in serum lipids, glucose, and hs-CRP. These changes are consistent with improved cardiometabolic health.

Use of a convolutional neural network to identify infarct core using computed tomography perfusion parameters

Purpose

Computed tomography perfusion (CTP) is used to diagnose ischemic strokes through contralateral hemisphere comparisons of various perfusion parameters. Various perfusion parameter thresholds have been utilized to segment infarct tissue due to differences in CTP software and patient baseline hemodynamics. This study utilized a convolutional neural network (CNN) to eliminate the need for non-universal parameter thresholds to segment infarct tissue.

Methods

CTP data from 63 ischemic stroke patients was retrospectively collected and perfusion parameter maps were generated using Vitrea CTP software. Infarct ground truth labels were segmented from diffusion-weighted imaging (DWI) and CTP and DWI volumes were registered. A U-net based CNN was trained and tested five separate times using each CTP parameter (cerebral blood flow (CBF), cerebral blood volume (CBV), time-to-peak (TTP), mean-transit-time (MTT), delay time). 8,352 infarct slices were utilized with a 60:30:10 training:testing:validation split and Monte Carlo cross-validation was conducted using 20 iterations. Infarct volumes were reconstructed following segmentation from each CTP slice. Infarct spatial and volumetric agreement was compared between each CTP parameter and DWI.

Results

Spatial agreement metrics (Dice coefficient, positive predictive value) for each CTP parameter in predicting infarct volumes are: CBF=(0.67, 0.76), CBV=(0.44, 0.62), TTP=(0.60, 0.67), MTT=(0.58, 0.62), delay time=(0.57, 0.60). 95% confidence intervals for volume differences with DWI infarct are: CBF=14.3±11.5 mL, CBV=29.6±21.2 mL, TTP=7.7±15.2 mL, MTT=-10.7±18.6 mL, delay time=-5.7±23.6 mL.

Conclusions

CBF is the most accurate CTP parameter in segmenting infarct tissue. Segmentation of infarct using a CNN has the potential to eliminate non-universal CTP contralateral hemisphere comparison thresholds.

Investigation of Lipid Metabolism in Dynamic Progression of Coronary Artery Atherosclerosis of Humans by Time-of-Flight Secondary Ion Mass Spectrometry

Alterations in lipid metabolites in coronary artery tissues are phenotypic changes in the progression of atherosclerosis (AS). A full picture of the spatiotemporal distribution of lipid metabolites in coronary AS is needed for a deeper understanding of its pathology and the identification of potential biomarkers of disease progression. In this work, the changes in species, quantity, and distribution of lipid metabolites at different stages of AS, which were standardized by the disease areas, were analyzed through the high spatial resolution- and high sensitivity-time-of-flight secondary ion mass spectrometry (ToF-SIMS) under delayed extraction mode. Based on high lateral resolution imaging, we further analyzed the ToF-SIMS data extracted from the subregions of AS lesion tissues at different disease progression stages by semiquantitative comparison, clustering analysis (t-stochastic neighbor embedding and HCA), and KEGG enrichment. Thus, a much-detailed description of lipids' features in coronary AS was achieved. We constructed a ToF-SIMS mass spectrometry database of coronary AS lipids. 40 specific lipid metabolites with distinctive patterns between different pathological stages were obtained. Chemical imaging unveiled further details regarding the spatial distribution of lipids. Moreover, linoleic acid and arachidonic acid metabolic pathway were predicted to be critical in AS progression.

Stress and Cardiometabolic Disease Risk for Indigenous Populations throughout the Lifespan

BACKGROUND

Indigenous people experience the greatest cardiometabolic disease disparity in the Unites States, yet high cardiometabolic disease risk factors do not fully explain the extent of the cardiometabolic disease disparity for Indigenous people. Stress, trauma, and racism occur at high rates within Indigenous communities and have not been well explored as significant contributors to cardiometabolic disease disparities despite emerging literature, and therefore will be described here.

METHODS

This descriptive study explores the relationship between cardiometabolic disease risks and Indigenous-specific stressors (e.g., early childhood stress and trauma, adulthood stress and trauma, and historical and intergenerational trauma) using current literature. Indigenous-specific protective factors against cardiometabolic disease are also reviewed.

RESULTS

Increasing research indicates that there is a relationship between Indigenous-specific stressful and traumatic life experiences and increased cardiometabolic disease risk. Mental health and psychophysiology play an important role in this relationship. Effective interventions to reduce cardiometabolic disease risk in Indigenous communities focus on ameliorating the negative effects of these stressors through the use of culturally specific health behaviors and activities.

CONCLUSIONS

There is increasing evidence that cultural connection and enculturation are protective factors for cardiometabolic disease, and may be galvanized through Indigenous-led training, research, and policy change.

Cardiometabolism as an Interlocking Puzzle between the Healthy and Diseased Heart: New Frontiers in Therapeutic Applications

Cardiac metabolism represents a crucial and essential connecting bridge between the healthy and diseased heart. The cardiac muscle, which may be considered an omnivore organ with regard to the energy substrate utilization, under physiological conditions mainly draws energy by fatty acids oxidation. Within cardiomyocytes and their mitochondria, through well-concerted enzymatic reactions, substrates converge on the production of ATP, the basic chemical energy that cardiac muscle converts into mechanical energy, i.e., contraction. When a perturbation of homeostasis occurs, such as an ischemic event, the heart is forced to switch its fatty acid-based metabolism to the carbohydrate utilization as a protective mechanism that allows the maintenance of its key role within the whole organism. Consequently, the flexibility of the cardiac metabolic networks deeply influences the ability of the heart to respond, by adapting to pathophysiological changes. The aim of the present review is to summarize the main metabolic changes detectable in the heart under acute and chronic cardiac pathologies, analyzing possible therapeutic targets to be used. On this basis, cardiometabolism can be described as a crucial mechanism in keeping the physiological structure and function of the heart; furthermore, it can be considered a promising goal for future pharmacological agents able to appropriately modulate the rate-limiting steps of heart metabolic pathways.

Response Time Threshold for Predicting Outcomes of Patients with Out-of-Hospital Cardiac Arrest

Ambulance response time is a prognostic factor for out-of-hospital cardiac arrest (OHCA), but the impact of ambulance response time under different situations remains unclear. We evaluated the threshold of ambulance response time for predicting survival to hospital discharge for patients with OHCA. A retrospective observational analysis was conducted using the emergency medical service (EMS) database (January 2015 to December 2019). Prehospital factors, underlying diseases, and OHCA outcomes were assessed. Receiver operating characteristic (ROC) curve analysis with Youden Index was performed to calculate optimal cut-off values for ambulance response time that predicted survival to hospital discharge. In all, 6742 cases of adult OHCA were analyzed. After adjustment for confounding factors, age (odds ratio [OR] = 0.983, 95% confidence interval [CI]: 0.975-0.992, p < 0.001), witness (OR = 3.022, 95% CI: 2.014-4.534, p < 0.001), public location (OR = 2.797, 95% CI: 2.062-3.793, p < 0.001), bystander cardiopulmonary resuscitation (CPR, OR = 1.363, 95% CI: 1.009-1.841, p=0.044), EMT-paramedic response (EMT-P, OR = 1.713, 95% CI: 1.282-2.290, p < 0.001), and prehospital defibrillation using an automated external defibrillator ([AED] OR = 3.984, 95% CI: 2.920-5.435, p < 0.001) were statistically and significantly associated with survival to hospital discharge. The cut-off value was 6.2 min. If the location of OHCA was a public place or bystander CPR was provided, the threshold was prolonged to 7.2 min and 6.3 min, respectively. In the absence of a witness, EMT-P, or AED, the threshold was reduced to 4.2, 5, and 5 min, respectively. The adjusted OR of EMS response time for survival to hospital discharge was 1.217 (per minute shorter, CI: 1.140-1299, p < 0.001) and 1.992 (<6.2 min, 95% CI: 1.496-2.653, p < 0.001). The optimal response time threshold for survival to hospital discharge was 6.2 min. In the case of OHCA in public areas or with bystander CPR, the threshold was prolonged, and without witness, the optimal response time threshold was shortened.

Prevalence of dyslipidemia and associated risk factors among adult residents of Mekelle City, Northern Ethiopia

Introduction

Dyslipidemia is a major risk factor for cardiovascular diseases (CVD). The prevalence of dyslipidemia is not known among Ethiopian adults. The prevalence is expected to rise due to the socio-economic development accompanied by lifestyle changes. This study was conducted to estimate the prevalence of dyslipidemia and associated risk factors among adult residents of Mekelle City.

Methods

A community-based cross-sectional study was conducted among 321 randomly selected subjects. Data were collected on sociodemographic, anthropometric, lifestyle, and clinical characteristics of the participants using the WHO STEPS survey instrument. Data were analyzed using SPSS software version 24.0. Student’s t-test and Pearson’s Chi-square test were used to assessing the interrelationship between each factor and outcome variables. Bivariate and multivariable logistic regression analysis were used to identify risk factors associated with dyslipidemia. All statistical significance was considered at p ≤0.05.

Results

The prevalence of dyslipidemia in this study was 66.7%. The prevalence of high low-density lipoprotein cholesterol (LDL-C), elevated triglyceride, elevated total cholesterol, and low high-density lipoprotein cholesterol (HDL-C) was 49.5%, 40.2%, 30.8%, and 16.5%, respectively. Being above 64 years (aOR: 2.196, 95% CI: 1.183–4.078) and 40–64 years old (aOR: 2.196, 95% CI: 1.183–4.078), overweight (aOR: 2.50, 95% CI: 1.314–4.756) and obesity (aOR: 15.489, 95% CI: 3.525–68.070), walking <150 minutes per week (aOR: 1.722, 95% CI: 1.004–2.953), raised fasting blood glucose (FBG) (aOR: 4.804, 95% CI: 1.925–11.988), and medium socio-economic status (aOR: 2.017, 95% CI: 1.044–3.899) were identified as significant predictors of dyslipidemia.

Conclusions

The finding of this study indicated that the prevalence of dyslipidemia is unacceptably high among adult residents of Mekelle City, which underlines an urgent need for early detection and public health interventions through the integrated involvement of public, governmental, and non-governmental organizations.

Lipoprotein receptor signalling in atherosclerosis

The founding member of the lipoprotein receptor family, low-density lipoprotein receptor (LDLR) plays a major role in the atherogenesis through the receptor-mediated endocytosis of LDL particles and regulation of cholesterol homeostasis. Since the discovery of the LDLR, many other structurally and functionally related receptors have been identified, which include low-density lipoprotein receptor-related protein (LRP)1, LRP5, LRP6, very low-density lipoprotein receptor, and apolipoprotein E receptor 2. The scavenger receptor family members, on the other hand, constitute a family of pattern recognition proteins that are structurally diverse and recognize a wide array of ligands, including oxidized LDL. Among these are cluster of differentiation 36, scavenger receptor class B type I and lectin-like oxidized low-density lipoprotein receptor-1. In addition to the initially assigned role as a mediator of the uptake of macromolecules into the cell, a large number of studies in cultured cells and in in vivo animal models have revealed that these lipoprotein receptors participate in signal transduction to modulate cellular functions. This review highlights the signalling pathways by which these receptors influence the process of atherosclerosis development, focusing on their roles in the vascular cells, such as macrophages, endothelial cells, smooth muscle cells, and platelets. Human genetics of the receptors is also discussed to further provide the relevance to cardiovascular disease risks in humans. Further knowledge of the vascular biology of the lipoprotein receptors and their ligands will potentially enhance our ability to harness the mechanism to develop novel prophylactic and therapeutic strategies against cardiovascular diseases.

Nateglinide Exerts Neuroprotective Effects via Downregulation of HIF-1α/TIM-3 Inflammatory Pathway and Promotion of Caveolin-1 Expression in the Rat's Hippocampus Subjected to Focal Cerebral Ischemia/Reperfusion Injury

Ischemic stroke is a major cause of death and motor disabilities all over the world. It is a muti-factorial disorder associated with inflammatory, apoptotic, and oxidative responses. Nateglinide (NAT), an insulinotropic agent used for the treatment of type 2 diabetes mellitus, recently showed potential anti-inflammatory and anti-apoptotic effects. The aim of our study was to elucidate the unique neuroprotective role of NAT in the middle cerebral artery occlusion (MCAO)-induced stroke in rats. Fifty-six male rats were divided to 4 groups (n = 14 in each group): the sham-operated group, sham receiving NAT (50 mg/kg/day, p.o) group, ischemia/reperfusion (IR) group, and IR receiving NAT group (50 mg/kg/day, p.o). MCAO caused potent deficits in motor and behavioral functions of the rats. Significant increase in inflammatory and apoptotic biomarkers has been observed in rats' hippocampi. Janus kinase 2 (JAK2)/signal transducer and activator of transcription 3 (STAT3) pathway was significantly stimulated causing activation of series inflammatory biomarkers ending up neuro-inflammatory milieu. Pretreatment with NAT preserved rats' normal behavioral and motor functions. Moreover, NAT opposed the expression of hypoxia-inducible factor-1α (HIF-1α) resulting in downregulation of more inflammatory mediators namely, NF-κB, tumor necrosis factor-β (TNF-β), and the anti-survival gene PMAIP-1. NAT stimulated caveolin-1 (Cav-1) which prevented expression of oxidative biomarkers, nitric oxide (NO), and myeloperoxidase (MPO) and hamper the activation of apoptotic biomarker caspase-3. In conclusion, our work postulated that NAT exhibited its neuroprotective effects in rats with ischemic stroke via attenuation of different unique oxidative, apoptotic, and inflammatory pathways.

Protective Role of Polyphenols in Heart Failure: Molecular Targets and Cellular Mechanisms Underlying Their Therapeutic Potential

Heart failure (HF) is a leading cause of death in the United States, with a 5-year mortality rate of 50% despite modern pharmacological therapies. Plant-based diets are comprised of a diverse polyphenol profile, which lends to their association with reduced cardiovascular disease risk. Whether a polyphenol-rich diet can slow the progression of or reverse HF in humans is not known. To date, in vitro and in vivo studies have reported on the protective role of polyphenols in HF. In this review, we will discuss the major mechanisms by which polyphenols mitigate HF in vitro and in vivo, including (1) reduced cardiac inflammation and oxidative stress, (2) reduced mitochondrial dysfunction, (3) improved Ca²⁺ homeostasis, (4) increased survival signaling, and (5) increased sirtuin 1 activity.

The Regulatory Functions of lncRNAs on Angiogenesis Following Ischemic Stroke

Ischemic stroke is one of the leading causes of global mortality and disability. It is a multi-factorial disease involving multiple factors, and gene dysregulation is considered as the major molecular mechanisms underlying disease progression. Angiogenesis can promote collateral circulation, which helps the restoration of blood supply in the ischemic area and reduces ischemic necrosis following ischemic injury. Aberrant expression of long non-coding RNAs (lncRNAs) in ischemic stroke is associated with various biological functions of endothelial cells and serves essential roles on the angiogenesis of ischemic stroke. The key roles of lncRNAs on angiogenesis suggest their potential as novel therapeutic targets for future diagnosis and treatment. This review elucidates the detailed regulatory functions of lncRNAs on angiogenesis following ischemic stroke through numerous mechanisms, such as interaction with target microRNAs, downstream signaling pathways and target molecules.

Dual Energy Computed Tomography of Internal Carotid Artery: A Modified Dual-Energy Algorithm for Calcified Plaque Removal, Compared With Digital Subtraction Angiography

Background: Atherosclerotic disease of the internal carotid artery (ICA) is a common reason for ischemic stroke. Computed tomography angiography (CTA) is a common tool for evaluation of internal carotid artery (ICA) stenosis. However, blooming artifacts caused by calcified plaques might lead to overestimation of the stenosis grade. Furthermore, the intracranial ICA is more vulnerable to calcification than other ICA segments. The proposed technique, dual-energy computed tomography (DECT) with a modified three-material decomposition algorithm may facilitate the removal of calcified plaques and thus increase diagnostic accuracy.

Objectives: The objective of the study is to assess the accuracy of the modified three-material decomposition algorithm for grading intracranial ICA stenosis after calcified plaque removal, with digital subtraction angiography (DSA) used as a reference standard.

Materials and Methods: In total, 41 patients underwent DECT angiography and DSA. The three-material decomposition DECT algorithm for calcium removal was applied. We evaluated 64 instances of calcified stenosis using conventional CTA, the previous non-modified calcium removal DECT technique, the modified DECT algorithm, and DSA. The correlation coefficient (r²) between the results generated by the modified algorithm and DSA was also calculated.

Results: The virtual non-calcium images (VNCa) produced by the previous non-modified calcium removal algorithm were named VNCa 1, and those produced by the modified algorithm were named VNCa 2. The assigned degree of stenosis of VNCa 1 (mean stenosis: 39.33 ± 19.76%) differed significantly from that of conventional CTA images (mean stenosis: 59.03 ± 25.96%; P = 0.001), DSA (13.19 ± 17.12%, P < 0.001). VNCa 1 also significantly differed from VNCa 2 (mean stenosis: 15.35 ± 18.70%, P < 0.001). In addition, there was a significant difference between the degree of stenosis of VNCa 2 and conventional CTA images (P < 0.001). No significant differences were observed between VNCa 2 and DSA (P = 0.076). The correlation coefficient (r²) between the stenosis degree of the VNCa 2 and DSA images was 0.991.

Conclusions: The proposed DECT with a modified three-material decomposition algorithm for calcium removal has high sensitivity for the detection of relevant stenoses, and its results were more strongly correlated with DSA than with those of conventional CTA or the previous non-modified algorithm. Further, it overcomes CTA's previous problem of overestimating the degree of stenosis because of blooming artifacts caused by calcified plaques. It is useful to account for calcified plaques while evaluating carotid stenosis.

High Coronary Wall Shear Stress Worsens Plaque Vulnerability: A Systematic Review and Meta-Analysis

Aim:

The aim of this meta-analysis is to assess the impact of wall shear stress (WSS) severity on arterial plaque vulnerability.

Methods:

We systematically searched electronic databases and selected studies which assessed the relationship between WSS measured by intravascular ultrasound and coronary artery plaque features. In 7 studies, a total of 615 patients with 28 276 arterial segments (median follow-up: 7.71 months) were identified. At follow-up, the pooled analysis showed high WSS to be associated with regression of plaque fibrous area, weighted mean difference (WMD) −0.11 (95% CI: −0.20 to −0.02, P = .02) and fibrofatty area, WMD −0.09 (95% CI: −0.17 to −0.01, P = .02), reduction in plaque total area, WMD −0.09 (95% CI: −0.14 to −0.04, P = .007) and increased necrotic core area, and WMD 0.04 (95% CI: 0.01-0.09, P = .03) compared with low WSS. Dense calcium deposits remained unchanged in high and low WSS (0.01 vs 0.02 mm²; P > .05). High WSS resulted in profound remodeling (40% vs 18%, P < .05) and with more constructive remodeling than low WSS (78% vs 40%, P < .01).

Conclusions:

High WSS in coronary arteries is associated with worsening plaque vulnerability and more profound arterial wall remodeling compared with low WSS.

Engineering and Assessing Cardiac Tissue Complexity

Cardiac tissue engineering is very much in a current focus of regenerative medicine research as it represents a promising strategy for cardiac disease modelling, cardiotoxicity testing and cardiovascular repair. Advances in this field over the last two decades have enabled the generation of human engineered cardiac tissue constructs with progressively increased functional capabilities. However, reproducing tissue-like properties is still a pending issue, as constructs generated to date remain immature relative to native adult heart. Moreover, there is a high degree of heterogeneity in the methodologies used to assess the functionality and cardiac maturation state of engineered cardiac tissue constructs, which further complicates the comparison of constructs generated in different ways. Here, we present an overview of the general approaches developed to generate functional cardiac tissues, discussing the different cell sources, biomaterials, and types of engineering strategies utilized to date. Moreover, we discuss the main functional assays used to evaluate the cardiac maturation state of the constructs, both at the cellular and the tissue levels. We trust that researchers interested in developing engineered cardiac tissue constructs will find the information reviewed here useful. Furthermore, we believe that providing a unified framework for comparison will further the development of human engineered cardiac tissue constructs displaying the specific properties best suited for each particular application.

Hyperhomocysteinemia is an emerging comorbidity in ischemic stroke

Hyperhomocysteinemia or systemic elevation of the amino acid homocysteine is a common metabolic disorder that is considered to be a risk factor for ischemic stroke. However, it is still unclear whether predisposition to hyperhomocysteinemia could contribute to the severity of stroke outcome. This review highlights the advantages and limitations of the current rodent models of hyperhomocysteinemia, describes the consequence of mild hyperhomocysteinemia on the severity of ischemic brain damage in preclinical studies and summarizes the mechanisms involved in homocysteine induced neurotoxicity. The findings provide the premise for establishing hyperhomocysteinemia as a comorbidity for ischemic stroke and should be taken into consideration while developing potential therapeutic agents for stroke treatment.

Decreased plasma musclin levels are associated with potential atrial fibrillation in non-diabetic patients

Background

Musclin is involved in the regulation of natriuretic peptide (NP) clearance and may affect the concentration of atrial natriuretic peptide (ANP). It has also been found to play an important role in several diseases, such as diabetes mellitus and hypertension. Both abnormalities in ANP and associated medical history are involved in the pathogenesis of atrial fibrillation (AF). However, plasma concentration of musclin as a biomarker for risk stratification in patients with AF has not been fully investigated.

Methods

Plasma musclin levels were measured in 290 patients with AF (including 199 paroxysmal AF patients and 91 persistent AF patients) and 120 control subjects. The association between plasma musclin levels and AF onset, as well as its predictive effects on clinical outcomes after cryoballoon ablation were analyzed.

Results

AF patients were found to have a lower concentration of plasma musclin than healthy controls. Moreover, in the non-diabetic group and normal N-terminal pro-brain natriuretic peptide (NT-proBNP) level group, the association between lower plasma concentration of musclin and AF remained significant. According to receiver operating characteristic (ROC) curve analysis, the optimal cut-off point of musclin for predicting AF onset was 54.94 ng/mL, which had a sensitivity of 81.67% and a specificity of 31.47% [area under the ROC curve (AUC) =60.71%]. In follow-up studies, both diabetes and left atrial size were independent predictors of AF recurrence after ablation, while musclin showed only a modest relationship with the outcome of cryoballoon ablation.

Conclusions

Our data indicated that decreased musclin was associated with the onset of AF. Moreover, lower plasma levels of musclin were an independent risk factor of AF in non-diabetic patients. Our studies suggest that musclin could be a predictive factor for the onset of AF.

A METHOD FOR DETECTING CORONARY ARTERY STENOSIS BASED ON ECG SIGNALS

Coronary heart disease (CHD) is a typical cardiovascular disease whose occurrence and development is a long process. Timely and accurate diagnosis of patients with varying degrees of coronary artery stenosis (VDCAS) is conducive to accurate treatment and prognosis assessment. This study aims to correctly classify VDCAS patients by utilizing multi-domain features fusion of single-lead 5-min ECG signals and machine learning methods, so as to provide reference for doctors to judge the CHD development process. ECG signals were collected from 206 subjects with CHD, mild CHD, thoracalgia and normal coronary angiograms (TNCA), and healthy. Then, the time, frequency, time–frequency, and nonlinear domain features of ECG signals were extracted to establish a multi-domain feature set. To get the optimum subset of features, the recursive feature elimination (RFE) and information gain (IG) were selected. Subsequently, eXtreme Gradient Boosting (XGBoost) and random forest (RF) were adopted for classification. Results indicated that RFE combined with XGBoost was significantly effective in classifying VDCAS patients. When the four categories of subjects (CHD, mild CHD, TNCA, and healthy) were classified, the average accuracy, sensitivity, specificity, and F1-score of the proposed method were 91.74%, 89.39%, 96.80%, and 90.09%, respectively. Besides, three categories of subjects (no stenosis, luminal narrowing [Formula: see text] 50%, and luminal narrowing [Formula: see text] 50%) and two categories of subjects (CHD and healthy) were also analyzed, and the average accuracy was 91.27% and 98.46%, respectively. The results suggest that the proposed method can provide reference for doctors to judge VDCAS patients.

The effects of marital status on outcome of heart failure population: a systematic review and meta-analysis

BACKGROUND

Traditional risk factors for worse outcome in heart failure (HF) are well-established. However, there are still many unknown risk factors for worse outcome in this population. Several studies have shown that unmarried status is associated with an increased risk of rehospitalization and mortality in HF patients. However, there is no systematic review or meta-analysis to confirm this association. We performed a systematic review and meta-analysis to explore the effect of marital status on outcome regarding mortality and rehospitalization in HF population.

METHODS

We searched the databases of MEDLINE and EMBASE from inception to July 2019. Included studies were published cohort studies or randomised controlled trials reporting rates of mortality and/or rehospitalization in HF patients, married and unmarried. Data from each study were combined using the random-effects model.

RESULTS

Ten studies were included in our meta-analysis. We found that unmarried status is associated with increased risk of mortality (pooled OR = 1.52, 95%CI = 1.30-1.78, p < .001), increased risk of rehospitalization (pooled OR = 1.80, 95%CI = 1.18-2.74, p = .007), and increased risk of combined endpoint of mortality and rehospitalization (pooled OR = 1.72, 95%CI = 1.36-2.17, p < .001).

CONCLUSIONS

Our meta-analysis demonstrated that being unmarried, divorced, and widowed is associated with a worse outcome in HF population regarding mortality and rehospitalization rate.

Decomposing Race and Ethnic Differences in CVD Risk Factors for Mid-life Women

OBJECTIVE

This study decomposes race and ethnic differences in hypertension, waist circumference, obesity and allostatic load between black non-Hispanic (BNH), Mexican American (MA), and white non-Hispanic (WNH) women.

DATA

This study uses 10,109 observations from The National Health and Nutrition Examination Survey from years 1999-2014 for BNH, MA women, and WNH between 40 and 75 years old.

METHODOLOGY

We used the Oaxaca-Blinder decomposition to explore how demographic, socioeconomic, healthcare access, and health behavior factors are associated with race and ethnic differences in blood pressure, waist circumference, body mass index (BMI), and allostatic load score (ALS).

RESULTS

We found that demographic factors, socioeconomic status, healthcare access, and health behaviors explained from 0 to 50% of the difference in CVD risk factors between BNH and WNH. However, these factors explain from 39 to 100% of the difference in CVD risk factors between MA and WNH. Differences in demographic, socioeconomic, access to care, and health behavior factor variables explained very little of the differences in CVD risk factors between NHB and MA women.

CONCLUSION

The impact of the determinants on CVD risk factors varies by race and ethnicity. Efforts to address differences in CVD risk factors should promote health equity programs and acknowledge that even race and ethnic groups that have similar demographic, SES, access to care, and health behavior factors can have different outcomes.

Advanced In Vitro Modeling to Study the Paradox of Mechanically Induced Cardiac Fibrosis

In heart failure, cardiac fibrosis is the result of an adverse remodeling process. Collagen is continuously synthesized in the myocardium in an ongoing attempt of the heart to repair itself. The resulting collagen depositions act counterproductively, causing diastolic dysfunction and disturbing electrical conduction. Efforts to treat cardiac fibrosis specifically have not been successful and the molecular etiology is only partially understood. The differentiation of quiescent cardiac fibroblasts to extracellular matrix-depositing myofibroblasts is a hallmark of cardiac fibrosis and a key aspect of the adverse remodeling process. This conversion is induced by a complex interplay of biochemical signals and mechanical stimuli. Tissue-engineered 3D models to study cardiac fibroblast behavior in vitro indicate that cyclic strain can activate a myofibroblast phenotype. This raises the question how fibroblast quiescence is maintained in the healthy myocardium, despite continuous stimulation of ultimately profibrotic mechanotransductive pathways. In this review, we will discuss the convergence of biochemical and mechanical differentiation signals of myofibroblasts, and hypothesize how these affect this paradoxical quiescence. Impact statement Mechanotransduction pathways of cardiac fibroblasts seem to ultimately be profibrotic in nature, but in healthy human myocardium, cardiac fibroblasts remain quiescent, despite continuous mechanical stimulation. We propose three hypotheses that could explain this paradoxical state of affairs. Furthermore, we provide suggestions for future research, which should lead to a better understanding of fibroblast quiescence and activation, and ultimately to new strategies for the prevention and treatment of cardiac fibrosis and heart failure.

Metformin attenuates ischemia/reperfusion-induced apoptosis of cardiac cells by downregulation of p53/microRNA-34a via activation of SIRT1

Metformin has been demonstrated to be beneficial for the treatment of an impaired myocardium as a result of ischemia/reperfusion (I/R) injury, and miR-34a may be involved in this process. The aim of the present study was to determine the mechanisms by which metformin attenuated myocardial I/R injury-induced apoptosis. In the in vivo I/R model using Sprague-Dawley rats, metformin reduced the area of damaged myocardium and serum creatine MB isoform (CKMB) activity resulting in protection of the myocardium. Metformin also reduced apoptosis and the expression of apoptosis associated proteins, including caspase 3 and cleaved caspase, and decreased the expression of miR-34a, which is upregulated during I/R injury, which in turn resulted in corresponding changes in expression of Bcl-2, a direct target of miR-34a both in vitro and in vivo. To further examine the role of miR-34a in this process, H9C2 cells were transfected by a miR-34a mimic and inhibitor. Overexpression of miR-34a increased apoptosis in H9C2 cells induced by oxygen-glucose deprivation/recovery and knockdown of miR-34a expression-reduced apoptosis under the same conditions. Therefore, the effect of metformin on miR-34a in vitro were assessed. Metformin decreased the deacetylation activity of silent information regulator 1 resulting in reduced Ac-p53 levels, which reduced the levels of pri-miR-34a, and thus in turn reduced miR-34a levels. To confirm these results clinically, 90 patients with ST-segment elevation myocardial infarction following percutaneous coronary intervention were recruited. Patients who took metformin regularly before infarction had lower miR-34a levels and lower serum CKMB activity. Metformin also improved the sum ST-segment recovery following I/R injury. In conclusion, metformin may be helpful in the treatment of myocardial I/R.

Deep convolutional neural networks to predict cardiovascular risk from computed tomography

Coronary artery calcium is an accurate predictor of cardiovascular events. While it is visible on all computed tomography (CT) scans of the chest, this information is not routinely quantified as it requires expertise, time, and specialized equipment. Here, we show a robust and time-efficient deep learning system to automatically quantify coronary calcium on routine cardiac-gated and non-gated CT. As we evaluate in 20,084 individuals from distinct asymptomatic (Framingham Heart Study, NLST) and stable and acute chest pain (PROMISE, ROMICAT-II) cohorts, the automated score is a strong predictor of cardiovascular events, independent of risk factors (multivariable-adjusted hazard ratios up to 4.3), shows high correlation with manual quantification, and robust test-retest reliability. Our results demonstrate the clinical value of a deep learning system for the automated prediction of cardiovascular events. Implementation into clinical practice would address the unmet need of automating proven imaging biomarkers to guide management and improve population health.

Case Report: Brain Metastasis Confined to the Infarcted Area Following Stroke

Background: Ischemic stroke and cancer are frequent in the elderly and are the two common causes of death and disability. They are related to each other, and cancer may lead to ischemic stroke and vice versa. If patients with cancer exhibited recurrent acute neurological deficits after index stroke, a cancer-related stroke could be considered. However, a brain metastasis is another common cause of neurological complications and has a poor prognosis in patients with ischemic stroke and comorbid cancer. Here, we report a rare case of metastatic cancer that occurred after index stroke in a patient with renal cell carcinoma (RCC) and unusual imaging findings. Through the case, we discuss the pathophysiology and probable predisposing factors for metastatic disease in areas of infarction. Case Presentation: A 48-year-old man presented with sudden onset of left facial palsy and hemiparesis. He had a history of hypertension and RCC with pulmonary metastases treated with radical nephrectomy and chemotherapy. Brain magnetic resonance imaging (MRI) revealed multiple scattered acute infarctions in the right insular, frontal, parietal, and left occipital cortices. There were no definite sources of embolism. Eight months after the index stroke, he presented with subacute onset of progressive left hemiparesis. He had no focal neurological deficits except left-sided weakness and left nasolabial fold blunting. MRI scan demonstrated partial diffusion restriction on the right frontotemporal cortices without decline of apparent diffusion coefficient values on the corresponding lesions and T1 hypointensities and T2 hyperintensities with perilesional vasogenic edema on the right insular, frontal, parietal, and left occipital cortices, indicative of brain metastases confined to the area of previous infarctions. Conclusions: Cerebral infarctions can cause neovascularization and disruption of the blood-brain barrier. Moreover, the compartmentalized cavity formed by the ischemic injury may accept a large volume of metastatic tumor cells. Such an altered microenvironment of infarcted tissue would be suitable for the colonization and proliferation of metastatic seed. Further, brain metastases should be considered, in addition to recurrence, when new focal neurological deficits develop in patients with ischemic stroke and comorbid cancer.

Ethnic and sex differences in the longitudinal association between heart rate variability and blood pressure

PURPOSE

Elevated blood pressure is a risk factor for increased cardiovascular morbidity and mortality. Decreased vagally-mediated heart rate variability has previously been prospectively linked with increased blood pressure; however, to date, no such prospective data exist regarding this relationship among Blacks.

MATERIALS AND METHODS

We examined this association in 387 normotensive young adults (mean age, 23 years, 52% female, 54% Black) who participated in two laboratory evaluations spanning approximately six years. Blood pressure was measured at both timepoints with a non-invasive oscillometric device and heart rate variability was assessed via bio-impedance.

RESULTS

In the total sample, heart rate variability significantly predicted systolic (p = .022) and diastolic (p < .001) blood pressure increases six years into the future. However, this pattern varied as a function of ethnicity and sex with the effect of heart rate variability on Time 2 systolic blood pressure only significant among White males (p = .007). Heart rate variability was also predictive of Time 2 diastolic blood pressure in White males (p = .038) as well as among both White (p = .032) and Black (p = .015) females, but was not related to blood pressure among Black males.

CONCLUSION

We report for the first time significant ethnic and sex differences in the prospective relationship between heart rate variability and blood pressure change. These findings may give clues as to the underlying mechanisms that are involved in the well-known health disparities in blood pressure and hypertension-related cardiovascular diseases.

Impact of hyperthyroidism on in-hospital outcomes of patients with heart failure

Congestive heart failure (CHF) exacerbations are a frequent cause of hospitalization. Thyroid hormones impact myocardial function; elevated levels of thyroxine, as seen in hyperthyroidism (HT), can worsen CHF symptoms. We retrospectively evaluated the Hospital Corporation of America (HCA) Enterprise Data Warehouse and examined mortality and length of stay (LOS) in patients hospitalized with CHF with and without a diagnosis of HT. 55,031 patients with CHF were identified. The presence of HT was not significantly associated with mortality (p = 0.24) nor LOS (p = 0.32). A significant difference in the distribution of sex (p = 0.001) and age (p = 0.002) was noted, with a higher percentage of females and a lower median age in patients with HT. There was a significant difference in LOS (p = 0.04) for patients with a cardiovascular comorbidity, who had a mean LOS of 6.33 days versus 5.31 days for patient without HT.

TRPV4 Mediates Cardiac Fibrosis via the TGF-β1/Smad3 Signaling Pathway in Diabetic Rats

Emerging evidence shows that the transient receptor potential vanilloid 4 (TRPV4) channel is involved in fibrosis in many organs. However, its role in diabetic cardiac fibrosis remains unclear. Our aim was to evaluate the expression level of TRPV4 in the diabetic heart and clarify its role in diabetes-induced cardiac fibrosis. A diabetic animal model was induced by a single intraperitoneal injection of streptozotocin into Sprague-Dawley rats. We also investigated cardiac fibroblasts isolated from neonatal Sprague-Dawley rats. TRPV4 expression was significantly upregulated in both diabetic myocardium and cardiac fibroblasts cultured in high-glucose medium. Masson's trichrome staining revealed that the TRPV4 antagonist HC067047 attenuated the diabetes-induced cardiac fibrosis. Furthermore, HC067047 reduced collagen Ι synthesis and suppressed the transforming growth factor beta 1 (TGF-β1) level as well as the phosphorylation of Smad3 in the diabetic heart. In addition, the TRPV4 antagonist inhibited the proliferation of cardiac fibroblasts, collagen Ι synthesis, and activation of the TGF-β1/Smad3 signaling pathway induced by high-glucose culture medium. Our findings demonstrate that the upregulation of TRPV4 expression mediates diabetic cardiac fibrosis via activation of the TGF-β1/Smad3 signaling pathway.

Artificial-Intelligence-Enhanced Mobile System for Cardiovascular Health Management

The number of patients with cardiovascular diseases is rapidly increasing in the world. The workload of existing clinicians is consequently increasing. However, the number of cardiovascular clinicians is declining. In this paper, we aim to design a mobile and automatic system to improve the abilities of patients’ cardiovascular health management while also reducing clinicians’ workload. Our system includes both hardware and cloud software devices based on recent advances in Internet of Things (IoT) and Artificial Intelligence (AI) technologies. A small hardware device was designed to collect high-quality Electrocardiogram (ECG) data from the human body. A novel deep-learning-based cloud service was developed and deployed to achieve automatic and accurate cardiovascular disease detection. Twenty types of diagnostic items including sinus rhythm, tachyarrhythmia, and bradyarrhythmia are supported. Experimental results show the effectiveness of our system. Our hardware device can guarantee high-quality ECG data by removing high-/low-frequency distortion and reverse lead detection with 0.9011 Area Under the Receiver Operating Characteristic Curve (ROC–AUC) score. Our deep-learning-based cloud service supports 20 types of diagnostic items, 17 of them have more than 0.98 ROC–AUC score. For a real world application, the system has been used by around 20,000 users in twenty provinces throughout China. As a consequence, using this service, we could achieve both active and passive health management through a lightweight mobile application on the WeChat Mini Program platform. We believe that it can have a broader impact on cardiovascular health management in the world.

Depression and Rehospitalization in Patients With Heart Failure After Discharge From Hospital to Home: An Integrative Review

Patients with heart failure are known to be particularly vulnerable to depression resulting in adverse health outcomes. However, there has been no literature review on current evidence regarding the relationship between depression and rehospitalization. This review aims to explore the relationship between depression and rehospitalization in patients with heart failure. A systematic review employing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines included articles published between 2001 and 2019 taken from Scopus, PubMed, CINAHL, and PsycINFO databases. We identified 12 relevant studies with participants ranging from 115 to 160,169 patients. Heart failure patients with depression were more likely to be rehospitalized than those without. To explain this, few reasons have been proposed. First, depression could disrupt the regulation of autonomic nervous system, neurohormonal activation, and body’s natural rhythm. Second, depressed patients tend to have poor adherence to medication. Healthcare providers should not only focus on drug and dietary management but also on implementing effective interventions to manage depression, in order to reduce the risk of rehospitalization. Moreover, palliative care should start at the stage of heart failure diagnosis to improve quality of life, better outcomes, and lower cost of care for the patients.

Rare cause of cardioembolic stroke and central retinal artery occlusion

Primary cardiac valve tumours are rare. This is a case report of a 32-year-old non-smoker man with a history of stroke 1 year prior and no other cardiovascular risk factors. The patient was admitted to our acute stroke ward for recurrent left hemiparesis, slurring of speech, facial asymmetry and central retinal artery occlusion. Initial laboratory investigations and ECG were normal. An urgent CT brain showed a large hypodense area at the right frontal, parietal, temporal, occipital region with effaced sulci and right lateral ventricle with midline shift and cerebral oedema in keeping with acute infarction. We proceeded with CT angiography of the cerebral and carotid on the following day, which revealed no evidence of thrombosis, aneurysm or arteriovenous malformation. There were no abnormal beaded vessels to suggest vasculitis. Transthoracic echocardiography revealed a large mobile mass in the left atrium. Meanwhile, MRI cardiac confirmed a large ill-defined mobile solid mass attached to the mitral valve's inferoseptal component suggestive of mitral valve myxoma. This case report highlights the significance of considering a cardiogenic source of emboli in patients with large cerebral infarcts and other cardiac embolic phenomena. Imaging modalities such as echocardiography and cardiac MRI will help detect treatable conditions, such as valvular myxoma and prevent further complications.

Early Thrombectomy Outcomes in Transfer Patients

OBJECTIVE

The optimal patient transportation destination of acute ischemic stroke (AIS) patients remains uncertain. The purpose of this study was to evaluate the predictive variables that determine stroke outcomes depending on the patient transportation destination.

METHODS

We performed a retrospective study using an AIS database consisting of patients who underwent thrombectomy admitted to our institution from November 1, 2011, through October 1, 2018.

RESULTS

A total of 171 patients were included in the statistical analysis; 42.1% (72/171) of patients were in the mothership group (directly admitted) and 57.9% (99/171) in the drip-and-ship group (transferred). Multivariable logistic regression revealed the predictive factors for favorable outcomes were driving distance (expressed in miles) between the patient's home and a comprehensive stroke center (CSC) (odds ratio [OR] = 0.95; 95% confidence interval [CI], 0.90-0.99; P = .035), absence of diabetes mellitus (OR = 3.60; 95% CI, 1.20-10.82; P = .022), lower National Institutes of Health Stroke Scale score at admission (OR = 0.91; 95% CI, 0.85-0.97; P = .003), and shorter symptom onset to CSC arrival time (expressed in hours) (OR = 0.84; 95% CI, 0.72-0.99; P = .038).

CONCLUSIONS

Our study revealed that a shorter driving distance between the patient's home and CSC, absence of diabetes, lower National Institutes of Health Stroke Scale score, and shorter onset to hospital arrival time positively impacted the outcomes of endovascularly treated AIS patients.

Differentially Expressed Genes and Their Clinical Significance in Ischaemic Stroke: An In-Silico Study

Background

Ischaemic stroke (IS), a multifactorial neurological disorder, is mediated by interplay between genes and the environment and, thus, blood-based IS biomarkers are of significant clinical value. Therefore, this study aimed to find global differentially expressed genes (DEGs) in-silico, to identify key enriched genes via gene set enrichment analysis (GSEA) and to determine the clinical significance of these genes in IS.

Methods

Microarray expression dataset GSE22255 was retrieved from the Gene Expression Omnibus (GEO) database. It includes messenger ribonucleic acid (mRNA) expression data for the peripheral blood mononuclear cells of 20 controls and 20 IS patients. The bioconductor-package ‘affy’ was used to calculate expression and a pairwise t-test was applied to screen DEGs (P < 0.01). Further, GSEA was used to determine the enrichment of DEGs specific to gene ontology (GO) annotations.

Results

GSEA analysis revealed 21 genes to be significantly plausible gene markers, enriched in multiple pathways among all the DEGs (n = 881). Ten gene sets were found to be core enriched in specific GO annotations. JunD, NCX3 and fibroblast growth factor receptor 4 (FGFR4) were under-represented and glycoprotein M6-B (GPM6B) was persistently over-represented.

Conclusion

The identified genes are either associated with the pathophysiology of IS or they affect post-IS neuronal regeneration, thereby influencing clinical outcome. These genes should, therefore, be evaluated for their utility as suitable markers for predicting IS in clinical scenarios.

The Impact of Door to Diuretic Time in Acute Heart Failure on Hospital Length of Stay and In-Patient Mortality

Background Acute heart failure (AHF) can be life-threatening if not treated promptly and can significantly increase the number of annual emergency department (ED) encounters in the United States. Achieving adequate and prompt euvolemic state in AHF patients using intravenous (IV) diuretics is the cornerstone of treatment, which not only reduces in-hospital stay and mortality but also decreases healthcare expenditures. Surprisingly, the door to diuretic (D2D) time in AHF patients has always been a debatable issue among physicians worldwide, and so far, there are no set guidelines. This study examines a large cohort of AHF patients to determine the association between diuretics use within 90 minutes of ED admission and hospital length of stay (LOS) and patient mortality.  Methods Retrospective institutional data of AHF patients receiving IV diuretics following ED admission were extracted from 2016 to 2017. A total of 7,751 patients treated for AHF exacerbation were included, which were further divided into two groups based on the timing of diuretics administration (<90 minutes vs. ≥90 minutes). The primary outcomes were LOS between the two groups and hospital mortality. The standard statistical methodology was used for data analysis. Results  A total of 7,751 AHF cases receiving IV diuretics were identified. Almost 1,432 patients (18.5%) received IV diuretics within 90 minutes of ER admission (group 1) while 6,319 patients (81.5%) patients received IV diuretics after 90 minutes (group 2). Furthermore, among group 1 patients, average LOS was noted to be associated with shorter hospitalization (average of 1.423 days less as compared to group 2 patients (confidence interval (CI) =1.02-1.82; p<0.05). Finally, after controlling for other mortality risk factors, patients in group 2 were 1.435 times more likely to have died compared to patients in group 1 (CI=1.03-1.98; p<0.05). Conclusions  D2D time in AHF patients has always been a crucial judgmental decision. The current study successfully demonstrated the relation between IV diuretics administration within 90 minutes of ED admission, favorable clinical outcomes, and decreased mortality rates. More adequately powered studies are needed to validate the results of our current study further.

The Role of Oxidative Stress in Cardiovascular Aging and Cardiovascular Diseases

Aging can be seen as process characterized by accumulation of oxidative stress induced damage. Oxidative stress derives from different endogenous and exogenous processes, all of which ultimately lead to progressive loss in tissue and organ structure and functions. The oxidative stress theory of aging expresses itself in age-related diseases. Aging is in fact a primary risk factor for many diseases and in particular for cardiovascular diseases and its derived morbidity and mortality. Here we highlight the role of oxidative stress in age-related cardiovascular aging and diseases. We take into consideration the molecular mechanisms, the structural and functional alterations, and the diseases accompanied to the cardiovascular aging process.

Clinical Implications of Uric Acid in Heart Failure: A Comprehensive Review

Affecting more than 26 million people worldwide and with rising prevalence, heart failure (HF) represents a major global health problem. Hence, further research is needed in order to abate poor HF outcomes and mitigate significant expenses that burden health care systems. Based on available data, experts agree that there is an urgent need for a cost-effective prognostic biomarker in HF. Although a significant number of biomarkers have already been investigated in this setting, the clinical utility of adding biomarker evaluation to routine HF care still remains ambiguous. Specifically, in this review we focused on uric acid (UA), a purine metabolism detriment whose role as cardiovascular risk factor has been exhaustingly debated for decades. Multiple large population studies indicate that UA is an independent predictor of mortality in acute and chronic HF, making it a significant prognostic factor in both settings. High serum levels have been also associated with an increased incidence of HF, thus expanding the clinical utility of UA. Importantly, emerging data suggests that UA is also implicated in the pathogenesis of HF, which sheds light on UA as a feasible therapeutic target. Although to date clinical studies have not been able to prove the benefits of xanthine oxidase in HF patients, we discuss the putative role of UA and xanthine oxidase in the pathophysiology of HF as a therapeutic target.

Association Between Change in Circulating Progenitor Cells During Exercise Stress and Risk of Adverse Cardiovascular Events in Patients With Coronary Artery Disease

Importance

Stem and progenitor cells mobilize from the bone marrow in response to myocardial ischemia. However, the association between the change in circulating progenitor cell (CPC) counts and disease prognosis among patients with ischemia is unknown.

Objective

To investigate the association between the change in CPC counts during stress testing and the risk of adverse cardiovascular events in patients with stable coronary artery disease (CAD).

Design, Setting, and Participants

This prospective cohort study included a population-based sample of 454 patients with stable CAD who were recruited between June 1, 2011, and August 15, 2014, at Emory University-affiliated hospitals and followed up for 3 years. Data were analyzed from September 15, 2018, to October 15, 2018.

Exposures

Myocardial perfusion imaging with technetium Tc 99m sestamibi at rest and 30 to 60 minutes after conventional stress testing.

Main Outcomes and Measures

Circulating progenitor cells were enumerated with flow cytometry as CD34-expressing mononuclear cells (CD45med/CD34+), with additional quantification of subsets coexpressing the chemokine (C-X-C motif) receptor 4 (CD34+/CXCR4+). Changes in CPC counts were calculated as poststress minus resting CPC counts. Cox proportional hazards regression models were used to identify factors associated with the combined end point of cardiovascular death and myocardial infarction after adjusting for clinical covariates, including age, sex, race, smoking history, body mass index, and history of heart failure, hypertension, dyslipidemia, and diabetes.

Results

Of the 454 patients (mean [SD] age, 63 [9] years; 76% men) with stable CAD enrolled in the study, 142 (31.3%) had stress-induced ischemia and 312 (68.7%) did not, as measured by single-photon emission computed tomography. During stress testing, patients with stress-induced ischemia had a mean decrease of 20.2% (interquartile range [IQR], -45.3 to 5.5; P < .001) in their CD34+/CXCR4+ counts, and patients without stress-induced ischemia had a mean increase of 3.2% (IQR, -20.6 to 35.1; P < .001) in their CD34+/CXCR4+ counts. Twenty-four patients (5.2%) experienced adverse events. After adjustment, baseline CPC counts were associated with worse adverse outcomes, but this association was not present after stress-induced ischemia was included in the model. However, the change in CPC counts during exercise remained significantly associated with adverse events (hazard ratio, 2.59; 95% CI, 1.15-5.32, per 50% CD34+/CXCR4+ count decrease), even after adjustment for clinical variables and the presence of ischemia. The discrimination of risk factors associated with incident adverse events improved (increase in C statistic from 0.72 to 0.77; P = .003) with the addition of the change in CD34+/CXCR4+ counts to a model that included clinical characteristics, baseline CPC count, and ischemia.

Conclusions and Relevance

In this study of patients with CAD, a decrease in CPC counts during exercise is associated with a worse disease prognosis compared with the presence of stress-induced myocardial ischemia. Further studies are needed to evaluate whether strategies to improve CPC responses during exercise stress will be associated with improvements in the prognosis of patients with CAD.

The Hemoglobin, Albumin, Lymphocyte, and Platelet (HALP) Score Is Associated With Poor Outcome of Acute Ischemic Stroke

Background: The combined index of hemoglobin, albumin, lymphocyte, and platelet (HALP) is considered a novel score to reflect systemic inflammation and nutritional status. This study aimed to investigate the association between HALP score and poor outcome in patients with acute ischemic stroke (AIS). Methods: Consecutive AIS patients within 24 h after onset were prospectively enrolled. Poor outcome was a combination of a new stroke event (ischemic and hemorrhagic) and all-cause death within 90 days and 1 year. The association between HALP score and poor outcome was analyzed using Cox proportional hazards. Results: A total of 1,337 patients were included. Overall, 60 (4.5%) and 118 (8.8%) patients experienced poor outcome within 90 days and 1 year, respectively. Patients in the highest tertile of HALP score had a lower risk of poor outcome within 90 days and 1 year (hazard ratio: 0.25 and 0.42; 95% confidence intervals: 0.11-0.57 and 0.25-0.69, P for trend <0.01 for all) compared with those in the lowest tertile after adjusting relevant confounding factors. Adding HALP score to the conventional risk factors improved prediction of poor outcome in patients with AIS within 90 days and 1 year (net reclassification index, 48.38 and 28.95%; integrated discrimination improvement, 1.51 and 1.51%; P < 0.05 for all). Conclusions: Increased HALP score was associated with a decreased risk of recurrent stroke and death within 90 days and 1 year after stroke onset, suggesting that HALP score may serve as a powerful indicator for AIS.

DL-3n-Butylphthalide Improves Blood-Brain Barrier Integrity in Rat After Middle Cerebral Artery Occlusion

Objective: DL-3n-butylphthalide (NBP) has beneficial effects in different stages of ischemic stroke. Our previous studies have demonstrated that NBP promoted angiogenesis in the perifocal region of the ischemic brain. However, the molecular mechanism of NBP for blood–brain barrier protection in acute ischemic stroke was unclear. Here, we explored the neuroprotective effects of NBP on blood–brain barrier integrity in the acute phase of ischemic stroke in a rat model.

Methods: Adult male Sprague–Dawley rats (n = 82) underwent 2 h of transient middle cerebral artery occlusion and received 90 mg/kg of NBP for 3 days. Brain edema, infarct volume, surface blood flow, and neurological severity score were evaluated. Blood–brain barrier integrity was evaluated by Evans blue leakage and changes in tight junction proteins. We further examined AQP4 and eNOS expression, MMP-9 enzyme activity, and possible signaling pathways for the role of NBP after ischemic stroke.

Results: NBP treatment significantly increased eNOS expression and surface blood flow in the brain, reduced brain edema and infarct volume, and improved neurological severity score compared to the control group (p < 0.05). Furthermore, NBP attenuated Evans blue and IgG leakage and increased tight junction protein expression compared to the control after 1 and 3 days of ischemic stroke (p < 0.05). Finally, NBP decreased AQP4 expression, MMP-9 enzyme activity, and increased MAPK expression during acute ischemic stroke.

Conclusion: NBP protected blood–brain barrier integrity and attenuated brain injury in the acute phase of ischemic stroke by decreasing AQP4 expression and MMP-9 enzyme activity. The MAPK signaling pathway may be associated in this process.

Cardiovascular Health Trajectories From Childhood Through Middle Age and Their Association With Subclinical Atherosclerosis

Importance

Cross-sectional measures of cardiovascular health (CVH) have been associated with cardiovascular disease in older age, but little is known about longitudinal trajectories in CVH and their association with subclinical atherosclerosis in middle age.

Objectives

To model long-term patterns in CVH starting in childhood and to assess their association with subclinical atherosclerosis in middle age.

Design, Setting, and Participants

This cohort study used data from 5 prospective cardiovascular cohort studies from the United States and Finland from 1973 to 2015. A total of 9388 participants aged 8 to 55 years had at least 3 examinations and were eligible for this study. Statistical analysis was performed from December 1, 2015, to June 1, 2019.

Exposures

Clinical CVH factors (body mass index, total cholesterol level, blood pressure, and glucose level) were classified as ideal, intermediate, or poor, and were summed as a clinical CVH score. Group-based latent class modeling identified trajectories in this score over time.

Main Outcomes and Measures

Carotid intima-media thickness (cIMT) was measured for participants in 3 cohorts, and high cIMT was defined as a value at or above the 90th percentile. The association between CVH trajectory and cIMT was modeled using both linear and logistic regression adjusted for demographics, baseline health behaviors, and baseline (or proximal) CVH score.

Results

Among 9388 participants (5146 [55%] female; 6228 [66%] white; baseline mean [SD] age, 17.5 [7.5] years), 5 distinct trajectory groups were identified: high-late decline (1518 participants [16%]), high-moderate decline (2403 [26%]), high-early decline (3066 [32%]), intermediate-late decline (1475 [16%]), and intermediate-early decline (926 [10%]). The high-late decline group had significantly lower adjusted cIMT vs other trajectory groups (high-late decline: 0.64 mm [95% CI, 0.63-0.65 mm] vs intermediate-early decline: 0.72 mm [95% CI, 0.69-0.75 mm] when adjusted for demographics and baseline smoking, diet, and physical activity; P < .01). The intermediate-early declining group had higher odds of high cIMT (odds ratio, 2.4; 95% CI, 1.3-4.5) compared with the high-late decline group, even after adjustment for baseline or proximal CVH score.

Conclusions and Relevance

In this study, CVH declined from childhood into adulthood. Promoting and preserving ideal CVH from early life onward may be associated with reduced CVD risk later in life.

Body Mass Index and Clinical Outcomes in Asian Patients With Atrial Fibrillation Receiving Oral Anticoagulation

BACKGROUND AND PURPOSE

The influence of body mass index (BMI) on clinical outcomes in patients with atrial fibrillation remains controversial, especially among Asians. We aimed to evaluate the association between BMI and clinical outcomes in Asian patients with atrial fibrillation receiving oral anticoagulants.

METHODS

Using the Korean National Health Insurance database between January 2015 and December 2017, we identified oral anticoagulant new users among patients with nonvalvular atrial fibrillation who had BMI information. We analyzed ischemic stroke, intracranial hemorrhage, hospitalization for gastrointestinal bleeding, major bleeding, all-cause death, and the composite clinical outcome according to BMI categories.

RESULTS

A total of 43 173 patients were included across BMI categories (kg/m²): underweight (<18.5) in 3%, normal (18.5 to <23) in 28%, overweight (23 to <25) in 24%, obese I (25 to <30) in 39%, and obese II (≥30) in 6%. Higher BMI (per 5 kg/m² increase) was significantly associated with lower risks of ischemic stroke (hazard ratio [HR], 0.891 [95% CI, 0.801-0.992]), hospitalization for gastrointestinal bleeding (HR, 0.785 [95% CI, 0.658-0.937]), major bleeding (HR, 0.794 [95% CI, 0.686-0.919]), all-cause death (HR, 0.658 [95% CI, 0.605-0.716]), and the composite clinical outcome (HR, 0.751 [95% CI, 0.706-0.799]), except for intracranial hemorrhage (HR, 0.815 [95% CI, 0.627-1.061]). The underweight group was associated with an increased risk of composite clinical outcome (HR, 1.398 [95% CI, 1.170-1.671]), mainly driven by an increased risk of all-cause death. The effects of non-vitamin K antagonist oral anticoagulant versus warfarin on clinical outcomes were similar across BMI groups.

CONCLUSIONS

Higher BMI was independently associated with a lower risk of ischemic stroke, major bleeding, and better survival. Underweight patients had a higher risk of all-cause death and composite clinical outcome. The optimal BMI for patients with atrial fibrillation should be defined and managed according to an integrated care pathway.

Neuropsychological Assessment and Screening in Heart Failure: a Meta-Analysis and Systematic Review

A variety of neuropsychological changes secondary to heart failure have been documented in the literature. However, what remains unclear are which neuropsychological abilities are the most impacted by heart failure and what tests have the sensitivity to measure that impact. Eight databases were searched for articles that examined the neuropsychological functioning of patients with heart failure. Some of the inclusion criteria were articles had to have a heart failure group with a demographically comparable control group and standardized neuropsychological testing. Exclusion criteria included articles with a heart failure group with any other type of major organ failure, or comparisons that were between different classes of heart failure rather than between a heart failure and non-heart failure group. A total of 33 articles met the inclusion criteria (total heart failure sample n = 8900) and provided effect size data for 20 neuropsychological domains. All observed domain-level differences between heart failure and non-heart failure groups were statistically significant, except for simple motor functioning and confrontation naming. The greatest differences in performance were in executive functioning, global cognition, complex psychomotor speed, and verbal memory. The highest effect sizes came from Trail-Making Test-Part B, CAMCOG, Symbol Digit Modality Test, and California Verbal Learning Test. The neuropsychological patterns of heart failure suggested diffuse cognitive involvement, with higher-level processes being most affected. It is important to track neurocognition in this clinical population since neuropsychological impairment is prevalent, and screening measures appear to be reliable. Such screening and further assessment would inform future medical treatment and may improve patient care management.

Activation of Glutamate Transporter-1 (GLT-1) Confers Sex-Dependent Neuroprotection in Brain Ischemia

Stroke is one of the leading causes of long-term disability. During ischemic stroke, glutamate is released, reuptake processes are impaired, and glutamate promotes excitotoxic neuronal death. Astrocytic glutamate transporter 1 (GLT-1) is the major transporter responsible for removing excess glutamate from the extracellular space. A translational activator of GLT-1, LDN/OSU 0212320 (LDN) has been previously developed with beneficial outcomes in epileptic animal models but has never been tested as a potential therapeutic for ischemic strokes. The present study evaluated the effects of LDN on stroke-associated brain injury. Male and female mice received LDN or vehicle 24 h before or 2 h after focal ischemia was induced in the sensorimotor cortex. Sensorimotor performance was determined using the Rung Ladder Walk and infarct area was assessed using triphenyltetrazolium chloride staining. Males treated with LDN exhibited upregulated GLT-1 protein levels, significantly smaller infarct size, and displayed better sensorimotor performance in comparison to those treated with vehicle only. In contrast, there was no upregulation of GLT-1 protein levels and no difference in infarct size or sensorimotor performance between vehicle- and LDN-treated females. Taken together, our results indicate that the GLT-1 translational activator LDN improved stroke outcomes in young adult male, but not female mice.

Efficacy and cost-effectiveness of a therapist-assisted web-based intervention for depression and anxiety in patients with ischemic heart disease attending cardiac rehabilitation [eMindYourHeart trial]: a randomised controlled trial protocol

BACKGROUND

One in five patients with ischaemic heart disease (IHD) develop comorbid depression or anxiety. Depression is associated with risk of non-adherence to cardiac rehabilitation (CR) and dropout, inadequate risk factor management, poor quality of life (QoL), increased healthcare costs and premature death. In 2020, IHD and depression are expected to be among the top contributors to the disease-burden worldwide. Hence, it is paramount to treat both the underlying somatic disease as well as depression and anxiety. eMindYourHeart will evaluate the efficacy and cost-effectiveness of a therapist-assisted eHealth intervention targeting depression and anxiety in patients with IHD, which may help fill this gap in clinical care.

METHODS

eMindYourHeart is a multi-center, two-armed, unblinded randomised controlled trial that will compare a therapist-assisted eHealth intervention to treatment as usual in 188 CR patients with IHD and comorbid depression or anxiety. The primary outcome of the trial is symptoms of depression, measured with the Hospital Anxiety and Depression Scale (HADS) at 3 months. Secondary outcomes evaluated at 3, 6, and 12 months include symptoms of depression and anxiety (HADS), perceived stress, health complaints, QoL (HeartQoL), trial dropout (number of patients dropped out in either arm at 3 months) and cost-effectiveness.

DISCUSSION

To our knowledge, this is the first trial to evaluate both the efficacy and cost-effectiveness of a therapist-assisted eHealth intervention in patients with IHD and comorbid psychological distress as part of CR. Integrating screening for and treatment of depression and anxiety into standard CR may decrease dropout and facilitate better risk factor management, as it is presented as "one package" to patients, and they can access the eMindYourHeart program in their own time and at their own convenience. The trial holds a strong potential for improving the quality of care for an increasing population of patients with IHD and comorbid depression, anxiety or both, with likely benefits to patients, families, and society at large due to potential reductions in direct and indirect costs, if proven successful. Trial registration The trial was prospectively registered on https://clinicaltrials.gov/ct2/show/NCT04172974 on November 21, 2019 with registration number [NCT04172974].

Novel insights in the relationship of gut microbiota and coronary artery diseases

Atherosclerosis is a chronic, progressive, inflammatory disease in the vasculature and is common in both coronary and peripheral arteries. Human beings harbor a complex and dynamic population of microorganisms defined as the microbiota. Importantly, alterations in the bacterial composition (dysbiosis) and the metabolic compounds produced by these bacteria have been associated with the pathogenesis of many inflammatory diseases and infections. There is also a close relationship between intestinal microbiota and cardiovascular diseases. The aim of this review was to analyze how changes in the gut microbiota and their metabolites might affect coronary artery diseases. The most representative groups of bacteria that make up the intestinal microbiota are altered in coronary artery disease patients, resulting in a decrease in Bacteroidetes and an increase in Firmicutes. In relation to metabolites, trimethylamine-N-oxide plays an important role in atherosclerosis and may act as a cardiovascular risk predictor. In addition, the use of probiotics, prebiotics, diet modulation, and fecal transplantation, which may represent alternative treatments for these diseases, is thoroughly discussed. Finally, the role of lipid-lowering treatments is also analyzed as they may affect and alter the gut microbiota and, conversely, gut microbiota diversity could be associated with resistance or sensitivity to these treatments.

Loss of Chloride Channel 6 (CLC-6) Affects Vascular Smooth Muscle Contractility and Arterial Stiffness via Alterations to Golgi Calcium Stores

Genome-wide association studies have found a number of potential genes involved in blood pressure regulation; however, the functional role of many of these candidates has yet to be established. One such candidate gene is CLCN6, which encodes the transmembrane protein, chloride channel 6 (ClC-6). Although the CLCN6 locus has been widely associated with human blood pressure regulation, the mechanistic role of ClC-6 in blood pressure homeostasis at the molecular, cellular, and physiological levels is completely unknown. In this study, we demonstrate that rats with a functional knockout of ClC-6 on the Dahl Salt-Sensitive rat background (SS-Clcn6) have lower diastolic but not systolic blood pressures. The effect of diastolic blood pressure attenuation was independent of dietary salt exposure in knockout animals. Moreover, SS-Clcn6 rats are protected from hypertension-induced cardiac hypertrophy and arterial stiffening; however, they have impaired vasodilation and dysregulated intracellular calcium handling. ClC-6 is highly expressed in vascular smooth muscle cells where it is targeted to the Golgi apparatus. Using bilayer electrophysiology, we provide evidence that recombinant human ClC-6 protein can function as a channel. Last, we demonstrate that loss of ClC-6 function reduces Golgi calcium stores, which may play a previously unidentified role in vascular contraction and relaxation signaling in vascular smooth muscle cells. Collectively, these data indicate that ClC-6 may modulate blood pressure by regulating Golgi calcium reserves, which in turn contribute to vascular smooth muscle function.

Role of Gut Microbiota and Their Metabolites on Atherosclerosis, Hypertension and Human Blood Platelet Function: A Review

Emerging data have demonstrated a strong association between the gut microbiota and the development of cardiovascular disease (CVD) risk factors such as atherosclerosis, inflammation, obesity, insulin resistance, platelet hyperactivity, and plasma lipid abnormalities. Several studies in humans and animal models have demonstrated an association between gut microbial metabolites such as trimethylamine-N-oxide (TMAO), short-chain fatty acids, and bile acid metabolites (amino acid breakdown products) with CVD. Human blood platelets are a critical contributor to the hemostatic process. Besides, these blood cells play a crucial role in developing atherosclerosis and, finally, contribute to cardiac events. Since the TMAO, and other metabolites of the gut microbiota, are asociated with platelet hyperactivity, lipid disorders, and oxidative stress, the diet-gut microbiota interactions have become an important research area in the cardiovascular field. The gut microbiota and their metabolites may be targeted for the therapeutic benefit of CVD from a clinical perspective. This review's main aim is to highlight the complex interactions between microbiota, their metabolites, and several CVD risk factors.

Role of vitamin B12 deficiency in ischemic stroke risk and outcome

Currently, ischemic stroke is the most prevalent form of stroke compared to hemorrhagic and there is a high incidence in older adults. Nutrition is a modifiable risk factor for stroke. B-vitamins are part of a metabolic network that integrates nutritional signals with biosynthesis, redox homeostasis, and epigenetics. These vitamins play an essential role in the regulation of cell proliferation, stress resistance, and embryo development. A deficiency in vitamin B12 is common in older adults and has been reported to be implicated in ischemic stroke. The aim of this review was to investigate whether vitamin B12 deficiencies impact the risk and outcome of ischemic stroke. Clinical data from our literature review strongly suggest that a deficiency in vitamin B12 is a risk factor for ischemic stroke and possible outcome. Our survey of the literature has identified that there is a gap in the understanding of the mechanisms through which a vitamin B12 deficiency leads to an increased risk of stroke and outcome. A vitamin B12 deficiency can increase homocysteine levels, which are a well-established risk factor for ischemic stroke. Another potential mechanism through which vitamin B12 deficient may impact neurological function and increase risk of stroke, is changes in myelination, however this link requires further investigation. Further studies are required in model systems to understand how a vitamin B12 deficiency changes the brain.

Medical Foods: Science, Regulation, and Practical Aspects. Summary of a Workshop

On August 13-14, 2019, the Healthcare Nutrition Council and the ASN held the Medical Foods Workshop: Science, Regulation, and Practical Aspects. Medical food products help patients manage their disease and improve their quality of life. Yet many hurdles exist to getting patients new products. In this workshop, participants addressed some of these hurdles, with specific emphasis on topics like the statutory term distinctive nutritional requirements, the regulatory term modification of the diet alone, the role of clinical guidelines, the requirement that medical foods be used under medical supervision, and differentiation of foods for special dietary use from medical foods, as well as product innovation and future research. Real-world examples were discussed for intractable epilepsy, diabetes, end-stage renal disease, and inflammatory bowel disease.

Ser9 phosphorylation of GSK-3β promotes aging in the heart through suppression of autophagy

INTRODUCTION

Glycogen synthase kinase-3β (GSK-3β) is a serine/threonine kinase and a negative regulator of cardiac hypertrophy. Phosphorylation of GSK-3β at Ser9 negatively regulates its kinase activity. The role of GSK-3β in cardiac aging remains poorly understood.

AIM

The study aimed to elucidate the role of GSK-3β Ser9 phosphorylation in mediating cardiac aging and the underlying mechanism.

METHODS AND RESULTS

Phosphorylation of GSK-3β at Ser9 and the levels of β-catenin and Mcl-1 were increased in the mouse heart during aging, suggesting that GSK-3β is inactivated during aging in the heart. Age-induced cardiac hypertrophy, fibrosis, left ventricular dysfunction, and increases in cardiomyocyte apoptosis and senescence were all attenuated in constitutively active GSK-3β^S9A knock-in (KI) mice compared to littermate wild type mice. Although autophagy is inhibited in the heart during aging, KI of GSK-3β^S9A reversed the age-associated decline in autophagy in the mouse heart. GSK-3β directly phosphorylates Ulk1, a regulator of autophagy, at Ser913, thereby stimulating autophagy in cardiomyocytes. Ulk1Ser913A KI mice exhibited decreased autophagic flux and increased senescence in cardiomyocytes.

CONCLUSION

Our results suggest that GSK-3β is inactivated during aging through Ser9 phosphorylation, which in turn plays an important role in mediating cardiac aging. GSK-3β promotes autophagy through phosphorylation of Ulk1 at Ser913, which in turn prevents aging in the heart.

Phospho-ablation of cardiac sodium channel Nav1.5 mitigates susceptibility to atrial fibrillation and improves glucose homeostasis under conditions of diet-induced obesity

BACKGROUND

Atrial fibrillation (AF) is the most common sustained arrhythmia, with growing evidence identifying obesity as an important risk factor for the development of AF. Although defective atrial myocyte excitability due to stress-induced remodeling of ion channels is commonly observed in the setting of AF, little is known about the mechanistic link between obesity and AF. Recent studies have identified increased cardiac late sodium current (I_Na,L) downstream of calmodulin-dependent kinase II (CaMKII) activation as an important driver of AF susceptibility.

METHODS

Here, we investigated a possible role for CaMKII-dependent I_Na,L in obesity-induced AF using wild-type (WT) and whole-body knock-in mice that ablates phosphorylation of the Na_v1.5 sodium channel and prevents augmentation of the late sodium current (S571A; SA mice).

RESULTS

A high-fat diet (HFD) increased susceptibility to arrhythmias in WT mice, while SA mice were protected from this effect. Unexpectedly, SA mice had improved glucose homeostasis and decreased body weight compared to WT mice. However, SA mice also had reduced food consumption compared to WT mice. Controlling for food consumption through pair feeding of WT and SA mice abrogated differences in weight gain and AF inducibility, but not atrial fibrosis, premature atrial contractions or metabolic capacity.

CONCLUSIONS

These data demonstrate a novel role for CaMKII-dependent regulation of Na_v1.5 in mediating susceptibility to arrhythmias and whole-body metabolism under conditions of diet-induced obesity.

Targeting the pathways of regulated necrosis: a potential strategy for alleviation of cardio-cerebrovascular injury

Apoptosis, necrosis and autophagy-dependent cell death are the three major types of cell death. Traditionally, necrosis is thought as a passive and unregulated form of cell death. However, certain necrosis can also occur in a highly regulated manner, referring to regulated necrosis. Depending on the signaling pathways, regulated necrosis can be further classified as necroptosis, pyroptosis, ferroptosis, parthanatos and CypD-mediated necrosis. Numerous studies have reported that regulated necrosis contributes to the progression of multiple injury-relevant diseases. For example, necroptosis contributes to the development of myocardial infarction, atherosclerosis, heart failure and stroke; pyroptosis is involved in the progression of myocardial or cerebral infarction, atherosclerosis and diabetic cardiomyopathy; while ferroptosis, parthanatos and CypD-mediated necrosis participate in the pathological process of myocardial and/or cerebral ischemia/reperfusion injury. Thereby, targeting the pathways of regulated necrosis pharmacologically or genetically could be an efficient strategy for reducing cardio-cerebrovascular injury. Further study needs to focus on the crosstalk and interplay among different types of regulated necrosis. Pharmacological intervention of two or more types of regulated necrosis simultaneously may have advantages in clinic to treat injury-relevant diseases.