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

Cost-Effectiveness of Obstructive Sleep Apnea Screening and Treatment Before Catheter Ablation for Symptomatic Atrial Fibrillation

Background: Although management of obstructive sleep apnea (OSA) has been recommended to improve outcomes of catheter ablation (CA) in patients with symptomatic atrial fibrillation (AF), the most cost-effective way of preprocedural OSA screening is undetermined. This study assessed the cost-effectiveness of OSA management before CA for symptomatic AF.

Methods and Results: A Markov model was developed to assess the cost-effectiveness of 3 OSA detection strategies before CA: no screening; Type 3 portable monitor (PM)-guided screening; and polysomnography (PSG)-guided screening. The target population consisted of a hypothetical cohort of patients aged 65 years with symptomatic AF, with 50% prevalence of OSA. We used a 5-year horizon, with sensitivity analyses for significant variables and scenario analyses for lower and higher OSA prevalence (30% and 70%, respectively). In the base-case, both types of OSA screening were dominant (less costly and more effective) relative to no screening. Although PSG-guided management was more effective than PM-guided management, it was more costly and therefore did not show clear benefit. These findings were replicated in cohorts with lower and higher OSA risks.

Conclusions: OSA screening before CA is cost-effective in patients with symptomatic AF, with PM screening being the most cost-effective. Physicians should consider OSA management using this simple tool in the decision making for treatment of symptomatic AF.

Who Watches the "Watchman" and How Often?

Atrial fibrillation (AF) is a common cardiac arrhythmia that is encountered during the hospitalization. Sometimes, many patients cannot be anticoagulated to prevent AF-related cardiovascular accidents because of the risk of bleeding. In these cases, we recommend putting left atrial appendage (LAA) to prevent thrombus formation in the left atrium due to AF. There is no clear time frame of how long we need to follow up with echocardiogram to monitor device-related blood clot formation and continue anticoagulation therapy if there is recurrent thrombus formation after LAA placement. We would like to present a case with AF in which the patient had epistaxis, which required to hold anticoagulation and arterial embolization. The patient agreed to the placement of the Watchman device and subsequently it was complicated by device-related thrombosis (DRT). The patient required prolonged anticoagulation treatment and follow-up echocardiogram to prevent DRT in the future.

PRediction of acute coronary syndrome in acute ischemic StrokE (PRAISE) - protocol of a prospective, multicenter trial with central reading and predefined endpoints

BACKGROUND

Current guidelines recommend measurement of troponin in acute ischemic stroke (AIS) patients. In AIS patients, troponin elevation is associated with increased mortality and worse outcome. However, uncertainty remains regarding the underlying pathophysiology of troponin elevation after stroke, particularly regarding diagnostic and therapeutic consequences. Troponin elevation may be caused by coronary artery disease (CAD) and more precisely acute coronary syndrome (ACS). Both have a high prevalence in stroke patients and contribute to poor outcome. Therefore, better diagnostic algorithms are needed to identify those AIS patients likely to have ACS or other manifestations of CAD.

METHODS/DESIGN

The primary goal of the "PRediction of Acute coronary syndrome in acute Ischemic StrokE" (PRAISE) study is to develop a diagnostic algorithm for prediction of ACS in AIS patients. The primary hypothesis will test whether dynamic high-sensitivity troponin levels determined by repeat measurements (i.e., "rise or fall-pattern") indicate presence of ACS when compared to stable (chronic) troponin elevation. PRAISE is a prospective, multicenter, observational trial with central reading and predefined endpoints guided by a steering committee. Clinical symptoms, troponin levels as well as findings on electrocardiogram, echocardiogram, and coronary angiogram will be recorded and assessed by central academic core laboratories. Diagnosis of ACS will be made by an endpoint adjudication committee. Severe adverse events will be evaluated by a critical event committee. Safety will be judged by a data and safety monitoring board. Follow-up will be conducted at three and twelve months and will record new vascular events (i.e., stroke and myocardial infarction) as well as death, functional and cognitive status. According to sample size calculation, 251 patients have to be included.

DISCUSSION

PRAISE will prospectively determine the frequency of ACS and characterize cardiac and coronary pathologies in a large, multicenter cohort of AIS patients with troponin elevation. The findings will elucidate the origin of troponin elevation, shed light on its impact on necessary diagnostic procedures and provide data on the safety and diagnostic yield of coronary angiography early after stroke. Thereby, PRAISE will help to refine algorithms and develop guidelines for the cardiac workup in AIS.

TRIAL REGISTRATION

NCT03609385 registered 1st August 2018.

UMBRELLA protocol: systematic reviews of multivariable biomarker prognostic models developed to predict clinical outcomes in patients with heart failure

BACKGROUND

Heart failure (HF) is a chronic and common condition with a rising prevalence, especially in the elderly. Morbidity and mortality rates in people with HF are similar to those with common forms of cancer. Clinical guidelines highlight the need for more detailed prognostic information to optimise treatment and care planning for people with HF. Besides proven prognostic biomarkers and numerous newly developed prognostic models for HF clinical outcomes, no risk stratification models have been adequately established. Through a number of linked systematic reviews, we aim to assess the quality of the existing models with biomarkers in HF and summarise the evidence they present.

METHODS

We will search MEDLINE, EMBASE, Web of Science Core Collection, and the prognostic studies database maintained by the Cochrane Prognosis Methods Group combining sensitive published search filters, with no language restriction, from 1990 onwards. Independent pairs of reviewers will screen and extract data. Eligible studies will be those developing, validating, or updating any prognostic model with biomarkers for clinical outcomes in adults with any type of HF. Data will be extracted using a piloted form that combines published good practice guidelines for critical appraisal, data extraction, and risk of bias assessment of prediction modelling studies. Missing information on predictive performance measures will be sought by contacting authors or estimated from available information when possible. If sufficient high quality and homogeneous data are available, we will meta-analyse the predictive performance of identified models. Sources of between-study heterogeneity will be explored through meta-regression using pre-defined study-level covariates. Results will be reported narratively if study quality is deemed to be low or if the between-study heterogeneity is high. Sensitivity analyses for risk of bias impact will be performed.

DISCUSSION

This project aims to appraise and summarise the methodological conduct and predictive performance of existing clinically homogeneous HF prognostic models in separate systematic reviews.Registration: PROSPERO registration number CRD42019086990.

Recent updates on novel therapeutic targets of cardiovascular diseases

In recent times cardiovascular diseases (CVDs) are the leading cause of mortality universally, caused more or less 17.7 million casualties with 45% of all illnesses (except communicable ones) in 2015 as per World Health Organization (WHO). According to American National Center for Health Statistics, cardiac disorders are costliest. Moreover, health care expenditures related to cardiac disorders are anticipated to exceed than diabetes and Alzheimer's. Straining of reactive oxygen species with diminished neutralization & inflammation critically adds to atherosclerosis and also proceed to other cardiovascular diseases such as cardiac remodeling and myocardial infarction (MI). In the past few years, researchers revealed multiple drug targets from animal studies and evaluated them in the therapeutics of cardiac disorders, which offered exciting clues for novel therapeutic strategies. Although, only few newer agents approved clinically and actual approaches for treatment are lagging behind. Several novel drugs found effective for the treatment of hypertension, congestive heart failure, cardiac arrhythmia and angina pectoris. Detailed mechanism of action, basic and clinical pharmacology of all novel drugs has been discussed in this review.

Effects of Statins for Primary Prevention in the Elderly: Recent Evidence

The number of the elderly individuals is steeply increasing, and their absolute cardiovascular risk is higher than that of younger age groups. However, very few statin trials have included elderly patients alone. Recently, we published the SCOPE-75 study, which analyzed the effect of statins for primary prevention in elderly Koreans (>75 years). In this study, statin users showed significantly fewer cardiovascular events and a lower all-cause mortality rate, supporting more active use of statins in this population. In the current review, we further compare and discuss similar studies reported in the past decades and in recent years.

Atherogenic L5 LDL induces cardiomyocyte apoptosis and inhibits KATP channels through CaMKII activation

Background

Cardiac Ca²⁺/calmodulin-dependent protein kinase II (CaMKII) activation plays a critical role in cardiomyocyte (CM) apoptosis and arrhythmia. Functional ATP-sensitive potassium (K_ATP) channels are essential for cardiac protection during ischemia. In cultured CMs, L5 low-density lipoprotein (LDL) induces apoptosis and QTc prolongation. L5 is a highly electronegative and atherogenic aberrant form of LDL, and its levels are significantly higher in patients with cardiovascular-related diseases. Here, the role of L5 in cardiac injury was studied by evaluating the effects of L5 on CaMKII activity and K_ATP channel physiology in CMs.

Methods

Cultured neonatal rat CMs (NRCMs) were treated with a moderate concentration (ie, 7.5 μg/mL) of L5 or L1 (the least electronegative LDL subfraction). NRCMs were examined for apoptosis and viability, CaMKII activity, and the expression of phosphorylated CaMKIIδ and NOX2/gp91^phox. The function of K_ATP and action potentials (APs) was analyzed by using the patch-clamp technique.

Results

In NRCMs, L5 but not L1 significantly induced cell apoptosis and reduced cell viability. Furthermore, L5 decreased Kir6.2 expression by more than 50%. Patch-clamp analysis showed that L5 reduced the K_ATP current (I_KATP) density induced by pinacidil, a K_ATP opener. The partial recovery of the inward potassium current during pinacidil washout was susceptible to subsequent inhibition by the I_KATP blocker glibenclamide. Suppression of I_KATP by L5 significantly prolonged the AP duration. L5 also significantly increased the activity of CaMKII, the phosphorylation of CaMKIIδ, and the expression of NOX2/gp91^phox. L5-induced apoptosis was prevented by the addition of the CaMKII inhibitor KN93 and the reactive oxygen species scavenger Mn (III)TBAP.

Conclusions

L5 but not L1 induces CM damage through the activation of the CaMKII pathway and increases arrhythmogenicity in CMs by modulating the AP duration. These results help to explain the harmful effects of L5 in cardiovascular-related disease.

Comparative effect of nutraceuticals on lipid profile: a protocol for systematic review and network meta-analysis

INTRODUCTION

According to the common definition, nutraceuticals are components found in food that can act as therapeutic substances. Recently, the International Lipid Expert Panel published two position papers covering the topic of lipid-lowering nutraceuticals and their potential use as a complementary treatment in addition to statins or as an alternative treatment in statin-intolerant patients. The aim of this study was to compare the effect of different nutraceuticals on lipid profiles in a systematic review with pairwise and network meta-analyses.

METHODS AND ANALYSIS

Three databases, including PubMed, Embase and the Cochrane Central Register of Controlled Trials, will be searched without time or publication language restrictions. The estimated end date for the searches will be 29 March 2020. Each stage of the review, including the study section, data extraction, and risk of bias and quality of evidence assessments, will be performed in duplicate. Randomised controlled trials meeting the following criteria will be eligible for inclusion: (1) participants aged ≥18 years, (2) intervention with a selected nutraceutical (artichoke, berberine, bergamot, soluble fibres, green tea, garlic, lupin, plant sterols and stanols, red yeast rice, soybean, spirulina or a combination of the aforementioned nutraceuticals), (3) administration of the treatment in the form of capsules, pills, powders, solutions, tablets or enriched food items, (4) comparison with another nutraceutical or placebo, (5) intervention period ≥3 weeks and (6) lipid profile (low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, total cholesterol, triglycerides) as an outcome. Random-effect pairwise and network meta-analyses will be used to summarise the relative effect of each nutraceutical in comparison to the effect of every other nutraceutical. Subgroup analyses will be stratified by age, sex, ethnicity, sample size, length of trial follow-up, baseline cholesterol level and presence of other comorbidities.

ETHICS AND DISSEMINATION

This review will summarise findings from primary studies, and therefore no ethics approval is required. The results will be presented at conferences as well as published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42019132877.

Long Non-Coding RNA (lncRNA) NEAT1 Aggravates Cerebral Ischemia-Reperfusion Injury by Suppressing the Inhibitory Effect of miR-214 on PTEN

Background

Cerebral ischemia-reperfusion injury is a form of serious nervous system injury. Activation of the PI3K/Akt pathway can effectively relieve cerebral ischemia-reperfusion injury. miR-214 can target and inhibit the expression of PTEN, thereby alleviating its inhibitory effect on the PI3K/Akt pathway. Moreover, lncRNA NEAT1 was reported to affect proliferation and metastasis of tumor cells by targeting and suppressing the expression of miR-214. However, whether lncRNA NEAT1 affects the cerebral ischemia-reperfusion-induced damage by regulating the miR-214/PTEN/PI3K/Akt pathway is unclear.

Material/Methods

The miR-214 agomir and miR-214 antagomir were designed and injected into the encephalocele of MCAO rats. Next, the production of oxidative stress kinase and apoptosis of brain cells were detected using commercial kits. The levels of PTEN, PI3K, Akt, p-Akt, and VEGF in brain tissues were determined. Next, the targeting effect of lncRNA NEAT1 and miR-214 was determined with luciferase reporter assay.

Results

Overexpression of miR-214 relieved the apoptosis and oxidative stress of brain tissues. Overexpression of miR-214 promoted the expression of PI3K, Akt, p-Akt, and VEGF by inhibiting the production of PTEN. However, overexpression of lncRNA NEAT1 repressed the remission effect of miR-214 on cerebral ischemia-reperfusion-induced damage and inhibited the production of PI3K, Akt, p-Akt, and VEGF by rescuing the levels of PTEN.

Conclusions

lncRNA NEAT1 aggravates cerebral ischemia-reperfusion injury by abolishing the activation effect of miR-214 on the PI3K/Akt pathway.

TET2 expedites coronary heart disease by promoting microRNA-126 expression and inhibiting the E2F3-PI3K-AKT axis

DNA demethylases of the ten-eleven translocation (TET) family serve as tumor suppressors in various human cancers, but their pathogenic effects in coronary heart disease (CHD) remain unclear. Here we report that TET2 is transcriptionally upregulated in CHD patients, where it shows potential as a diagnostic tool. Mechanistic investigations revealed that TET2 facilitates inflammatory responses and cardiomyocyte apoptosis in rats through demethylation of microRNA-126 (miR-126) promoter. This interaction leads to sequestration of miR-126 from its target E2F transcription factor 3 (E2F3), contributing to E2F3 suppression in CHD. Upregulation of miR-126 when TET2 was silenced restored levels of inflammatory factors and aggravated the degree of cardiac injury and cardiomyocyte apoptosis in rats. By contrast, simultaneous overexpression of E2F3 and miR-126 reduced the levels of inflammatory factors, cardiac injury, and cardiomyocyte apoptosis in rats. Also, TET2 was found to regulate the activity of the PI3K-AKT pathway through the miR-126-E2F3 axis. Our findings uncover a novel function for TET2 in facilitating the progression of CHD.

Doevendans P, Schiffelers RM, Lei Z, Sluijter JP. Cellular and Molecular Mechanism of Cardiac Regeneration: A Comparison of Newts, Zebrafish, and Mammals

Cardiovascular disease is the leading cause of death worldwide. Current palliative treatments can slow the progression of heart failure, but ultimately, the only curative treatment for end-stage heart failure is heart transplantation, which is only available for a minority of patients due to lack of donors' hearts. Explorative research has shown the replacement of the damaged and lost myocardium by inducing cardiac regeneration from preexisting myocardial cells. Lower vertebrates, such as the newt and zebrafish, can regenerate lost myocardium through cardiomyocyte proliferation. The preexisting adult cardiomyocytes replace the lost cells through subsequent dedifferentiation, proliferation, migration, and re-differentiation. Similarly, neonatal mice show complete cardiac regeneration post-injury; however, this regenerative capacity is remarkably diminished one week after birth. In contrast, the adult mammalian heart presents a fibrotic rather than a regenerative response and only shows signs of partial pathological cardiomyocyte dedifferentiation after injury. In this review, we explore the cellular and molecular responses to myocardial insults in different adult species to give insights for future interventional directions by which one can promote or activate cardiac regeneration in mammals.

A Stepwise Approach to the Management of Heart Failure and its Comorbidities

Modern medical and technological advances provide highly effective management for the treatment of patients with heart failure with reduced ejection fraction (HFrEF). In this review, the authors propose a 2-step approach to treatment that is straightforward, practical, and thorough. For the patient whose life now includes HFrEF, the physician's first step is to ensure that the patient is taking the 3 key medications ([1] renin-angiotensin inhibitors (angiotensin receptor/neprilysin inhibitors, angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers), [2] β-blockers, and [3] mineralocorticoid receptor antagonists) recommended in guideline-directed doses to attain comprehensive receptor blockade. Significant coexisting medical issues are also characteristic in patients with HFrEF. Therefore, the physician's second step is to address the comorbidities of heart failure to fulfill comprehensive patient care. This review presents evidence to implement the management of HFrEF and heart failure comorbidities that will reduce cardiac mortality and hospitalization and to avoid treatments that are of no benefit or may cause harm.

Childhood Misfortune and Late-Life Stroke Incidence, 2004-2014

BACKGROUND AND OBJECTIVES

Although most strokes occur in later life, recent studies reveal that negative exposures decades earlier are associated with stroke risk. The purpose of this study was to examine whether accumulated and/or specific domains of early misfortune are related to stroke incidence in later life.

RESEARCH DESIGN AND METHODS

A decade of longitudinal data from stroke-free participants 50 years or older in the Health and Retirement Study were analyzed (N = 12,473). Incident stroke was defined as either self-reported first incident stroke or death due to stroke between 2004 and 2014.

RESULTS

Analyses revealed that accumulated misfortune was associated with increased stroke risk, but the relationship was moderated by wealth. Examining specific domains of childhood misfortune revealed that stroke incidence was greater for persons with behavioral/psychological risks, but that this relationship also was moderated by higher wealth for those with only one behavioral/psychological risk.

DISCUSSION AND IMPLICATIONS

Accumulated childhood misfortune and adolescent depression heighten the risk of stroke in later life, but the influence is remediable through adult wealth. Reducing poverty in later life may decrease stroke incidence for persons exposed to negative childhood exposures.

Suppression of inflammation and fibrosis using soluble epoxide hydrolase inhibitors enhances cardiac stem cell-based therapy

Stem cell replacement offers a great potential for cardiac regenerative therapy. However, one of the critical barriers to stem cell therapy is a significant loss of transplanted stem cells from ischemia and inflammation in the host environment. Here, we tested the hypothesis that inhibition of the soluble epoxide hydrolase (sEH) enzyme using sEH inhibitors (sEHIs) to decrease inflammation and fibrosis in the host myocardium may increase the survival of the transplanted human induced pluripotent stem cell derived-cardiomyocytes (hiPSC-CMs) in a murine postmyocardial infarction model. A specific sEHI (1-trifluoromethoxyphenyl-3-(1-propionylpiperidine-4-yl)urea [TPPU]) and CRISPR/Cas9 gene editing were used to test the hypothesis. TPPU results in a significant increase in the retention of transplanted cells compared with cell treatment alone. The increase in the retention of hiPSC-CMs translates into an improvement in the fractional shortening and a decrease in adverse remodeling. Mechanistically, we demonstrate a significant decrease in oxidative stress and apoptosis not only in transplanted hiPSC-CMs but also in the host environment. CRISPR/Cas9-mediated gene silencing of the sEH enzyme reduces cleaved caspase-3 in hiPSC-CMs challenged with angiotensin II, suggesting that knockdown of the sEH enzyme protects the hiPSC-CMs from undergoing apoptosis. Our findings demonstrate that suppression of inflammation and fibrosis using an sEHI represents a promising adjuvant to cardiac stem cell-based therapy. Very little is known regarding the role of this class of compounds in stem cell-based therapy. There is consequently an enormous opportunity to uncover a potentially powerful class of compounds, which may be used effectively in the clinical setting.

Velocity Pulsatility and Arterial Distensibility Along the Internal Carotid Artery

Background Attenuation of velocity pulsatility along the internal carotid artery (ICA) is deemed necessary to protect the microvasculature of the brain. The role of the carotid siphon within the whole ICA trajectory in pulsatility attenuation is still poorly understood. This study aims to assess arterial variances in velocity pulsatility and distensibility over the whole ICA trajectory, including effects of age and sex. Methods and Results We assessed arterial velocity pulsatility and distensibility using flow-sensitized 2-dimensional phase-contrast 3.0 Tesla magnetic resonance imaging in 118 healthy participants. Velocity pulsatility index (vPI=(V_max-V_min)/V_mean) and arterial distensibility defined as area pulsatility index (A_max-A_min)/A_mean) were calculated at C1, C3, and C7 segments of the ICA. vPI increased between C1 and C3 (0.85±0.13 versus 0.93±0.13, P<0.001 for averaged right+left ICA) and decreased between C3 and C7 (0.93±0.13 versus 0.84±0.13, P<0.001) with overall no effect (C1-C7). Conversely, the area pulsatility index decreased between C1 and C3 (0.18±0.06 versus 0.14±0.04, P<0.001) and increased between C3 and C7 (0.14±0.04 versus 0.31±0.09, P<0.001). vPI in men is higher than in women and increases with age (P<0.015). vPI over the carotid siphon declined with age but remained stable over the whole ICA trajectory. Conclusions Along the whole ICA trajectory, vPI increased from extracranial C1 up to the carotid siphon C3 with overall no effect on vPI between extracranial C1 and intracranial C7 segments. This suggests that the bony carotid canal locally limits the arterial distensibility of the ICA, increasing the vPI at C3 which is consequently decreased again over the carotid siphon. In addition, vPI in men is higher and increases with age.

The effects of percutaneous coronary intervention on mortality in elderly patients with non-ST-segment elevation myocardial infarction undergoing coronary angiography

INTRODUCTION

Although it is recommended that elderly patients with non-ST-segment elevation myocardial infarction (NSTEMI) should undergo an assessment for invasive revascularization, these patients undergo fewer coronary interventions despite the current guidelines. The aim of the study is to evaluate the effectiveness of percutaneous coronary intervention on all-cause mortalities monthly and annually in the population.

METHODS

Three hundred and twenty-four patients with NSTEMI aged 65 years or older who underwent coronary angiography and treated with conservative strategy or percutaneous coronary intervention were included in the study. All demographic and clinical characteristics of the patients were recorded and one-month and one-year follow-up results were analysed.

RESULTS

Two hundred eight cases (64.19%) were treated with percutaneous coronary intervention and 116 cases (35.81%) of the participant were treated with conservative methods. The mean age of the participants was 75.41 ± 6.65 years. The treatment strategy was an independent predictor for the mortality of one-year (HR: 1.965). Furthermore, Killip class ≥2 (HR:2.392), Left Ventricular Ejection Fraction (HR:2.637) and renal failure (HR: 3.471) were independent predictors for one-year mortality.

CONCLUSION

The present study has revealed that percutaneous coronary intervention was effective on one-year mortality in NSTEMI patients over the age of 65. It is considered that percutaneous coronary intervention would decrease mortality in these patients but it should be addressed in larger population studies.

Assessment of regional left ventricular myocardial strain in patients with left anterior descending coronary stenosis using computed tomography feature tracking

Background

Computed tomography feature tracking (CT-FT) has emerged as a valuable method for the assessment of cardiac function. However, no studies have investigated the usefulness of CT-derived assessments of left ventricular (LV) strain in coronary artery disease (CAD). Our aim was to evaluate regional LV systolic deformation in patients with left anterior descending coronary artery (LAD) stenosis using CT-FT.

Methods

Seventy-six patients with LAD stenosis were enrolled. The patients were divided into four groups according to the percentage of LAD stenosis: ≤25% was defined as group I (24 patients), 26 to 49% as group II (17 patients), 50 to 74% as group III (21 patients), and ≥ 75% as group IV (14 patients). Thirty-two sex- and age-matched healthy subjects were included as controls.

Results

No intergroup differences were found between groups I-IV and the controls in terms of the left ventricular ejection fraction, end-diastolic volume and end-systolic volume. However, the longitudinal strain (LS) of the LAD territory was significantly reduced in groups I-IV compared with the controls (− 20.8, − 18.6%, − 18.6%, and − 17.0% vs − 23.7%, respectively). The circumferential strain (CS) of the LAD territory was significantly reduced in groups III and IV compared with the controls and groups I and II (− 22.4% and − 22.1% vs − 25.4, − 24.1%, and − 25.3%, respectively). Compared with the non-LAD territory, the LAD territory in groups II-IV showed significantly increased LS (− 18.6% vs − 21.9%, p = 0.07; − 18.6% vs − 21.9%, p = 0.024; − 17.5% vs − 20%, p = 0.032, respectively). The severity of LAD stenosis was positively correlated with the LS of the LAD territory (r = 0.438, p = 0.002).

Conclusion

CT-FT can detect decreasing LV systolic function in patients with LAD stenosis. LV regional systolic deformation of the LAD territory was reduced with increasing LAD stenosis severity.

Aspirin and low-dose rivaroxaban - the dual pathway concept in patients with stable atherosclerotic disease: a comprehensive review

INTRODUCTION

Cardiovascular disease is the leading cause of morbidity and mortality in adults in western nations. In the last decades, tremendous research has been conducted in the field of secondary prevention in order to reduce recurrent cardiovascular events. This review summarizes the novel dual pathway concept of aspirin and very low-dose rivaroxaban, from mechanisms to clinical practice.

AREAS COVERED

The COMPASS trial demonstrated that in patients with stable atherosclerotic disease, very low-dose rivaroxaban, a direct factor Xa inhibitor, when combined with aspirin, reduced the rate of recurrent ischemic events, at the cost of increased bleeding. This effect was present in patients with ischemic heart disease, as well as in patients with atherosclerosis in other beds, such as in peripheral arterial disease. Sub-studies from the COMPASS trial examined other high-risk populations who might benefit the most from this regimen.

EXPERT OPINION

There are currently multiple antiplatelet and anticoagulation treatment regimens for patients with stable atherosclerotic disease. The dual pathway concept is a novel approach that combines both mechanisms. Identifying patients who might benefit the most in terms of ischemic events at the least bleeding events still remains a challenge, yet prescribing this combination to high-risk patients might be the most effective.

Inequalities in heart failure care in a tax-financed universal healthcare system: a nationwide population-based cohort study

Aims

Data on socioeconomic‐related differences in heart failure (HF) care are sparse. Inequality in care may potentially contribute to a poor clinical outcome. We examined socioeconomic‐related differences in quality of HF care among patients with incident HF with reduced ejection fraction (EF) (HFrEF).

Methods and results

We conducted a nationwide population‐based cohort study among patients with HFrEF (EF ≤40%) registered from January 2008 to October 2015 in the Danish Heart Failure Registry, a nationwide registry of patients with a first‐time primary HF diagnosis. Associations between individual‐level socioeconomic factors (cohabitation status, education, and family income) and the quality of HF care defined by six guideline‐recommended process performance measures [New York Heart Association (NYHA) classification, treatment with angiotensin‐converting‐enzyme inhibitors (ACEI)/angiotensin receptor blockers (ARB), beta‐blockers and mineralocorticoid receptor antagonists, exercise training, and patient education] were assessed using multiple imputation and multivariable logistic regression controlling for potential confounders. Among 17 122 HFrEF patients included, 15 290 patients had data on all six process performance measures. Living alone was associated with lower odds of NYHA classification [adjusted OR (aOR) 0.81; 95% confidence interval (CI): 0.72–0.90], prescription of ACEI/ARB (aOR 0.76; 95% CI: 0.68–0.88) and beta‐blockers (aOR 0.84; 95% CI: 0.76–0.93), referral to exercise training (aOR 0.75; 95% CI: 0.69–0.81), and patient education (aOR 0.73; 95% CI: 0.67–0.80). Compared with high‐level education, low‐level education was associated with lower odds of NYHA classification (aOR 0.93; 95% CI: 0.79–1.11), treatment with ACEI/ARB (aOR 0.99; 95% CI: 0.81–1.20) and beta‐blockers (aOR 0.93; 95% CI: 0.79–1.09), referral to exercise training (aOR 0.73; 95% CI: 0.65–0.82), and patient education (aOR 0.86, 95% CI: 0.75–0.98). An income in the lowest tertile was associated with lower odds of NYHA classification (aOR 0.67; 95% CI: 0.58–0.79), prescription of ACEI/ARB (aOR 0.80, 95% CI: 0.67–0.95) and beta‐blockers (aOR 0.88, 95% CI: 0.86–1.01), referral to exercise training (aOR 0.59, 95% CI: 0.53–0.64), and patient education (aOR 0.66; 95% CI: 0.59–0.74) compared with an income in the highest tertile. Overall, no systematic differences were seen when the analyses were stratified by sex and age groups.

Conclusions

Living alone, low‐level education, and income in the lowest tertile were associated with reduced use of recommended processes of HF care among Danish HFrEF patients with a first‐time primary HF diagnosis. Efforts are warranted to ensure guideline‐recommended HF care to all HFrEF patients, irrespective of socioeconomic background.

Sarcopenia is associated with hypertension in older adults: a systematic review and meta-analysis

Background

Sarcopenia, particularly low handgrip strength has been observed and correlated in association with hypertension among the older people. However, the results reported in different studies were inconsistent. In the current study, we conducted a systematic review and meta-analysis to reveal the significant association between sarcopenia, handgrip strength, and hypertension in older adults.

Methods

PubMed, MEDLINE, Cochrane Library, and EMBASE databases were searched from inception to 15 November 2019 to retrieve the original research studies that addressed the association between sarcopenia, handgrip strength, and hypertension. All the relevant data were retrieved, analyzed, and summarized.

Results

Twelve articles met the inclusion criteria and a total of 21,301 participants were included in the meta-analysis. Eight eligible studies have reported the odd ratios (ORs) of hypertension and sarcopenia, and the ORs ranged from 0.41 to 4.38. When pooled the ORs together, the summarized OR was 1.29 [95% confidence interval (CI) =1.00–1.67]. The summarized OR for the Asian group 1.50 (95% CI = 1.35–1.67) was significantly higher than that of Caucasian group 1.08 (95% CI = 0.39–2.97). Eleven studies have provided the data on association between handgrip strength and hypertension. The overall OR and 95% CI was 0.99 (95% CI = 0.80–1.23), showing no significant association.

Conclusion

Sarcopenia was associated with hypertension, but no correlation was found between handgrip strength and hypertension in older adults.

Planning After Stroke Survival: Advance Care Planning in the Stroke Clinic

Background

Stroke survivors have high rates of mortality and recurrent stroke. Stroke patients are often unable to participate in decision making, highlighting the need for advance care planning (ACP) in poststroke care. We sought to better understand experiences and perceptions around stroke risk and ACP in our stroke clinic.

Methods and Results

Clinic patients completed the Planning After Stroke Survival survey assessing (1) advance directive (AD) documentation and ACP conversations, (2) factors associated with ADs and ACP, (3) perceptions of stroke risk, and (4) ACP needs. We used a physician survey and the electronic medical record to assess clinical and demographic information. We collected 219 surveys (78% response rate). Forty‐five percent reported having completed ADs, although the correlation between patient report and EMS documentation of ADs was low. Most patients (73%) had discussed ACP, and 58% desired additional conversation. Predictors of completing ADs included age (≥65 years; odds ratio, 4.8; 95% CI, 2.3–10.1), white race (odds ratio, 3.1; 95% CI, 1.2–7.8), milder poststroke disability (modified Rankin Scale score ≤1; odds ratio, 2.9; 95% CI, 1.3–6.4), having previously discussed ACP with a physician (odds ratio, 4.8; 95% CI, 2.0–11.7), and discussing risk of stroke recurrence (odds ratio, 2.2; 95% CI, 1.1–4.5).

Conclusions

Stroke survivors had low AD completion rates and desired more conversations about stroke risk and ACP. Completed ADs were inconsistently documented in the electronic medical record. These findings provide guidance to improve ACP in our stroke clinic and may provide a model for others interested in enhancing ACP and ultimately goal‐concordant care.

Novel Role of Carbon Monoxide in Improving Neurological Outcome After Cardiac Arrest in Aged Rats: Involvement of Inducing Mitochondrial Autophagy

Background

Dysfunctional mitochondria are associated with neurological injury after cardiac arrest (CA). Although carbon monoxide (CO) has shown various potential therapeutic effects in preclinical tissue injury models, its mechanism of action in CA remains unclear. We sought to investigate the effects of a novel CO‐releasing molecule on cerebral mitochondrial dysfunction and neurological injury after CA.

Methods and Results

Male Sprague‐Dawley rats aged 20 to 22 months were subjected to 6‐minute asphyxia CA before receiving CO treatment. Survival, neurologic deficit scores, neuronal death, mitochondrial function, and autophagy were evaluated after the return of spontaneous circulation. Results showed that CO post‐treatment increased 3‐day survival rate from 25% to 70.83% and reduced neurologic deficit scores. CO also ameliorated CA‐induced neuronal apoptosis and necrosis in the cerebral cortex and improved cerebral mitochondrial function by reducing reactive oxygen species, reversing mitochondrial membrane potential depolarization, and preventing cytochrome C release. Furthermore, CO increased mitochondrial autophagy by inducing mitochondrial accumulation of PINK1 (PTEN‐induced putative kinase 1) and Parkin. Downregulation of PINK1 with genetic silencing siRNA abolished CO‐afforded mitochondrial autophagy.

Conclusions

Taken together, our results indicate, for the first time, that CO treatment confers neuroprotection against ischemic neurological injury after CA possibly by promoting mitochondrial autophagy.

Functional Electrical Stimulation Controlled by Motor Imagery Brain-Computer Interface for Rehabilitation

Sensorimotor rhythm (SMR)-based brain–computer interface (BCI) controlled Functional Electrical Stimulation (FES) has gained importance in recent years for the rehabilitation of motor deficits. However, there still remain many research questions to be addressed, such as unstructured Motor Imagery (MI) training procedures; a lack of methods to classify different MI tasks in a single hand, such as grasping and opening; and difficulty in decoding voluntary MI-evoked SMRs compared to FES-driven passive-movement-evoked SMRs. To address these issues, a study that is composed of two phases was conducted to develop and validate an SMR-based BCI-FES system with 2-class MI tasks in a single hand (Phase 1), and investigate the feasibility of the system with stroke and traumatic brain injury (TBI) patients (Phase 2). The results of Phase 1 showed that the accuracy of classifying 2-class MIs (approximately 71.25%) was significantly higher than the true chance level, while that of distinguishing voluntary and passive SMRs was not. In Phase 2, where the patients performed goal-oriented tasks in a semi-asynchronous mode, the effects of the FES existence type and adaptive learning on task performance were evaluated. The results showed that adaptive learning significantly increased the accuracy, and the accuracy after applying adaptive learning under the No-FES condition (61.9%) was significantly higher than the true chance level. The outcomes of the present research would provide insight into SMR-based BCI-controlled FES systems that can connect those with motor disabilities (e.g., stroke and TBI patients) to other people by greatly improving their quality of life. Recommendations for future work with a larger sample size and kinesthetic MI were also presented.

Prevalence, types, risk factors, and outcomes of cardiorenal syndrome in a rural population of central India: A cross-sectional study

Background and Objectives:

Heart failure leading to renal dysfunction and vice-versa termed as Cardio-Renal Syndrome(CRS) has now been increasingly identified as a marker of higher morbidity and mortality. Till date, there is limited data available regarding clinical profile, associated risk factors and outcome of CRS in rural population of central India. This study was conducted to elucidate the prevalence, risk factors, and outcome of CRS and its types.

Methods:

This was a single-centric, cross-sectional study conducted amongst the patients admitted to medicine wards and ICCU from October 2017 to September 2019. Classification given by RONCO et al. in 2008 was used for classifying CRS patients into various types. Cross-sectional data was used to find the prevalence, risk factors and their inter-relationship with outcome and mortality. STATA software was used for statistical analysis.

Results:

Out of 96 CRS patients, 47(48.96%) were Type 1, 22 (22.92%) were type 2, 19(19.79%) were type 4 and 3 (3.13% ) were type 3, and 5 (5.21%) were of type 5. Most common risk factor was Hypertension (HTN) found in 46 (47.92%), followed closely by Coronary Artery Disease (CAD) and anaemia. Mortality was seen in 44(45.83%) of CRS patients and it was significantly high. High mortality was common in patients of types 3 and type 5 CRS. Risk factors like HTN, CAD, smoking, reduced glomerular filtration rate, low ejection fraction and sepsis were significantly associated with worse outcomes across all CRS sub-types.

Interpretation and Conclusions:

There is high mortality among CRS. Prevention or optimal management of HTN, CAD and sepsis is required to decrease mortality. There is need for more population based studies for confirming our study findings.

Sugar-sweetened beverages consumption in relation to hypertension among Iranian university students: the MEPHASOUS study

PURPOSE

This study aimed to assess the link between sugar-sweetened beverages (SSBs) consumption and hypertension among a large population in the Middle East.

METHODS

In this cross-sectional study (a part of Mental and Physical Health Assessment of University Student: MEPHASOUS study), 66,634 university students from all provinces of Iran, aged ≥ 18 years, were included. A self-administered dietary habits questionnaire was used to assess SSBs consumption as well as other dietary intakes. Participants were categorized based on three levels of SSB consumption: < 1 time/wk, 1-3 times/wk, and ≤ 3 times/wk. Hypertension was defined as systolic blood pressure (SBP) of ≥ 140 and diastolic blood pressure of ≥ 90.

RESULTS

Compared with those in the bottom category, students in the top category of SSBs consumption were more likely to have hypertension (OR 1.71, 95% CI 1.54-1.90). This association remained significant even after adjusting for confounding variables; such that participants in the highest category of SSBs consumption had 2.17 times greater odds of hypertension compared with those in the lowest category (OR 2.17, 95% CI 1.91-2.47). Stratified analysis based on gender and BMI status revealed such significant association in men (OR 2.12, 95% CI 1.79-2.50) and women (OR 2.03, 95% CI 1.67-2.48), and in all categories of BMI including students with underweight (OR 2.53, 95% CI 1.81-3.52), normal-weight (OR 2.13, 95% CI 1.81-2.51), overweight (OR 2.14, 95% CI 1.58-2.89) and obesity (OR 1.59, 95% CI 1.00-2.53).

CONCLUSION

Our results support previous findings indicating a significant positive association between SSBs consumption and hypertension.

LEVEL OF EVIDENCE

Level III, cross-sectional analytic studies.

Cardiovascular/stroke risk predictive calculators: a comparison between statistical and machine learning models

Background

Statistically derived cardiovascular risk calculators (CVRC) that use conventional risk factors, generally underestimate or overestimate the risk of cardiovascular disease (CVD) or stroke events primarily due to lack of integration of plaque burden. This study investigates the role of machine learning (ML)-based CVD/stroke risk calculators (CVRC_ML) and compares against statistically derived CVRC (CVRC_Stat) based on (I) conventional factors or (II) combined conventional with plaque burden (integrated factors).

Methods

The proposed study is divided into 3 parts: (I) statistical calculator: initially, the 10-year CVD/stroke risk was computed using 13 types of CVRC_Stat (without and with plaque burden) and binary risk stratification of the patients was performed using the predefined thresholds and risk classes; (II) ML calculator: using the same risk factors (without and with plaque burden), as adopted in 13 different CVRC_Stat, the patients were again risk-stratified using CVRC_ML based on support vector machine (SVM) and finally; (III) both types of calculators were evaluated using AUC based on ROC analysis, which was computed using combination of predicted class and endpoint equivalent to CVD/stroke events.

Results

An Institutional Review Board approved 202 patients (156 males and 46 females) of Japanese ethnicity were recruited for this study with a mean age of 69±11 years. The AUC for 13 different types of CVRC_Stat calculators were: AECRS2.0 (AUC 0.83, P<0.001), QRISK3 (AUC 0.72, P<0.001), WHO (AUC 0.70, P<0.001), ASCVD (AUC 0.67, P<0.001), FRS_cardio (AUC 0.67, P<0.01), FRS_stroke (AUC 0.64, P<0.001), MSRC (AUC 0.63, P=0.03), UKPDS56 (AUC 0.63, P<0.001), NIPPON (AUC 0.63, P<0.001), PROCAM (AUC 0.59, P<0.001), RRS (AUC 0.57, P<0.001), UKPDS60 (AUC 0.53, P<0.001), and SCORE (AUC 0.45, P<0.001), while the AUC for the CVRC_ML with integrated risk factors (AUC 0.88, P<0.001), a 42% increase in performance. The overall risk-stratification accuracy for the CVRC_ML with integrated risk factors was 92.52% which was higher compared all the other CVRC_Stat.

Conclusions

ML-based CVD/stroke risk calculator provided a higher predictive ability of 10-year CVD/stroke compared to the 13 different types of statistically derived risk calculators including integrated model AECRS 2.0.

Concordance of hypertension, diabetes and dyslipidaemia in married couples: cross-sectional study using nationwide survey data in Japan

OBJECTIVE

Because married couples have many environmental influences in common, spouses may develop similar diseases. This study aimed to determine the concordance of hypertension, diabetes and dyslipidaemia, which are major risk factors for cardiovascular disease, among married couples in Japan.

RESEARCH DESIGN AND METHODS

We conducted a cross-sectional study of married couples who were both aged ≥40 years using the 2016 Comprehensive Survey of Living Conditions, which is a Japanese national survey. We first determined the proportions of wives and husbands who were receiving therapy for each of the diseases of interest. We then conducted logistic regression analyses using the wives undergoing therapy for each disease as outcomes and the husbands undergoing therapy for the same disease as the principal exposure, adjusting for covariates.

RESULTS

The subjects of the analyses were 86 941 married couples. The wives of male patients were significantly more likely to be receiving therapy for the same disease. Logistic regression revealed that when husbands were undergoing therapy for these diseases their wives had ORs (95% CIs) of 1.79 (1.72-1.86) for hypertension, 1.45 (1.34-1.58) for diabetes, 2.58 (2.41-2.75) for dyslipidaemia and 1.87 (1.80-1.93) for any of these diseases.

CONCLUSIONS

If men have hypertension, diabetes or dyslipidaemia, their wives were also more susceptible to the same disease. Medical professionals and couples may need to recognise these results and consider couple-based interventions to help the prevention, early detection and treatment of these diseases.

VEGF-A in Cardiomyocytes and Heart Diseases

The vascular endothelial growth factor (VEGF), a homodimeric vasoactive glycoprotein, is the key mediator of angiogenesis. Angiogenesis, the formation of new blood vessels, is responsible for a wide variety of physio/pathological processes, including cardiovascular diseases (CVD). Cardiomyocytes (CM), the main cell type present in the heart, are the source and target of VEGF-A and express its receptors, VEGFR1 and VEGFR2, on their cell surface. The relationship between VEGF-A and the heart is double-sided. On the one hand, VEGF-A activates CM, inducing morphogenesis, contractility and wound healing. On the other hand, VEGF-A is produced by CM during inflammation, mechanical stress and cytokine stimulation. Moreover, high concentrations of VEGF-A have been found in patients affected by different CVD, and are often correlated with an unfavorable prognosis and disease severity. In this review, we summarized the current knowledge about the expression and effects of VEGF-A on CM and the role of VEGF-A in CVD, which are the most important cause of disability and premature death worldwide. Based on clinical studies on angiogenesis therapy conducted to date, it is possible to think that the control of angiogenesis and VEGF-A can lead to better quality and span of life of patients with heart disease.

Global Epidemiology of Ischemic Heart Disease: Results from the Global Burden of Disease Study

Background Ischemic heart disease (IHD) is a leading cause of death worldwide. Also referred to as coronary artery disease (CAD) and atherosclerotic cardiovascular disease (ACD), it manifests clinically as myocardial infarction and ischemic cardiomyopathy. This study aims to evaluate the epidemiological trends of IHD globally. Methods The most up-to-date epidemiological data from the Global Burden of Disease (GBD) dataset were analyzed. GBD collates data from a large number of sources, including research studies, hospital registries, and government reports. This dataset includes annual figures from 1990 to 2017 for IHD in all countries and regions. We analyzed the incidence, prevalence, and disability-adjusted life years (DALY) for IHD. Forecasting for the next two decades was conducted using the Statistical Package for the Social Sciences (SPSS) Time Series Modeler (IBM Corp., Armonk, NY). Results Our study estimated that globally, IHD affects around 126 million individuals (1,655 per 100,000), which is approximately 1.72% of the world's population. Nine million deaths were caused by IHD globally. Men were more commonly affected than women, and incidence typically started in the fourth decade and increased with age. The global prevalence of IHD is rising. We estimated that the current prevalence rate of 1,655 per 100,000 population is expected to exceed 1,845 by the year 2030. Eastern European countries are sustaining the highest prevalence. Age-standardized rates, which remove the effect of population changes over time, have decreased in many regions. Conclusions IHD is the number one cause of death, disability, and human suffering globally. Age-adjusted rates show a promising decrease. However, health systems have to manage an increasing number of cases due to population aging.

NLRP3 inflammasome-mediated microglial pyroptosis is critically involved in the development of post-cardiac arrest brain injury

Background

Brain injury is the leading cause of death and disability in survivors of cardiac arrest, where neuroinflammation is believed to play a pivotal role, but the underlying mechanism remains unclear. Pyroptosis is a pro-inflammatory form of programmed cell death that triggers inflammatory response upon infection or other stimuli. This study aims to understand the role of microglial pyroptosis in post-cardiac arrest brain injury.

Methods

Sprague-Dawley male rats underwent 10-min asphyxial cardiac arrest and cardiopulmonary resuscitation or sham-operation. Flow cytometry analysis, Western blotting, quantitative real-time polymerase chain reaction (qRT-PCR), co-immunoprecipitation, and immunofluorescence were used to evaluate activated microglia and CD11b-positive leukocytes after cardiac arrest and assess inflammasome activation and pyroptosis of specific cellular populations. To further explore the underlying mechanism, MCC950 or Ac-YVAD-cmk was administered to block nod-like receptor family protein 3 (NLRP3) or caspase-1, respectively.

Results

Our results showed that, in a rat model, successful resuscitation from cardiac arrest resulted in microglial pyroptosis and consequential inflammatory infiltration which was mediated by the activation of NLRP3 inflammasome. Targeting NLRP3 and caspase-1, the executor of pyroptosis, with selective inhibitors MCC950 and Ac-YVAD-cmk treatment significantly prevented microglial pyroptosis, reduced infiltration of leukocytes, improved neurologic outcome, and alleviated neuro-pathological damages after cardiac arrest in modeling rats.

Conclusions

This study demonstrates that microglial pyroptosis mediated by NLRP3 inflammasome is critically involved in the pathogenesis of post-cardiac arrest brain injury and provides a new therapeutic strategy.

Vitamin C for Cardiac Protection during Percutaneous Coronary Intervention: A Systematic Review of Randomized Controlled Trials

Percutaneous coronary intervention (PCI) is the preferred treatment for acute coronary syndrome (ACS) secondary to atherosclerotic coronary artery disease. This nonsurgical procedure is also used for selective patients with stable angina. Although the procedure is essential for restoring blood flow, reperfusion can increase oxidative stress as a side effect. We address whether intravenous infusion of vitamin C (VC) prior to PCI provides a benefit for cardioprotection. A total of eight randomized controlled trials (RCT) reported in the literature were selected from 371 publications through systematic literature searches in six electronic databases. The data of VC effect on cardiac injury biomarkers and cardiac function were extracted from these trials adding up to a total of 1185 patients. VC administration reduced cardiac injury as measured by troponin and CK-MB elevations, along with increased antioxidant reservoir, reduced reactive oxygen species (ROS) and decreased inflammatory markers. Improvement of the left ventricular ejection fraction (LVEF) and telediastolic left ventricular volume (TLVV) showed a trend but inconclusive association with VC. Intravenous infusion of VC before PCI may serve as an effective method for cardioprotection against reperfusion injury.

Psychometric properties of the Japanese version of the Kansas City Cardiomyopathy Questionnaire in Japanese patients with chronic heart failure

Background

Heart failure is a worldwide health problem that significantly affects patients’ physical function and health state. The Kansas City Cardiomyopathy Questionnaire (KCCQ) is a disease-specific patient-reported outcome measure commonly used for the assessment of health states of patients with heart failure. This study aimed to evaluate the psychometric properties of the Japanese version of the KCCQ.

Methods

Using pooled data of 141 Japanese patients with chronic heart failure from three clinical trials, the Japanese version of the KCCQ was evaluated for validity and reliability, with a focus on the clinical summary score (CSS) and its component domains. For construct validity, the associations of baseline KCCQ scores with New York Heart Association (NYHA) class and the EuroQol five-dimension, three-level (EQ-5D-3L) scores at baseline were analyzed. For reliability, internal consistency was assessed using Cronbach’s α, and test–retest reliability (reproducibility) was assessed among stable patients. Responsiveness to changes in patients’ clinical status was assessed by analyzing score changes between two timepoints among patients whose health states improved.

Results

Among 141 patients (mean age, 73.7 ± 10.9 years), 76.6% were NYHA class II at baseline. For CSS and its component domains (physical limitations, symptom frequency, and symptom severity), baseline scores were all significantly lower in patients with a higher NYHA class (p <  0.001 for all, Jonckheere-Terpstra test). The physical limitations domain and CSS showed a moderate correlation (Spearman’s ρ = − 0.40 to − 0.54) with three functional status-related EQ-5D dimensions (mobility, self-care, and usual activities). The Cronbach’s standardized α was high (> 0.70) for all KCCQ domain/summary scores. In the test–retest analysis among 58 stable patients, all domain/summary scores minimally changed by 0.3–4.2 points with intraclass correlation coefficients of 0.65–0.84, demonstrating moderate to good reproducibility, except for the symptom stability domain. Among 44 patients with improved health states, all domain/summary scores except for the symptom stability and self-efficacy domains substantially improved from baseline with a medium to large effect size of 0.62–0.88.

Conclusions

The Japanese version of the KCCQ was demonstrated to be a valid and reliable tool for the assessment of symptoms and physical function of Japanese patients with chronic heart failure.

Effect of Simvastatin-Ezetimibe Compared With Simvastatin Monotherapy After Acute Coronary Syndrome Among Patients 75 Years or Older: A Secondary Analysis of a Randomized Clinical Trial

Importance

Limited evidence is available regarding the benefit and hazard of higher-intensity treatment to lower lipid levels among patients 75 years or older. As a result, guideline recommendations differ for this age group compared with younger patients.

Objective

To determine the effect on outcomes and risks of combination ezetimibe and simvastatin compared with simvastatin monotherapy to lower lipid levels among patients 75 years or older with stabilized acute coronary syndrome (ACS).

Design, Setting, Participants

In this prespecified secondary analysis of the global, multicenter, prospective clinical randomized Improved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT), outcomes and risks were compared by age among patients 50 years or older after a hospitalization for ACS. Data were collected from October 26, 2005, through July 8, 2010, with the database locked October 21, 2014. Data were analyzed May 29, 2015, through March 13, 2018, using Kaplan-Meier curves and Cox proportional hazards models.

Interventions

Double-blind randomized assignment to combined simvastatin and ezetimibe or simvastatin and placebo with follow-up for a median of 6 years (interquartile range, 4.3-7.1 years).

Main Outcomes and Measures

The primary composite end point consisted of death due to cardiovascular disease, myocardial infarction (MI), stroke, unstable angina requiring hospitalization, and coronary revascularization after 30 days. Individual adverse ischemic and safety end points and lipid variables were also analyzed.

Results

Of 18 144 patients enrolled (13 728 men [75.7%]; mean [SD] age, 64.1 [9.8] years), 5173 (28.5%) were 65 to 74 years old, and 2798 (15.4%) were 75 years or older at randomization. Treatment with simvastatin-ezetimibe resulted in lower rates of the primary end point than simvastatin-placebo, including 0.9% for patients younger than 65 years (HR, 0.97; 95% CI, 0.90-1.05) and 0.8% for patients 65 to 74 years of age (hazard ratio [HR], 0.96; 95% CI, 0.87-1.06), with the greatest absolute risk reduction of 8.7% for patients 75 years or older (HR, 0.80; 95% CI, 0.70-0.90) (P = .02 for interaction). The rate of adverse events did not increase with simvastatin-ezetimibe vs simvastatin-placebo among younger or older patients.

Conclusions and Relevance

In IMPROVE-IT, patients hospitalized for ACS derived benefit from higher-intensity therapy to lower lipid levels with simvastatin-ezetimibe compared with simvastatin monotherapy, with the greatest absolute risk reduction among patients 75 years or older. Addition of ezetimibe to simvastatin was not associated with any significant increase in safety issues among older patients. These results may have implications for guideline recommendations regarding lowering of lipid levels in the elderly.

Trial Registration

ClinicalTrials.gov identifier: NCT00202878.

FKBP5 Exacerbates Impairments in Cerebral Ischemic Stroke by Inducing Autophagy via the AKT/FOXO3 Pathway

Cerebral ischemic stroke is regarded as one of the most serious diseases in the human central nervous system. The secondary ischemia and reperfusion (I/R) injury increased the difficulty of treatment. Moreover, the latent molecular regulating mechanism in I/R injury is still unclear. Based on our previous clinical study, we discovered that FK506 binding protein 5 (FKBP5) is significantly upregulated in patients, who suffered acute ischemic stroke (AIS), with high diagnostic value. Levels of FKBP5 were positively correlated with patients’ neurological impairments. Furthermore, a transient middle cerebral artery occlusion (tMCAO) model of mice was used to confirm that FKBP5 expression in plasma could reflect its relative level in brain tissue. Thus, we hypothesized that FKBP5 participated in the regulation of cerebral I/R injury. In order to explore the possible roles FKBP5 acted, the oxygen and glucose deprivation and reoxygenation (OGD/R) model was established to mimic I/R injury in vitro. FKBP5 expressing levels were changed by plasmid stable transfection. The altered expression of FKBP5 influenced cell viability and autophagy after OGD/R injury notably. Besides, AKT/FOXO3 cascade was involved in the FKBP5-regulating process. In the present study, FKBP5 was verified upregulated in cerebral I/R injury, related to the severity of ischemia and reperfusion injury. Additionally, our analyses revealed that FKBP5 regulates autophagy induced by OGD/R via the downstream AKT/FOXO3 signaling pathway. Our findings provide a novel biomarker for the early diagnosis of ischemic stroke and a potential strategy for treatment.

Brain-Derived Neurotrophic Factor during Oral Glucose Tolerance Test Predicts Cardiovascular Outcomes

We investigated if brain-derived neurotrophic factor (BDNF) accumulation after glucose intake could predict cardiovascular outcomes. We enrolled patients admitted for angiography due to angina. After their conditions stabilized, serum BDNF levels were detected at 0, 30, and 120 min during oral glucose tolerance test (OGTT). Area under the curve (AUC) of BDNF was calculated. The first occurrence of nonfatal myocardial infarction, nonfatal stroke, and all-cause mortality served as the primary composite endpoint. Of 480 enrolled patients, 428 completed the follow-up, and 36 primary endpoint events occurred during a median follow-up of 4.4 years. The area under the receiver operating characteristic curve significantly increased from 0.61 (95% confidence interval (CI): 0.52–0.73) for the Framingham risk score (FRS) alone model to 0.72 (95%CI: 0.63–0.81) for the AUC of BDNF plus FRS model (p = 0.016) for predicting the primary endpoint, but not to 0.65 (95%CI: 0.55–0.75) for the fasting BDNF plus FRS model (p = 0.160). Grouped by median AUC of BDNF of 38.0 (ng/mL) × h, the low BDNF group had a significantly higher risk of the endpoint than the high BDNF group (hazard ratio = 3.410, 95%CI: 1.520–7.653, p = 0.003). In conclusion, AUC of BDNF during OGTT could be superior to fasting BDNF for predicting a low cardiovascular risk.

Double Vision: Isolated Third Cranial Nerve Palsy After Cardiac Catheterization

Neurological complications after cardiac catheterization are rare. We report an unusual case of isolated third cranial nerve palsy in a 72-year-old male patient whose past medical history was significant for diabetes mellitus and coronary artery disease (CAD). He presented for elective cardiac catheterization for stable angina, which revealed multivessel CAD and no intervention was done. Two hours after the procedure, the patient suddenly started complaining of new-onset double vision in his left eye. Ophthalmologic exam revealed ptosis of the left eye lid, sluggish pupillary reflex and impaired adduction of the left eye along with exotropia of the left eye on primary gaze, all findings consistent with the left third nerve palsy. Rest of the neurological exam and neuroimaging (CT angiogram of head and MRI brain) were normal. Embolic phenomenon has been described as a possible mechanism in such patients leading to small vessel ischemic disease and cerebral microinfarction. Neuro-ophthalmologic complications after cardiac catheterization are rare but devastating for the patients. These should be recognized promptly, and patients should undergo neuroimaging to evaluate for any identifiable causes. These patients should be treated with aspirin and statin therapy and evaluated by ophthalmology for correction with prism lenses if symptoms persist.

Radiological outpatient' visits to avoid inappropriate cardiac CT examinations: an 8-year experience report

PURPOSE

The aim of this study was to evaluate the appropriateness of the cardiac computed tomography angiography (CCTA) prescriptions according to the "2010-Appropriate-Use-Criteria-for-Cardiac-Computed-Tomography-Angiography" (AUCCTA) and "Clinical-indication-for-CCTA" (CICCTA) among different specialities (Cardiologist [CA], General Practitioner [GP], Other Specialists [OS]) and prescribers' age.

MATERIALS AND METHODS

This is a single-centre, single-arm, cohort study. We prospectively enrolled 815 patients (October 2012-May 2019) who underwent a radiological outpatient visit, before CCTA examination. Prescriptions to the examination were categorized as follows: Appropriate (A), Uncertain (U) and Inappropriate (Ina), according to AUCCTA and I, II, III and Inv for CICCTA. This categorization was stratified according to CA, GP and OS and prescribers' age. CCTA was performed in patients whom indications belong to A/U categories.

RESULTS

Eight hundred and fifteen CCTA prescriptions were analysed. An yearly increase in prescriptions was found in the eight-year observational period (2012/2019 projection: 72 vs 223). Considering AUCCTA, indication A was 540/815 (66.3%), indication U was 113/815 (13.9%) and Ina accounted for 162/815 (19.9%; 128/162 [79.0%] indications with stress test listed as criterium of inappropriateness). Only U indications decreased over years (p = 0.003). Regarding CICCTA, 501/815 (61.5%) patients were categorized as I, 144/815 (17.7%) as II, 102/815 (12.5%) as III, 67/815 (8.2%) were INV and 1/815 (0.1%) were non-classified. Clinical referrals were CA in 495/786 (63.0%), GPs in 57/786 (7.3%) GP and OS in 234/786 (29.8%) [p < 0.01]. No statistically significant differences were observed in the appropriateness among different specialty physicians. Younger doctors have a lower chance to not meet A indication (OR 0.98 [CI 95% 0.96-0.99]; p = 0.003).

CONCLUSION

Our study highlights the importance of a pre-radiological visit prior to CCTA, which prevented execution of 19.9% of inappropriate examinations. Age of prescribers had an impact on appropriateness, with younger doctors having a lower chance to not meet A indication.

Milk fat: opportunities, challenges and innovation

Milk fat is a high-value milk component that is processed mainly as butter, cheese, cream and whole milk powder. It is projected that approximately 35 million tonnes of milk fat will be produced globally by 2025. This surplus, enhances the need for diversification of milk fat products and the milk pool in general. Infant milk formula producers, for instance, have incorporated enzyme modified ("humanised") milk fat and fat globule phospholipids to better mimic human milk fat structures. Minor components like mono- and di-glycerides from milk fat are increasingly utilized as emulsifiers, replacing palm esters in premium-priced food products. This review examines the chemistry of milk fat and the technologies employed for its modification, fractionation and enrichment. Emerging processing technologies such as ultrasound, high pressure processing, supercritical fluid extraction and fractionation, can be employed to improve the nutritional and functional attributes of milk fat. The potential of recent developments in biological intervention, through dietary manipulation of milk fatty acid profiles in cattle also offers significant promise. Finally, this review provides evidence to help redress the imbalance in reported associations between milk fat consumption and human health, and elucidates the health benefits associated with consumption of milk fat and dairy products.

Preventing Cardiovascular Disease Among Urban African Americans With a Mobile Health App (the MOYO App): Protocol for a Usability Study

BACKGROUND

Cardiovascular disease (CVD) disparities are a particularly devastating manifestation of health inequity. Despite advancements in prevention and treatment, CVD is still the leading cause of death in the United States. Additionally, research indicates that African American (AA) and other ethnic-minority populations are affected by CVD at earlier ages than white Americans. Given that AAs are the fastest-growing population of smartphone owners and users, mobile health (mHealth) technologies offer the unparalleled potential to prevent or improve self-management of chronic disease among this population.

OBJECTIVE

To address the unmet need for culturally tailored primordial prevention CVD-focused mHealth interventions, the MOYO app was cocreated with the involvement of young people from this priority community. The overall project aims to develop and evaluate the effectiveness of a novel smartphone app designed to reduce CVD risk factors among urban-AAs, 18-29 years of age.

METHODS

The theoretical underpinning will combine the principles of community-based participatory research and the agile software development framework. The primary outcome goals of the study will be to determine the usability, acceptability, and functionality of the MOYO app, and to build a cloud-based data collection infrastructure suitable for digital epidemiology in a disparity population. Changes in health-related parameters over a 24-week period as determined by both passive (eg, physical activity levels, sleep duration, social networking) and active (eg, use of mood measures, surveys, uploading pictures of meals and blood pressure readings) measures will be the secondary outcome. Participants will be recruited from a majority AA "large city" school district, 2 historically black colleges or universities, and 1 urban undergraduate college. Following baseline screening for inclusion (administered in person), participants will receive the beta version of the MOYO app. Participants will be monitored during a 24-week pilot period. Analyses of varying data including social network dynamics, standard metrics of activity, percentage of time away from a given radius of home, circadian rhythm metrics, and proxies for sleep will be performed. Together with external variables (eg, weather, pollution, and socioeconomic indicators such as food access), these metrics will be used to train machine-learning frameworks to regress them on the self-reported quality of life indicators.

RESULTS

This 5-year study (2015-2020) is currently in the implementation phase. We believe that MOYO can build upon findings of classical epidemiology and longitudinal studies like the Jackson Heart Study by adding greater granularity to our knowledge of the exposures and behaviors that affect health and disease, and creating a channel for outreach capable of launching interventions, clinical trials, and enhancements of health literacy.

CONCLUSIONS

The results of this pilot will provide valuable information about community cocreation of mHealth programs, efficacious design features, and essential infrastructure for digital epidemiology among young AA adults.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/16699.

Does Home Remedy Use Contribute to Medication Nonadherence Among Blacks with Hypertension?

Background

Home remedies (HRs) are described as foods, herbs, and other household products used to manage chronic conditions. The objective of this study was to examine home remedy (HR) use among Blacks with hypertension and to determine if home remedy use is correlated with blood pressure and medication adherence.

Methods

Data for this cross-sectional study were obtained from the TRUST study conducted between 2006-2008. Medication adherence was measured using the Morisky Medication Adherence Scale, and HR use was self-reported. Multivariable associations were quantified using ordinal logistic regression.

Results

The study sample consisted of 788 Blacks with hypertension living in the southern region of the United States. HR use was associated with higher systolic (HR users 152.79, nonusers 149.53; P=.004) and diastolic blood pressure (HR users 84.10, nonusers 82.14 P=.005). Use of two or more HRs was associated with low adherence (OR: .55, CI: .36-.83, P= .004).

Conclusion

The use of HR and the number of HRs used may be associated with medication nonadherence, and higher systolic and diastolic blood pressure among Blacks with hypertension. Medication nonadherence is of critical importance for individuals with hypertension, and it is essential that health care providers be aware of health behaviors that may serve as barriers to medication adherence, such as use of home remedies.

Racial and Ethnic Disparities in Postcardiac Arrest Targeted Temperature Management Outcomes

OBJECTIVES

To evaluate racial and ethnic disparities in postcardiac arrest outcomes in patients undergoing targeted temperature management.

DESIGN

Retrospective study.

SETTING

ICUs in a single tertiary care hospital.

PATIENTS

Three-hundred sixty-seven patients undergoing postcardiac arrest targeted temperature management, including continuous electroencephalogram monitoring.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Clinical variables examined in our clinical cohort included race/ethnicity, age, time to return of spontaneous circulation, cardiac rhythm at time of arrest, insurance status, Charlson Comorbidity Index, and time to withdrawal of life-sustaining therapy. CT at admission and continuous electroencephalogram monitoring during the first 24 hours were used as markers of early injury. Outcome was assessed as good (Cerebral Performance Category 1-2) versus poor (Cerebral Performance Category 3-5) at hospital discharge. White non-Hispanic ("White") patients were more likely to have good outcomes than white Hispanic/nonwhite ("Non-white") patients (34.4 vs 21.7%; p = 0.015). In a multivariate model that included age, time to return of spontaneous circulation, initial rhythm, combined electroencephalogram/CT findings, Charlson Comorbidity Index, and insurance status, race/ethnicity was still independently associated with poor outcome (odds ratio, 3.32; p = 0.003). Comorbidities were lower in white patients but did not fully explain outcomes differences. Nonwhite patients were more likely to exhibit signs of early severe anoxic changes on CT or electroencephalogram, higher creatinine levels and receive dialysis, but had longer duration to withdrawal of lifesustaining therapy. There was no significant difference in catheterizations or MRI scans. Subgroup analysis performed with patients without early electroencephalogram or CT changes still revealed better outcome in white patients.

CONCLUSIONS

Racial/ethnic disparity in outcome persists despite a strictly protocoled targeted temperature management. Nonwhite patients are more likely to arrive with more severe anoxic brain injury, but this does not account for all the disparity.

Huoxin Pill Attenuates Cardiac Inflammation by Suppression of TLR4/NF-κB in Acute Myocardial Ischemia Injury Rats

Huoxin Pill (HXP), a traditional Chinese medicine, has been prescribed widely in the treatment of coronary heart disease, angina pectoris, and other diseases. However, the possible protective mechanisms of HXP on myocardial ischemia remain unclear. In the current study, we investigated the effects and potential mechanism of HXP on myocardial ischemia and cardiac inflammation and the activation of TLR4/NF-κB pathway. Determination of electrocardiogram, echocardiography, and heart weight index (HWI) indicated that HXP treatment obviously attenuated the elevation of ST-segment, end-diastolic volume, and HWI in the AMI rat model. Enzyme-linked immunosorbent assay (ELISA) demonstrated that Huoxin Pill treatment significantly decreased the levels of CTnT, CK-MB, MDA, IL-6, and TNF-α, while it increased SOD content in serum of the AMI rat model. Moreover, hematoxylin and eosin (HE) and immunohistochemistry (IHC) staining revealed that HXP treatment alleviated pathological change, infiltration of inflammatory cells, levels of IL-6 and TNF-α, and expression of TLR4 and p-NF-κB in cardiac tissues of the AMI rat model. In conclusion, HXP treatment significantly improves cardiac function and attenuates cardiac inflammation by suppressing the activation of TLR4/NF-κB pathway in the ISO-induced AMI rat model. This study provides insights into the potential of HXP on prevention and treatment of AMI.

Nutraceutical Compounds Targeting Inflammasomes in Human Diseases

The macromolecular complex known as "inflammasome" is defined as an intracellular multi-protein complex composed of a sensor receptor (PRR), an adaptor protein and an effector enzyme (caspase-1), which oligomerize when they sense danger, such as how the NLR family, AIM-2 and RIG-1 receptors protect the body against danger via cytokine secretion. Within the NLR members, NLRP3 is the most widely known and studied inflammasome and has been linked to many diseases. Nowadays, people's interest in their lifestyles and nutritional habits is increasing, mainly due to the large number of diseases that seem to be related to both. The term "nutraceutical" has recently emerged as a hybrid term between "nutrition" and "pharmacological" and it refers to a wide range of bioactive compounds contained in food with relevant effects on human health. The relationship between these compounds and diseases based on inflammatory processes has been widely exposed and the compounds stand out as an alternative to the pathological consequences that inflammatory processes may have, beyond their defense and repair action. Against this backdrop, here we review the results of studies using several nutraceutical compounds in common diseases associated with the inflammation and activation of the NLRP3 inflammasomes complex. In general, it was found that there is a wide range of nutraceuticals with effects through different molecular pathways that affect the activation of the inflammasome complex, with positive effects mainly in cardiovascular, neurological diseases, cancer and type 2 diabetes.

Meta-analysis of the success rate of heartbeat recovery in patients with prehospital cardiac arrest in the past 40 years in China

BACKGROUND

Systematic evaluation of the successful heartbeat recovery rate (HRR) in patients during the platinum ten minutes after cardiac arrest.

METHODS

The databases of CNKI (January 1979-March 2019), Chongqing VIP (January 1989-March 2019), Wanfang (January 1990-March 2019) and Web of Science (1900-May 2020) were searched. To collect the clinical data of patients with cardiac arrest before hospitalization and analyze the cardiopulmonary resuscitation (CPR) at different times. Literature selection and data extraction were carried out by two researchers independently, and the meta package of R software (version 3. 61) was used for analysis.

RESULTS

A total of 116 papers met the inclusion criteria, including 37,181 patients. Of these patients, 3367 had their heartbeats successfully restored. The results showed a high degree of heterogeneity (χ2 = 6999.21, P < 0.01, I2 = 97.6%). The meta-analysis was conducted using a random-effects model. The combined effect size was 0.199 (0.157-0.250). (1) According to the five CPR groups (International Cardiopulmonary Resuscitation Guide 2000, 2005, 2010, 2015 and other versions), the HRR of other versions [0.264 (0.176-0.375)] was higher than the International Cardiopulmonary Resuscitation 2005 edition [0.121 (0.092-0.158)]. (2) The rescue time was divided into the 0 to ≤5 min group, the 5 to ≤10 min group, the 10 to ≤15 min group, and the > 15 min group. The HRR were 0.417 (0.341-0.496), 0.143 (0.104-0.193), 0.049 (0.034-0.069), and 0.022 (0.009-0.051), respectively. The HRR was higher in the 0 to ≤5 min group than in the 5 to ≤10 min group, the 10 to ≤15 min group and the > 15 min group. There was no difference between the 10 to ≤15 min group and the > 15 min group. (3) When the groups were stratified with the cutoff of 10 min, the ≤10 min group HRR [0.250 (0.202-0.306)] was higher than the > 10 min group rate [0.041 (0.029-0.057)]. (4) The HRR of the telephone guidance group was [0.273 (0.227-0.325)] lower than that of the 0 to ≤5 min group [0.429 (0.347-0.516)] but higher than that of the 5 to ≤10 min group, the 10 to ≤15 min group, and the > 15 min group. (5) The HRR of the witness group [0.325 (0.216-0.458)] was not different from that of the 0 to ≤5 min group, but it was higher than those of the 5 to ≤10 min group, the 10 to ≤15 min group and the > 15 min group. (6) There was no significant difference HRR between the witnessed group, the telephone guidance group and the ≤10 min group.

CONCLUSIONS

(1) The HRR is time-sensitive, and early rescue can improve it. (2) CPR performed within the platinum ten minutes must be executed by the public, and other forces are auxiliary. (3) The concept of peri-cardiac arrest period (PCAP) should be established and improved to guide CPR.

Cardiogenic Shock in the Setting of Acute Myocardial Infarction

Cardiogenic shock in the setting of acute myocardial infarction remains a major cause of morbidity and mortality. In fact, acute myocardial infarction accounts for 81% of patients in cardiogenic shock. Despite advances in pharmacologic and device-based approaches to support patients with cardiogenic shock, no significant improvement in mortality has been observed over the past 20 years, although multiple registries are providing new insight into this complex syndrome. Key elements for optimal treatment include integration of hemodynamic and metabolic data for diagnosis and risk stratification, early evaluation and appropriate initiation of acute mechanical circulatory support devices, and an organized algorithmic approach to decision making.

Predictive values of heart rate variability, deceleration and acceleration capacity of heart rate in post-infarction patients with LVEF ≥35

Background and aims

The aim was to investigate the predictive values of heart rate variability, deceleration, and acceleration capacity of heart rate in sudden cardiac death in postinfarction patients with left ventricular ejection fraction (LVEF) ≥ 35%.

Methods

We enrolled 138 acute myocardial infarction patients (MI) randomly in sinus rhythm with LVEF ≥ 35% after myocardial infarction. Data on heart rate variability, deceleration runs, deceleration, and acceleration capacity were obtained from 24h‐dynamic electrocardiogram recordings. Clinical characteristics, medications, and echocardiography data were noted. The endpoints were sudden cardiac arrhythmias (SCA), including malignant arrhythmias in the hospital and viewed sudden death out of the hospital. Relationships between autonomic parameters and endpoints were evaluated.

Results

During follow‐up for over 24 months in MI patients, 10 patients occurred sudden cardiac arrhythmias. Subjects with SCA showed lower levels of SDNN (p = .018), TP (p = .007), VLF (p < .001), DC (p < .001), and low‐risk DRs (p < .001) than those without SCA. A low SDNN level (HR: 8.888, p = .006), low VLF level (HR: 14.699, p = .016), low DC level (HR: 4.430, p = .045), and higher risk DRs (HR: 3.81, p = .040) were identified as independent risk factors of SCA for postinfarction patients with LVEF ≥ 35%. The area under the ROC curve (AUC) of SDNN, VLF, and DC for identification of SCA were, respectively, 0.724 (p = .019), 0.807 (p < .001), and 0.804 (p = .002). SDNN, VLF, and DC combined assessment area under the ROC curve were 0.828 (p < .001).

Conclusion

Decreased SDNN, VLF, DC, and abnormal DRs are independently associated with increased risks of sudden cardiac arrhythmias in post‐MI patients with LVEF ≥ 35%. Combined SDNN, VLF, and DC may help identify a high‐risk group of malignant arrhythmias in postinfarction patients.

Discovery of Novel Small-Molecule Calcium Sensitizers for Cardiac Troponin C: A Combined Virtual and Experimental Screening Approach

Heart failure is a leading cause of death throughout the world and is triggered by a disruption of the cardiac contractile machinery. This machinery is regulated in a calcium-dependent manner by the protein complex troponin. Calcium binds to the N-terminal domain of cardiac troponin C (cNTnC) setting into motion the cascade of events leading to muscle contraction. Because of the severity and prevalence of heart failure, there is a strong need to develop small-molecule therapeutics designed to increase the calcium sensitivity of cardiac troponin in order to treat this devastating condition. Molecules that are able to stabilize an open configuration of cNTnC and additionally facilitate the binding of the cardiac troponin I (cTnI) switch peptide have the potential to enable increased calcium sensitization and strengthened cardiac function. Here, we employed a high throughput virtual screening methodology built upon the ability of computational docking to reproduce known experimental results and to accurately recognize cNTnC conformations conducive to small molecule binding using a receiver operator characteristic curve analysis. This approach combined with concurrent stopped-flow kinetic experimental verification led to the identification of a number of sensitizers, which slowed the calcium off-rate. An initial hit, compound 4, was identified with medium affinity (84 ± 30 μM). Through refinement, a calcium sensitizing agent, compound 5, with an apparent affinity of 1.45 ± 0.09 μM was discovered. This molecule is one of the highest affinity calcium sensitizers known to date.