2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Effects of physical training on physical and functional fitness, physical activity level, endothelial function, hemodynamic variables, bone metabolism, and quality of life of post-bariatric patients: study protocol for a randomized controlled trial

BACKGROUND

Evidence of the benefits induced from resistance exercise on health markers of post-bariatric patients is limited. The study will investigate the effects of a resistance training (RT) program on muscle mass and strength, bone metabolism biomarkers, bone mineral density (BMD), bone microarchitecture, and endothelial function of patients subjected to Roux-en-Y gastric bypass.

METHODS/DESIGN

This randomized controlled trial will include 60 post-bariatric patients, physically inactive, aging 18 to 50 years, with a post-surgery period ≥ 12 months. They will be randomly assigned into two groups: (i) the non-exercised control group, which will receive the standard clinical follow-up, or (ii) the intervention group which will consist of RT (60 min/session; 3 times/week, for 6 months). The primary outcomes will include muscle mass and strength, bone metabolism biomarkers, BMD, and bone microarchitecture. The secondary outcomes will be anthropometry, hemodynamic measurements, cardiovascular risk factors, health-related quality of life (QoL), and endothelial function. Outcomes will be assessed by blood biomarkers of bone formation and reabsorption, dual X-ray absorptiometry, repetition maximum and handgrip strength tests, high-resolution peripheral quantitative computed tomography, 36-Item Short-Form Health Survey, venous occlusion plethysmography, and nailfold videocapillaroscopy.

DISCUSSION

It is expected that there are greater benefits from the RT program, possibly improving muscle mass and strength, bone metabolism, density and microarchitecture, QoL, and cardiovascular risk.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04193397. Registered on 7 December 2019.

Inflammatory bowel disease and cardiovascular disease: A two-sample Mendelian randomization analysis

Background

Although epidemiological studies have shown a positive relationship between inflammatory bowel disease (IBD) and risk of cardiovascular disease (CVD) outcomes, a solid causal relationship has not been established. Thus, a two-sample Mendelian randomization (MR) study was conducted to explore the potential causal effect between IBD and CVD outcomes.

Methods

We performed a two-sample MR analysis to analyze the causal effect of the IBD on CVD outcome by using summary-level genome-wide association studies of European descent. The inverse-variance weighted (IVW) method was used as the main MR analysis, with complementary analyses of MR Egger, maximum likelihood, weighted median, penalized weighted media, simple mode, weighted mode, and MR-PRESSO methods. Multiple sensitivity analyses were used to evaluate the robustness of our results.

Results

All P-values were greater than 0.05 in the IVW method, showing no evidence of a causal association between circulating IBD and CVD. Similar results were observed by using other MR methods. No evidence of heterogeneity, pleiotropy, or outlier single-nucleotide polymorphisms was detected. Sensitivity analyses demonstrated the robustness of the results.

Conclusion

The findings of this study provided no evidence to support that IBD has a large effect on risk of CVD outcomes, which is in contrast to many previous observational reports. Further studies are needed to determine the potential mechanism of association identified in observational studies.

Wearable accelerometer-derived physical activity and incident disease

Physical activity is regarded as favorable to health but effects across the spectrum of human disease are poorly quantified. In contrast to self-reported measures, wearable accelerometers can provide more precise and reproducible activity quantification. Using wrist-worn accelerometry data from the UK Biobank prospective cohort study, we test associations between moderate-to-vigorous physical activity (MVPA) – both total MVPA minutes and whether MVPA is above a guideline-based threshold of ≥150 min/week—and incidence of 697 diseases using Cox proportional hazards models adjusted for age, sex, body mass index, smoking, Townsend Deprivation Index, educational attainment, diet quality, alcohol use, blood pressure, anti-hypertensive use. We correct for multiplicity at a false discovery rate of 1%. We perform analogous testing using self-reported MVPA. Among 96,244 adults wearing accelerometers for one week (age 62 ± 8 years), MVPA is associated with 373 (54%) tested diseases over a median 6.3 years of follow-up. Greater MVPA is overwhelmingly associated with lower disease risk (98% of associations) with hazard ratios (HRs) ranging 0.70–0.98 per 150 min increase in weekly MVPA, and associations spanning all 16 disease categories tested. Overall, associations with lower disease risk are enriched for cardiac (16%), digestive (14%), endocrine/metabolic (10%), and respiratory conditions (8%) (chi-square p < 0.01). Similar patterns are observed using the guideline-based threshold of ≥150 MVPA min/week. Some of the strongest associations with guideline-adherent activity include lower risks of incident heart failure (HR 0.65, 95% CI 0.55–0.77), type 2 diabetes (HR 0.64, 95% CI 0.58–0.71), cholelithiasis (HR 0.61, 95% CI 0.54–0.70), and chronic bronchitis (HR 0.42, 95% CI 0.33–0.54). When assessed within 456,374 individuals providing self-reported MVPA, effect sizes for guideline-adherent activity are substantially smaller (e.g., heart failure HR 0.84, 95% CI 0.80–0.88). Greater wearable device-based physical activity is robustly associated with lower disease incidence. Future studies are warranted to identify potential mechanisms linking physical activity and disease, and assess whether optimization of measured activity can reduce disease risk.

Nutrition Education, Understanding, and Counseling Practices Among Physiatrists: A Survey Study

INTRODUCTION

 Nutritional counseling is relevant to physiatry practice. However, physiatrists' nutrition knowledge base and their frequency of incorporating nutritional education into routine clinical encounters are currently unknown. The objective of this study was to assess physiatrists' nutrition education, nutrition knowledge, willingness to implement nutrition counseling in clinical practice, and perceived barriers to providing nutritional counseling to patients, using an online survey. The hypothesis was that few physiatrists offer dietary counseling to their patients on a routine basis and that barriers likely include time constraints in a typical office visit, lack of provider confidence in providing dietary recommendations, and lack of provider reimbursement.

METHODS

This study was a cross-sectional online survey that was distributed via email to a convenience sample of 179 resident, fellow, and attending physiatrists associated with two major academic institutions. The survey consisted of 26 questions regarding demographics, nutrition counseling practices and attitudes, basic nutrition knowledge, and perceived barriers to providing nutrition counseling.

RESULTS

Of 59 participants, 78% reported receiving education in nutrition and/or behavioral counseling in medical school. In contrast, 39% of participants did not feel adequately trained to discuss nutrition and diet-related issues with patients. Barriers to providing nutritional counseling were time constraints (83%), socioeconomic factors outside of patients' control preventing them from adhering to a healthier diet (76%), and not having enough nutrition knowledge to do so appropriately (62%). Respondents (86%) either agreed or strongly agreed that additional training in nutrition would allow them to provide better clinical care in the prevention of progressive cardiovascular and neurovascular disease. Further, respondents (85%) either agreed or strongly agreed that they would be interested in a web-based continuing medical education training in nutrition behavioral counseling and evidence-based dietary recommendations.

CONCLUSIONS

 The findings refuted the hypothesis that few physiatrists in the sample offer dietary counseling to their patients on a routine basis. Results demonstrated that many of them acknowledge its relevance and would be interested in further education on the subject. Physiatrists also appear to have perceived barriers to offering nutritional counseling, but some of them varied by the amount of medical experience. Based on these findings, this study demonstrated that it would be worthwhile to develop such a continuing medical education activity with a focus on populations commonly treated by physiatrists.

Research Landscape on Atherosclerotic Cardiovascular Disease and Inflammation: A Bibliometric and Visualized Study

Background

The atherosclerotic cardiovascular disease (ASCVD) is a major killer and health care burden worldwide. Atherosclerosis, the common pathological foundation, has been associated with inflammation over the past few years. Some promising results also have emerged suggesting the role of targeting inflammation as a potential therapeutic option to reduce cardiovascular events. In light of the pathogenic role that inflammation plays in ASCVD, we propose to evaluate the worldwide research architecture for ASCVD and inflammation using bibliometric analysis.

Methods

A search of the Web of Science Core Collection of Clarivate Analytics was performed for articles in the field published between 2012 and 2022. The number of publications per year has been visualized using GraphPad Prism through time. CiteSpace and VOSviewer were used to generate knowledge maps about the collaboration of countries, institutions, and authors, and to represent the landscape on ASCVD and inflammation research as well as to reveal current foci.

Results

There were a total of 19,053 publications examined in this study. The most publications came from China (6232, 32.71%). Capital Med Univ was the most productive institution (410, 2.15%). Christian Weber published the greatest number of articles (75, 0.39%). PloS one was identified as the most prolific journal (706, 3.71%). Circulation was the most co-cited journal (13276, 2.81%). Keywords with the ongoing strong citation bursts were "nucleotide-binding oligomerization (NOD), Leucine-rich repeat (LRR)-containing protein (NLRP3) inflammasome", "intestinal microbiota", "exosome", "lncRNAs", etc.

Conclusions

It can be shown that ASCVD and inflammation research benefited from manuscripts that had a high impact on the scientific community. Asian, European and North American countries dominated in the field in terms of quantitative, qualitative and collaborative parameters. The NLRP3 inflammasome, gut microbiota and trimethylamine N-oxide, autophagy, lncRNAs, exosomes, and nuclear factor erythroid 2-related factor 2 were described to be hot themes in the field.

An update on the coronary calcium score: a review for clinicians

The clinical manifestation of coronary artery atherosclerosis is coronary artery disease (CAD) with symptoms ranging from exertional chest pain due to reduction of coronary flow reserve to acute coronary syndrome due to rupture of usually a nonobstructive plaque with abrupt coronary blood flow reduction. CAD is the leading cause of morbidity and mortality worldwide. Therefore, identifying asymptomatic people at risk of CAD is pivotal to guide decision-making for primary prevention. Coronary artery calcium (CAC) is a hallmark of coronary artery atherosclerosis. It can be detected using cardiac computed tomography and quantified by the Agatston method. CAC examination is a cheap, fast and low radiation dose test, without injecting a contrast agent. It provides prognostic information over other traditional cardiovascular risk markers and established scoring systems, especially for low-risk subgroups such as women and younger adults, and indicates the appropriate moment to implement primary prevention, including acetylsalicylic acid and statins. In this review, we discuss the methods of CAC evaluation, the meaning of a zero CAC score (CACS), its conversion to CACS > 0 and the impact of this fact on cardiovascular risk, the effect of statins and proprotein convertase subtilisin/kexin type 9 inhibitor on CAC progression, interpretation of CACS results, and CACS prognostic value in both asymptomatic and symptomatic patients.

Approach to risk stratification of atherosclerotic cardiovascular disease: Use of biomarkers and imaging in a Canadian context

OBJECTIVE

To outline the 2021 Canadian Cardiovascular Society (CCS) dyslipidemia guidelines and to present the current approaches to cardiovascular risk stratification, including the incorporation of biomarkers and imaging tests.

SOURCES OF INFORMATION

Current guidelines were reviewed and an Ovid MEDLINE literature search was performed.

MAIN MESSAGE

Cardiovascular disease (CVD) is the leading cause of global mortality, with ischemic heart disease contributing to nearly half of these deaths. Risk stratification is undertaken to identify patients who would benefit from primary prevention for atherosclerotic CVD (ASCVD), but commonly used methods for risk stratification are imperfect. The CCS guidelines endorse that the presence of risk modifiers (family history of premature ASCVD, high-sensitivity C-reactive protein level ≥2.0 mg/L, lipoprotein[a] level ≥500 mg/L [≥50 mg/dL], or coronary artery calcium >0) supports the use of statin therapy in those at intermediate risk (Framingham risk score 10% to 19.9%) who do not otherwise meet the recommendations for statin use. The CCS guidelines recommend statin therapy in patients at intermediate risk when cholesterol levels are elevated (low-density lipoprotein cholesterol level ≥3.5 mmol/L, non-high-density lipoprotein cholesterol level ≥4.2 mmol/L, or apolipoprotein B level ≥1.05 g/L). In addition, statin therapy should be considered for patients at low risk (Framingham risk score 5% to 9.9%) with elevated cholesterol levels, especially if risk modifiers are present. When cholesterol levels are not elevated, evidence still favours the use of statins in intermediate-risk patients when risk modifiers are present and in men 50 years and older and women 60 years and older with 1 additional risk factor.

CONCLUSION

Biomarkers and imaging tests have the potential to improve ASCVD risk stratification by reclassifying any patient whose risk has been inaccurately estimated by traditional methods. Recently published guidelines by the CCS suggest the use of biomarkers and imaging in certain patient groups.

Age-dependent sex differences in cardiometabolic risk factors

Cardiometabolic diseases (CMDs) are a major cause of mortality worldwide, yet men and women present remarkable differences in disease prognosis, onset and manifestation. Here we characterize how sex differences in cardiometabolic risk factors vary with age by examining 45 phenotypes and 6 lifestyle factors in 146,021 participants of the Dutch population cohort Lifelines. We show that sex differences are present in 71% of the studied phenotypes. For 31% of these phenotypes, the phenotypic difference between sexes is dependent on age. CMD risk factors show various patterns of age-related sex differences, ranging from no difference for phenotypes such as body mass index (BMI) to strong age-modified sex differences for lipid levels. We also identify lifestyle factors that influence phenotypes in a sex- and age-dependent manner. These results highlight the importance of taking age into account when studying sex differences in CMDs.

Non-dipping pattern in early-stage diabetes: association with glycemic profile and hemodynamic parameters

Patients with longstanding diabetes exhibit diminished nocturnal blood pressure (BP) drop, yet this phenomenon remains understudied in the early stages of the disease. Eighty patients with newly diagnosed (<6 months) Diabetes Mellitus type 2 (T2DM) and 80 non-T2DM individuals underwent office and 24-h ambulatory BP measurements, estimation of hemodynamic parameters using impedance cardiography and blood tests. Ten-year atherosclerotic cardiovascular disease (ASCVD) risk score was calculated. T2DM patients exhibited higher nighttime systolic blood pressure (SBP) (p = 0.028) and lower dipping (p < 0.001) compared to controls. In the total population, dipping correlated negatively with age, HbA_1c, ASCVD risk score, and positively with HDL Cholesterol and Velocity Index (VI), a marker of myocardial contractility (p < 0.05). Nighttime SBP correlated positively with ASCVD risk, BMI, HbA_1c, fasting glucose, eGFR, and negatively with VI (p < 0.05). After adjustment for other variables, HbA_1c (p = 0.03), eGFR (p = 0.02) and VI (p = 0.004) independently predicted non-dipping. Multivariate analysis revealed HbA_1c (p = 0.023), eGFR (p = 0.05), and VI (p = 0.006) as independent predictors of nighttime SBP. Patients diagnosed with T2DM concurrently present impaired circadian BP rhythm, which appears to be directly associated with impaired glycemic profile. The observed association with myocardial contractility might represent an additional mechanism for the aggravated cardiovascular risk in these patients.

Approche de la stratification du risque de maladies cardiovasculaires athéroscléreuses

Objectif

Donner un aperçu des lignes directrices de la Société canadienne de cardiologie (SCC) de 2021 sur la dyslipidémie et présenter les approches actuelles relatives à la stratification du risque cardiovasculaire, y compris l’intégration de la mesure des biomarqueurs et de l’imagerie.

Sources de l’information

Les lignes directrices actuelles ont été passées en revue, et une recherche documentaire dans Ovid MEDLINE a été effectuée.

Message principal

Les maladies cardiovasculaires (MCV) sont la principale cause de mortalité dans le monde, et les cardiopathies ischémiques contribuent à près de la moitié de ces décès. Une stratification du risque est entreprise pour identifier les patients susceptibles de bénéficier d’une prévention primaire de la MCV athéroscléreuse (MCVAS), mais les méthodes habituellement utilisées pour la stratification du risque sont imparfaites. Les lignes directrices de la SCC soutiennent que la présence de modificateurs du risque (antécédents familiaux de MCVAS prématurée, dosage de la protéine C réactive hypersensible ≥2,0 mg/L, dosage de la lipoprotéine [a] ≥500 mg/L [≥50 mg/dL] ou score calcique coronarien >0) justifie le recours à une thérapie aux statines chez les personnes à risque moyen (score de risque de Framingham de 10 à 19,9 %) qui ne sont pas autrement visées par les recommandations en faveur de l’utilisation de statines. Les lignes directrices de la SCC recommandent une thérapie aux statines chez les patients à risque modéré, lorsque leurs taux de cholestérol sont élevés (taux de cholestérol à lipoprotéines de basse densité ≥3,5 mmol/L, taux de cholestérol lié aux lipoprotéines autres que celles de haute densité ≥4,2 mmol/L ou taux d’apolipoprotéines B ≥1,05 g/L). De plus, une thérapie aux statines devrait être envisagée pour les patients à faible risque (score de risque de Framingham de 5 à 9,9 %) dont les taux de cholestérol sont élevés, surtout en présence de modificateurs du risque. Lorsque les taux de cholestérol ne sont pas élevés, des données probantes favorisent quand même le recours aux statines chez les patients à risque modéré lorsque des modificateurs du risque sont présents, de même que chez les hommes de 50 ans et plus et chez les femmes de 60 ans et plus ayant 1 facteur de risque additionnel.

Conclusion

La mesure des biomarqueurs et l’imagerie ont le potentiel d’améliorer la stratification du risque de MCVAS en reclassant les patients dont le risque avait été estimé de manière inexacte par les méthodes traditionnelles. Les lignes directrices récemment publiées par la SCC suggèrent de se servir des biomarqueurs et de l’imagerie chez certains groupes de patients.

Assessment of an Intervention to Reduce Aspirin Prescribing for Patients Receiving Warfarin for Anticoagulation

IMPORTANCE

For some patients receiving warfarin, adding aspirin (acetylsalicylic acid) increases bleeding risk with unclear treatment benefit. Reducing excess aspirin use could be associated with improved clinical outcomes.

OBJECTIVE

To assess changes in aspirin use, bleeding, and thrombosis event rates among patients treated with warfarin.

DESIGN, SETTING, AND PARTICIPANTS

This pre-post observational quality improvement study was conducted from January 1, 2010, to December 31, 2019, at a 6-center quality improvement collaborative in Michigan among 6738 adults taking warfarin for atrial fibrillation and/or venous thromboembolism without an apparent indication for concomitant aspirin. Statistical analysis was conducted from November 26, 2020, to June 14, 2021.

INTERVENTION

Primary care professionals for patients taking aspirin were asked whether an ongoing combination aspirin and warfarin treatment was indicated. If not, then aspirin was discontinued with the approval of the managing clinician.

MAIN OUTCOMES AND MEASURES

Outcomes were assessed before and after intervention for the primary analysis and before and after 24 months before the intervention (when rates of aspirin use first began to decrease) for the secondary analysis. Outcomes included the rate of aspirin use, bleeding, and thrombotic outcomes. An interrupted time series analysis assessed cumulative monthly event rates over time.

RESULTS

A total of 6738 patients treated with warfarin (3160 men [46.9%]; mean [SD] age, 62.8 [16.2] years) were followed up for a median of 6.7 months (IQR, 3.2-19.3 months). Aspirin use decreased slightly from a baseline mean use of 29.4% (95% CI, 28.9%-29.9%) to 27.1% (95% CI, 26.1%-28.0%) during the 24 months before the intervention (P < .001 for slope before and after 24 months before the intervention) with an accelerated decrease after the intervention (mean aspirin use, 15.7%; 95% CI, 14.8%-16.8%; P = .001 for slope before and after intervention). In the primary analysis, the intervention was associated with a significant decrease in major bleeding events per month (preintervention, 0.31%; 95% CI, 0.27%-0.34%; postintervention, 0.21%; 95% CI, 0.14%-0.28%; P = .03 for difference in slope before and after intervention). No change was observed in mean percentage of patients having a thrombotic event from before to after the intervention (0.21% vs 0.24%; P = .34 for difference in slope). In the secondary analysis, reducing aspirin use (starting 24 months before the intervention) was associated with decreases in mean percentage of patients having any bleeding event (2.3% vs 1.5%; P = .02 for change in slope before and after 24 months before the intervention), mean percentage of patients having a major bleeding event (0.31% vs 0.25%; P = .001 for change in slope before and after 24 months before the intervention), and mean percentage of patients with an emergency department visit for bleeding (0.99% vs 0.67%; P = .04 for change in slope before and after 24 months before the intervention), with no change in mean percentage of patients with a thrombotic event (0.20% vs 0.23%; P = .36 for change in slope before and after 24 months before the intervention).

CONCLUSIONS AND RELEVANCE

This quality improvement intervention was associated with an acceleration of a preexisting decrease in aspirin use among patients taking warfarin for atrial fibrillation and/or venous thromboembolism without a clear indication for aspirin therapy. Reductions in aspirin use were associated with reduced bleeding. This study suggests that an anticoagulation clinic-based aspirin deimplementation intervention can improve guideline-concordant aspirin use.

Cardiovascular Risk Management in the South Asian Patient: A Review

South Asians represent a growing percentage of the diverse population in the U.S. and are disproportionately impacted by a greater burden of aggressive and premature cardiovascular disease. There are multiple potential explanations for these findings including a high prevalence of traditional risk factors (particularly diabetes, dyslipidemia, and obesity), a genetic predisposition, and unique lifestyle factors. In this review, we discuss the cardiovascular risk stratification and disease management goals for South Asian adults. We review the pharmacologic and non-pharmacologic interventions studied in this population and discuss the role of specialized clinics and digital outreach to improve care for this vulnerable group of patients.

Relationship Among Coronary Artery Calcium Score, Myocardial Perfusion SPECT and Risk Stratification of Coronary Artery Disease

Since Agatston et al. first reported quantification of the coronary artery calcification score (CACS) in 1990, discussion of its clinical significance and use in diagnostic management has continued. Recent papers have reported the relationship between CACS and myocardial perfusion single photon emission computed tomography (SPECT: MPS) and its combined diagnostic value. When interpreting CACS results, it should be noted that the frequency of significant ischemia detected by MPS, likelihood of coronary artery disease (CAD), and event rate gradually increased from mild to moderate CACS (1-400). At present, high CACS is considered to be moderately consistent with abnormal MPS, and abnormal CACS in normal MPS may contribute to CAD risk stratification. However, it should be noted that CACS=0 does not completely exclude CAD, which is particularly important when using CACS as a gatekeeper for MPS. Both stand-alone computed tomography (CT) scanner and hybrid SPECT-CT scanner are available for combined risk stratification of CACS and MPS in addition to improvement of image quality with attenuation correction.

Extra-coronary Calcification and Cardiovascular Events: What Do We Know and Where Are We Heading?

PURPOSE OF REVIEW

The coronary artery calcium score is a guideline-endorsed aid for further risk stratification in the primary prevention of atherosclerotic cardiovascular disease. The non-contrast scan performed for detection of coronary artery calcium also gives an opportunity to visualize calcifications in the thoracic aorta and in the heart valves, at no additional cost or radiation exposure. The purpose of this review was to discuss the potential clinical value of measuring thoracic aortic calcification, aortic valve calcification, and mitral annulus calcification.

RECENT FINDINGS

After two decades of active research, all three calcifications have been extensively evaluated, across various cohorts. We discuss classic and recent studies, current knowledge gaps, and future directions in this space. The added value of these measurements has traditionally been considered modest at best, and they are not currently discussed in relevant primary prevention guidelines in North America and Europe. However, recent studies evaluating high thoracic calcification thresholds and younger populations have further enriched this space. Specifically, some studies suggest that detection of severe thoracic aortic calcification may be helpful in further risk assessment and that detection of aortic valve calcifications may have important prognostic implications in younger individuals. Although more research is needed, particularly in larger young-to-middle-aged cohorts, future guidelines might consider including these features as risk-enhancing factors.

Pharmacokinetic and pharmacodynamic profiles of a novel phospholipid-aspirin complex liquid formulation and low dose enteric-coated aspirin: results from a prospective, randomized, crossover study

Low dose enteric-coated aspirin (EC-ASA) is routinely used for secondary cardiovascular event prevention. However, absorption of EC tablets is poor, which can result in subtherapeutic antiplatelet effects. Phospholipid-aspirin liquid filled capsules (PL-ASA) are a novel FDA-approved immediate-release formulation designed to reduce gastrointestinal (GI) injury by limiting direct contact with the stomach lining. We compared the pharmacokinetic (PK) and pharmacodynamic (PD) profiles of PL-ASA versus EC-ASA at a low dose. This randomized, open-label, crossover study assessed PK and PD following a single 81-mg dose of PL-ASA versus EC-ASA under fasting conditions in 36 volunteers without cardiovascular disease between 18 and 75 years of age. Volunteers were randomly assigned 1:1 to either PL-ASA then EC-ASA or vice versa with a minimum 14-day washout. Assessments included PK parameters for acetylsalicylic acid and salicylic acid, platelet aggregation in response to arachidonic acid (AA), and serum thromboxane B2 (TxB₂) assessments over 24 h. PL-ASA was rapidly absorbed. PL-ASA reached T_max 3 h earlier (1.01 vs. 4.00 h, p < 0.0001), with almost double the C_max (720 vs. 368 ng/mL, p < 0.0001) and overall 44% higher exposure of acetylsalicylic acid (AUC_0-t: 601 vs. 416 h*ng/mL, p = 0.0013) compared with EC-ASA. Within 1 h of dosing, PL-ASA achieved significantly lower residual platelet aggregation, which persisted for the full 24 h (median AA-LTA was 47% with PL-ASA vs. 80.5% with EC-ASA; p = 0.0022 at hour-24). Treatment with PL-ASA also resulted in significantly lower serum TxB₂ concentrations at each time point compared with EC-ASA (all p-values < 0.05). PL-ASA resulted in faster and more complete aspirin absorption paralleled by more prompt and potent platelet inhibition compared with EC-ASA after a single 81 mg dose. PL-ASA represents an attractive novel aspirin formulation for the secondary prevention of cardiovascular events.

Clinical Trial Registration ClinicalTrials.gov identifier: NCT04811625.

Clinicians' Perceptions towards Precision Medicine Tools for Cardiovascular Disease Risk Stratification in South Africa

Cardiovascular diseases (CVDs) are a leading cause of mortality and morbidity in South Africa. Risk stratification is the preferred approach to disease prevention, but identifying patients at high risk for CVD remains challenging. Assessing genetic risk could improve stratification and inform a clinically relevant precision medicine (PM) approach. Clinicians are critical to PM adoption, thus, this study explores practicing clinicians’ perceptions of PM-based CVD risk stratification in South Africa’s public health setting. Practicing clinicians (n = 109) at four teaching hospitals in Johannesburg, South Africa, completed an electronic self-administered survey. The effect of demographic and professional characteristics on PM-based CVD risk stratification perceptions was assessed. Fewer than 25% of respondents used clinical genetic testing, and 14% had formal genetics training. 78% had a low mean knowledge score, with higher scores associated with genetic training (p < 0.0005) and research involvement (p < 0.05). Despite limited knowledge and resources, 84% perceived PM approaches positively. 57% felt confident in applying the PM-based approach, with those already undertaking CVD risk stratification more confident (p < 0.001). High cost and limited access to genetics services are key barriers. Integrating genetic information into established clinical tools will likely increase confidence in using PM approaches. Addressing the genetics training gap and investment into the country’s genomics capacity is needed to advance PM in South Africa.

Transitioning to active-controlled trials to evaluate cardiovascular safety and efficacy of medications for type 2 diabetes

Cardiovascular (CV) outcome trials (CVOTs) of type 2 diabetes mellitus (T2DM) therapies have mostly used randomized comparison with placebo to demonstrate non-inferiority to establish that the investigational drug does not increase CV risk. Recently, several glucagon-like peptide 1 receptor agonists (GLP-1 RA) and sodium glucose cotransporter 2 inhibitors (SGLT-2i) demonstrated reduced CV risk. Consequently, future T2DM therapy trials could face new ethical and clinical challenges if CVOTs continue with the traditional, placebo-controlled design. To address this challenge, here we review the methodologic considerations in transitioning to active-controlled CVOTs and describe the statistical design of a CVOT to assess non-inferiority versus an active comparator and if non-inferiority is proven, using novel methods to assess for superiority versus an imputed placebo. Specifically, as an example of such methodology, we introduce the statistical considerations used for the design of the "Effect of Tirzepatide versus Dulaglutide on Major Adverse Cardiovascular Events (MACE) in Patients with Type 2 Diabetes" trial (SURPASS CVOT). It is the first active-controlled CVOT assessing antihyperglycemic therapy in patients with T2DM designed to demonstrate CV efficacy of the investigational drug, tirzepatide, a dual glucose-dependent insulinotropic polypeptide and GLP-1 RA, by establishing non-inferiority to an active comparator with proven CV efficacy, dulaglutide. To determine the efficacy margin for the hazard ratio, tirzepatide versus dulaglutide, for the composite CV outcome of death, myocardial infarction, or stroke (MACE-3), which is required to claim superiority versus an imputed placebo, the lower bound of efficacy of dulaglutide compared with placebo was estimated using a hierarchical Bayesian meta-analysis of placebo-controlled CVOTs of GLP-1 RAs. SURPASS CVOT was designed so that when the observed upper bound of the 95% confidence interval of the hazard ratio is less than the lower bound of efficacy of dulaglutide, it demonstrates non-inferiority to dulaglutide by preserving at least 50% of the CV benefit of dulaglutide as well as statistical superiority of tirzepatide to a theoretical placebo (imputed placebo analysis). The presented methods adding imputed placebo comparison for efficacy assessment may serve as a model for the statistical design of future active-controlled CVOTs.

Polygenic Risk Scores for Cardiovascular Disease: A Scientific Statement From the American Heart Association

Cardiovascular disease is the leading contributor to years lost due to disability or premature death among adults. Current efforts focus on risk prediction and risk factor mitigation' which have been recognized for the past half-century. However, despite advances, risk prediction remains imprecise with persistently high rates of incident cardiovascular disease. Genetic characterization has been proposed as an approach to enable earlier and potentially tailored prevention. Rare mendelian pathogenic variants predisposing to cardiometabolic conditions have long been known to contribute to disease risk in some families. However, twin and familial aggregation studies imply that diverse cardiovascular conditions are heritable in the general population. Significant technological and methodological advances since the Human Genome Project are facilitating population-based comprehensive genetic profiling at decreasing costs. Genome-wide association studies from such endeavors continue to elucidate causal mechanisms for cardiovascular diseases. Systematic cataloging for cardiovascular risk alleles also enabled the development of polygenic risk scores. Genetic profiling is becoming widespread in large-scale research, including in health care-associated biobanks, randomized controlled trials, and direct-to-consumer profiling in tens of millions of people. Thus, individuals and their physicians are increasingly presented with polygenic risk scores for cardiovascular conditions in clinical encounters. In this scientific statement, we review the contemporary science, clinical considerations, and future challenges for polygenic risk scores for cardiovascular diseases. We selected 5 cardiometabolic diseases (coronary artery disease, hypercholesterolemia, type 2 diabetes, atrial fibrillation, and venous thromboembolic disease) and response to drug therapy and offer provisional guidance to health care professionals, researchers, policymakers, and patients.

Development of a metric Healthy Eating Index-2015 and comparison with the Healthy Eating Index-2015 for the evaluation of dietary quality

Background

Diet quality indices can provide important information about relationships between diet and health independent of energy balance. The Healthy Eating Index-2015 (HEI-2015) is widely used and has been extensively evaluated. However, due to imperial units the HEI-2015 is difficult to apply in countries with metric systems. Our objective was to develop a metric version of the HEI-2015 and compare it to the original. The metric Healthy Eating Index-2015 (mHEI-2015) is intended to simplify the application of a dietary quality index in countries using the metric system.

Methods

We developed a metric database logic following the methodology of the HEI-2015, which allows the application to metric databases and was applied to Food Patterns Equivalents Database (FPED). The HEI-2015 was calculated for the National Health and Nutrition Examination Survey (NHANES) 2017-2018 and the scoring standards for each component of the mHEI-2015 was calibrated against it. For the assessment of agreement between indices, HEI-2015 and mHEI-2015 were calculated for NHANES 2015-2016 and a Bland–Altman plot was created.

Results

Healthy Eating Index-2015 and mHEI-2015 for the NHANES 2015-2016 averaged 52.5 ± 13.5 and 52.6 ± 13.2, respectively. The total scores as well as component scores of the indices were strongly correlated. The Bland–Altman plot revealed a high agreement of the total scores. An illustrated analysis of six different menu plans showed only minor differences between the HEI-2015 and mHEI-2015 component scores.

Conclusion

The mHEI-2015 allows for superior analysis of metric dietary data to better examine the relationship between chronic diseases and diet. The streamlined metric methodology enables straightforward application to metric food databases and thus the development of country-specific indices.

Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: US Preventive Services Task Force Recommendation Statement

IMPORTANCE

Cardiovascular disease (CVD) is the leading cause of morbidity and death in the US and is the cause of more than 1 of every 4 deaths. Coronary heart disease is the single leading cause of death and accounts for 43% of deaths attributable to CVD in the US. In 2019, an estimated 558 000 deaths were caused by coronary heart disease and 109 000 deaths were caused by ischemic stroke.

OBJECTIVE

To update its 2016 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a review of the evidence on the benefits and harms of statins for reducing CVD-related morbidity or mortality or all-cause mortality.

POPULATION

Adults 40 years or older without a history of known CVD and who do not have signs and symptoms of CVD.

EVIDENCE ASSESSMENT

The USPSTF concludes with moderate certainty that statin use for the prevention of CVD events and all-cause mortality in adults aged 40 to 75 years with no history of CVD and who have 1 or more CVD risk factors (ie, dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year CVD event risk of 10% or greater has at least a moderate net benefit. The USPSTF concludes with moderate certainty that statin use for the prevention of CVD events and all-cause mortality in adults aged 40 to 75 years with no history of CVD and who have 1 or more of these CVD risk factors and an estimated 10-year CVD event risk of 7.5% to less than 10% has at least a small net benefit. The USPSTF concludes that the evidence is insufficient to determine the balance of benefits and harms of statin use for the primary prevention of CVD events and mortality in adults 76 years or older with no history of CVD.

RECOMMENDATION

The USPSTF recommends that clinicians prescribe a statin for the primary prevention of CVD for adults aged 40 to 75 years who have 1 or more CVD risk factors (ie, dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year CVD risk of 10% or greater. (B recommendation) The USPSTF recommends that clinicians selectively offer a statin for the primary prevention of CVD for adults aged 40 to 75 years who have 1 or more of these CVD risk factors and an estimated 10-year CVD risk of 7.5% to less than 10%. The likelihood of benefit is smaller in this group than in persons with a 10-year risk of 10% or greater. (C recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of initiating a statin for the primary prevention of CVD events and mortality in adults 76 years or older. (I statement).

Acute Myocardial Infarction in Young Patients and its Correlation with Obesity Status at Pre-adolescent Stage: A Narrative Review

Background:

Cardiovascular diseases (CVD), especially acute myocardial infarction (AMI), remain a worldwide major cause of premature morbidity and mortality, with considerable health care costs. Metabolic, behavioural, environmental, and social risk factors are significant drivers of AMI, with obesity being a key determinant among them. Childhood obesity constitutes a major health threat that is considered a global epidemic of the 21st century.

Objective:

To assess whether excess weight from the first years of life acts as a predisposing factor in increasing the risk of AMI in young adults.

Methods:

This is a narrative review of the evidence concerning the epidemiology of early AMI and obesity, using PubMed and Google Scholar.

Results:

There is substantial evidence showing that excess weight during childhood multiplies the risk of AMI at an early age.

Conclusion:

Premature AMI seems to have significant drivers related to lifestyle factors, such as childhood obesity. In the era of a childhood obesity epidemic, the aforementioned relationship underlines the need for early prevention and management.

Aspirin for the Primary Prevention of Atherosclerotic Cardiovascular Disease in Women

This JAMA Insights Clinical Update discusses updated recommendations on the use of aspirin for primary prevention of atherosclerotic cardiovascular disease in women and stresses the importance of shared clinical decision-making.

Progressive Additive Benefits of Prehabilitation and Subsequent Bariatric Surgery on Cardiac Autonomic Regulation as Assessed by Means of a Simple Unitary Composite Index: Preliminary Data from an Observational Study

Obesity is associated with an increased risk of several chronic comorbidities, which may also be determined by dysfunctional autonomic nervous system (ANS). The influence of bariatric surgery (BS) on ANS balance was explored in previous studies, but with high heterogeneity in both the assessment timing and methods employed. In the present observational study, we applied a clinical protocol which considers two subsequent phases. Twenty-nine non-diabetic obese subjects were studied at baseline (T0), after one month of lifestyle modification (prehabilitation) (phase 1-T1), and after eight months following BS (phase 2-T2). ANS regulation was assessed across the three study epochs by means of ANSI, a single composite percent-ranked proxy of autonomic balance, being free of gender and age bias, economical and simple to apply in a clinical setting. The aim of the present study was to investigate the effects of the clinical protocol based on prehabilitation and subsequent BS on the ANS regulation by means of ANSI. Potential intertwined correlations with metabolic parameters were also investigated. Notably, we observed a progressive improvement in ANS control, even by employing ANSI. Moreover, the reduction in the markers of sympathetic overactivity was found to significantly correlate with the amelioration in some metabolic parameters (fasting glucose, insulin levels, and waist circumference), as well as in stress and tiredness perception. In conclusion, this study provides convincing evidence that a unitary proxy of cardiac autonomic regulation (CAR) may reflect the progressive improvement in autonomic regulation following behavioral and surgical interventions in obese patients. Intriguingly, this might contribute to reducing cardiovascular and metabolic risk.

Statin Prescription Patterns and Associations with Subclinical Inflammation

Background and Objectives: Statins have been extensively utilised in atherosclerotic cardiovascular disease (ASCVD) prevention and can inhibit inflammation. However, the association between statin therapy, subclinical inflammation and associated health outcomes is poorly understood in the primary care setting. Materials and Methods: Primary care electronic health record (EHR) data from the electronic Practice-Based Research Network (ePBRN) from 2012−2019 was used to assess statin usage and adherence in South-Western Sydney (SWS), Australia. Independent determinants of elevated C-reactive protein (CRP) were determined. The relationship between baseline CRP levels and hospitalisation rates at 12 months was investigated. Results: The prevalence of lipid-lowering medications was 14.0% in all adults and 44.6% in the elderly (≥65 years). The prevalence increased from 2012 to 2019 despite a drop in statin use between 2013−2015. A total of 55% of individuals had good adherence (>80%). Hydrophilic statin use and higher intensity statin therapy were associated with elevated CRP levels. However, elevated CRP levels were not associated with all-cause or ASCVD hospitalisations after adjusting for confounders. Conclusions: The prevalence and adherence patterns associated with lipid-lowering medications highlighted the elevated ASCVD-related burden in the SWS population, especially when compared with the Australian general population. Patients in SWS may benefit from enhanced screening protocols, targeted health literacy and promotion campaigns, and timely incorporation of evidence into ASCVD clinical guidelines. This study, which used EHR data, did not support the use of CRP as an independent marker of future short-term hospitalisations.

Clinical profile analysis and nomogram for predicting in-hospital mortality among elderly severe community-acquired pneumonia patients with comorbid cardiovascular disease: a retrospective cohort study

BACKGROUND

Researchers have linked cardiovascular disease (CVD) with advancing age; however, how it drives disease progression in elderly severe community acquired pneumonia (SCAP) patients is still unclear. This study aims to identify leading risk predictors of in-hospital mortality in elderly SCAP patients with CVD, and construct a comprehensive nomogram for providing personalized prediction.

PATIENTS AND METHODS

The study retrospectively enrolled 2365 elderly patients identified SCAP. Among them, 413 patients were found to have CVD. The LASSO regression and multivariate logistic regression analysis were utilized to select potential predictors of in-hospital mortality in elderly SCAP patients with CVD. By incorporating these features, a nomogram was then developed and subjected to internal validations. Discrimination, calibration, and clinical use of the nomogram were assessed via C-index, calibration curve analysis, and decision plot.

RESULTS

Compared with patients without CVD, elderly SCAP patients with CVD had a significant poor outcome. Further analysis of the CVD population identified 7 independent risk factors for in-hospital mortality in elderly SCAP patients, including age, the use of vasopressor, numbers of primary symptoms, body temperature, monocyte, CRP and NLR. The nomogram model incorporated these 7 predictors showed sufficient predictive accuracy, with the C-index of 0.800 (95% CI 0.758-0.842). High C-index value of 0.781 was obtained in the internal validation via bootstrapping validation. Moreover, the calibration curve indicative a good consistency of risk prediction, and the decision curve manifested that the nomogram had good overall net benefits.

CONCLUSION

An integrated nomogram was developed to facilitate the personalized prediction of in-hospital mortality in elderly SCAP patients with CVD.

Effects of aerobic, resistance, and combined training on endothelial function and arterial stiffness in older adults: study protocol for a systematic review and meta-analysis

INTRODUCTION

Aging is an independent risk factor for cardiovascular events. It promotes vascular dysfunction which is associated with risk factors for cardiovascular diseases (CVDs). Exercise can modulate vascular function parameters, but little is known about the effects of different modalities of training (aerobic, resistance, and combined) on endothelial function and arterial stiffness in older adults.

METHODS

This systematic review study will include randomized controlled trials (RCTs) selected from the electronic databases MEDLINE (PubMed), Cochrane, LILACS, EMBASE, and Web of Science. We will follow the PRISMA guidelines and PICOS framework. Studies involving both male and female older adults (≥60 years old) with or without comorbidities undergoing aerobic, resistance, and/or combined training compared to a control group (no exercise) will be eligible. We will use the Cochrane Risk of Bias 2 (RoB 2) tool to evaluate the quality of individual studies and GRADE to assess the strength of evidence. Statistical analyses will be conducted with RStudio for Windows (v1.3.959) using R package meta.

DISCUSSION

A systematic review and meta-analysis involving data from studies of older adults would deepen our understanding of vascular adaptations to exercise training in this population. It could provide new insights into how health providers can improve patient management and prevention of cardiovascular events in older adults.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 42021275451.

Current Options and Future Perspectives in the Treatment of Dyslipidemia

Low-density lipoprotein cholesterol (LDL-C) plays a crucial role in the development of atherosclerosis. Statin therapy is the standard treatment for lowering LDL-C in primary and secondary prevention. However, some patients do not reach optimal LDL-C target levels or do not tolerate statins, especially when taking high doses long-term. Combining statins with different therapeutic approaches and testing other new drugs is the future key to reducing the burden of cardiovascular disease (CVD). Recently, several new cholesterol-lowering drugs have been developed and approved; others are promising results, enriching the pharmacological armamentarium beyond statins. Triglycerides also play an important role in the development of CVD; new therapeutic approaches are also very promising for their treatment. Familial hypercholesterolemia (FH) can lead to CVD early in life. These patients respond poorly to conventional therapies. Recently, however, new and promising pharmacological strategies have become available. This narrative review provides an overview of the new drugs for the treatment of dyslipidemia, their current status, ongoing clinical or preclinical trials, and their prospects. We also discuss the new alternative therapies for the treatment of dyslipidemia and their relevance to practice.

Lipid lowering effects of the CETP inhibitor obicetrapib in combination with high-intensity statins: a randomized phase 2 trial

Global guidelines for the management of high-cardiovascular-risk patients include aggressive goals for low-density lipoprotein cholesterol (LDL-C). Statin therapy alone is often insufficient to reach goals and nonstatin options have limitations. Here, we tested the lipid-lowering effects of the cholesteryl ester transfer protein (CETP) inhibitor drug obicetrapib in a randomized, double-blind, placebo-controlled trial in dyslipidaemic patients (n = 120, median LDL-C 88 mg dl^-1) with background high-intensity statin treatment (NCT04753606). Over the course of 8 weeks, treatment with 5 mg or 10 mg obicetrapib resulted in a significant decrease as compared with placebo in median LDL-C concentration (by up to 51%; P < 0.0001), the primary trial outcome. As compared with placebo, obicetrapib treatment also significantly (P < 0.0001) decreased apolipoprotein B (by up to 30%) and non-high-density lipoprotein cholesterol (non-HDL-C) concentration (by up to 44%), and significantly (P < 0.0001) increased HDL-C concentration (by up to 165%; the secondary trial outcomes) and had an acceptable safety profile. These results support the potential of obicetrapib to address an unmet medical need for high-cardiovascular-risk patients.

Cardioprotective Strategies from Cardiotoxicity in Cancer Patients: A Comprehensive Review

Cardiotoxicity is a significant complication of chemotherapeutic agents in cancer patients. Cardiovascular incidents including LV dysfunction, heart failure (HF), severe arrhythmias, arterial hypertension, and death are associated with high morbidity and mortality. Risk stratification of cancer patients prior to initiation of chemotherapy is crucial, especially in high-risk patients for cardiotoxicity. The early identification and management of potential risk factors for cardiovascular side effects seems to contribute to the prevention or minimization of cardiotoxicity. Screening of cancer patients includes biomarkers such as cTnI and natriuretic peptide and imaging measurements such as LV function, global longitudinal strain, and cardiac MRI. Cardioprotective strategies have been investigated over the last two decades. These strategies for either primary or secondary prevention include medical therapy such as ACE inhibitors, ARBs, b-blockers, aldosterone antagonists, statins and dexrazoxane, physical therapy, and reduction of chemotherapeutic dosages. However, data regarding dosages, duration of medical therapy, and potential interactions with chemotherapeutic agents are still limited. Collaboration among oncologists, cardiologists, and cardio-oncologists could establish management cardioprotective strategies and approved follow-up protocols in patients with cancer receiving chemotherapy.

Adherence Barriers to Treatment of Patients with Cardiovascular Diseases: A Qualitative Study

Background

Adherence to treatment is highly important in the management of Cardiovascular Diseases (CVD). Barriers to effective and long-term adherence to treatment by the patient make achieving care and treatment goals challenging. The aim of this study was to identify the adherence barriers to the treatment plan in patients with CVD.

Materials and Methods

A qualitative content analysis study was conducted to explore the experience of patients, family caregivers, and healthcare professionals (n = 35) using qualitative content analysis. The study was carried out between 2019 and 2020 in Isfahan, Iran. Purposive sampling was performed. Data collection was conducted through in-depth interviews and semi-structured until data saturation. Graneheim and Landman content analysis was performed simultaneously with data collection.

Results

After data analysis, 3 themes and 6 categories were identified and named. Themes (and categories) include "Patients unreadiness to change" (misunderstanding of conditions and consequences and deterrence cultural practices and beliefs); "gap in healthcare services" (lack of adequate support for patients and discordance between healthcare professionals); and "limited access to healthcare services" (limited physical access and financial burden).

Conclusions

The findings of the present study can provide a framework for healthcare professionals to employ preventive strategies, reduce disease complications, decrease unhealthy behaviours, and increase prolonged adherence to treatment recommendations in patients with CVD.

Cardiovascular Mortality Risk in Patients with Bladder Cancer: A Population-Based Study

Background: The purpose of this study was to evaluate the risk of cardiovascular mortality (CVM) among patients with bladder cancer (BC). Methods and Materials: Data were collected from the Surveillance, Epidemiology, and End Results (SEER) database for patients who were diagnosed with BC by pathology between 2000 and 2016. The standardized mortality rate (SMR) was calculated based on reference data from the general population. Nelson–Aalen cumulative hazard curves were used to assess the risk of experiencing CVM in BC patients. Multivariate competing risk models were performed. Results: In total, data from 237,563 BC patients were obtained from the SEER database for further analysis, of which 21,822 patients experienced CVM; the overall SMR for CVM in BC patients was 1.16 (95% CI: 1.14–1.17). Age, race, sex, year of diagnosis, histologic type, summary stage, surgery, marital status, and college education level were independent predictors of CVM in patients with BC. Conclusions: Patients with BC have a significantly increased risk of experiencing CVM compared to the general population. Pre-identification of high-risk groups and cardiovascular protection interventions are important measures to effectively improve survival in this group of patients.

Associations between electrocardiogram and carotid ultrasound parameters: a healthy chinese group study

Background: Electrocardiogram (ECG) and carotid ultrasound (CUS) are important tools for the diagnosis and prediction of cardiovascular disease (CVD). This study aimed to investigate the associations between ECG and CUS parameters and explore the feasibility of assessing carotid health with ECG.

Methods: This cross-sectional cohort study enrolled 319 healthy Chinese subjects. Standard 12-lead ECG parameters (including the ST-segment amplitude [STA]), CUS parameters (intima-media thickness [IMT] and blood flow resistance index [RI]), and CVD risk factors (including sex, age, and systolic blood pressure [SBP]) were collected for analysis. Participants were divided into the high-level RI group (average RI ≥ 0.76, n = 171) and the normal RI group (average RI < 0.76, n = 148). Linear and stepwise multivariable regression models were performed to explore the associations between ECG and CUS parameters.

Results: Statistically significant differences in sex, age, SBP, STA and other ECG parameters were observed in the normal and the high-level RI group. The STA in lead V₃ yielded stronger significant correlations (r = 0.27–0.42, p < 0.001) with RI than STA in other leads, while ECG parameters yielded weak correlations with IMT (|r| ≤ 0.20, p < 0.05). STA in lead V₂ or V₃, sex, age, and SBP had independent contributions (p < 0.01) to predicting RI in the stepwise multivariable models, although the models for IMT had only CVD risk factors (age, body mass index, and triglyceride) as independent variables. The prediction model for RI in the left proximal common carotid artery (CCA) had higher adjusted R² (adjusted R² = 0.31) than the model for RI in the left middle CCA (adjusted R² = 0.29) and the model for RI in the right proximal CCA (adjusted R² = 0.20).

Conclusion: In a cohort of healthy Chinese individuals, the STA was associated with the RI of CCA, which indicated that ECG could be utilized to assess carotid health. The utilization of ECG might contribute to a rapid screening of carotid health with convenient operations.

Assessing cardiovascular parameters and risk factors in physical therapy practice: findings from a cross-sectional national survey and implication for clinical practice

BACKGROUND

Cardiovascular diseases are the leading cause of death and comorbidity worldwide. High blood pressure and resting heart rate are risk factors (or vital signs) critical to cardiovascular health, patient safety, and medical management. Physiotherapists play a fundamental role in risk factor identification, early diagnosis, and subsequent management of cardiovascular disease. To date there is limited research in Europe investigating the level of knowledge and skills possessed by physiotherapists regarding cardiovascular disease screening. Three studies previously observed inadequate vital signs screening behaviors of physiotherapists practicing in the United States and Saudi Arabia. The primary aim of this study was to investigate cardiovascular knowledge and screening practices among Italian physiotherapists, according to the current practice recommendations.

METHODS

A Cross-Sectional Survey was developed adapting two previous surveys. The survey was administered to members of the Italian Physiotherapy Association. Chi squared test, Mann-Whitney test or Kruskal-Wallis test were used to study differences among subgroups and question responses.

RESULTS

The required sample size was met with total of 387 Italian physiotherapists completing the survey. 80% consider relevant cardiovascular assessment. However, 72.2% were not familiar to guidelines recommendations and only 50% screen vital signs routinely. Their knowledge of normative blood pressure (high-normal, 16%; hypertension, 12%) and heart rate values (bradycardia, 24%; tachycardia, 26%) were low. Although participants reported being skilled for blood pressure measurement (quite sure, 52%; sure, 27%), their adherence to guidelines is low (baseline measurement on both arm, 25%; 3 repeated measures, 46%). Only 27.8% reported to measure exercise related BP and 21.3% of them understood the concept of exaggerated BP. No significant differences between subgroups were found.

CONCLUSIONS

Our study revealed that a concerning proportion of Italian physiotherapists are not versed in fundamentals of properly performing cardiovascular screenings. This lack of knowledge is present across the profession and may impact on appropriate triage and management. The poorly executed screening has the potential to negatively impact the patient and the practitioner. Given the absence of Italian guidelines, we produced and implemented three infographics for public use, which have the dual objective of raising awareness about this subject and providing practical resources for everyday practice.

Adherence to Clinical Guidelines on STATIN Prescribing Among Diabetic Patients Aged 40-75 Years Old in a Primary Care Setting: A Cross-Sectional Study

BACKGROUND

Diabetes mellitus (D.M.) is a chronic metabolic disease caused by decreased insulin secretion, which increases the risk of cardiovascular diseases. Evidence has shown that statins reduce cardiovascular risk in patients with diabetes; moreover, most clinical guidelines recommend statins.

OBJECTIVE

This study aimed to assess the level and status of adherence to guidelines on statin prescription in patients with diabetes mellitus in a primary care setting in Palestine.

METHODS

A retrospective cross-sectional descriptive study was conducted at an ambulatory center in Palestine. Data were collected by auditing prescription records and reviewing medical charts of patients with diabetes who visited the clinic from February 15 to March 17, 2021. The collected data included patient characteristics, comorbidities, lipid profiles, and statin prescription. A chi-square test was used to evaluate the appropriateness of the prescribed statins with different demographic and clinical variables. Statistical significance was set at p < 0.05. Statistical Package for Social Sciences (SPSS) version 22 was used to analyze the data.

RESULTS

Out Of 262 diabetic patients included in the analysis, 74% were prescribed appropriate statin therapy according to the American Diabetes Association (ADA) guidelines, and 24% of patients had inappropriate statin therapy or needed statins. Furthermore, 82.8% were on high-intensity statins, while 11% were not taking any statins. More than 60% of patients had uncontrolled diabetes and hypertension.

CONCLUSION

Most guidelines recommend statin therapy in diabetic patients owing to its benefits in preventing cardiovascular complications. In this study, most patients were on appropriate STATIN therapy; however, 50% of diabetic patients had LDL of more than 100 mg/dl, and 25% were not prescribed statins, increasing their risk of ASCVD. Therefore, we recommend strict adherence to the established guidelines on statins prescribed to patients with diabetes to prevent cardiovascular complications, save lives, and reduce healthcare costs.

A 61-Year-Old Man with Chest Pain

A 61-Year-Old Man with Chest Pain A 61-year-old man presented for evaluation of chest pain that had been progressively worsening for 2 days. How do you approach the evaluation?

Strategies for Maintaining Brain Health: The Role of Stroke Risk Factors Unique to Elderly Women

Stroke risk and prevalence increase with advanced age and women tend to be older than men at the time of their first stroke. Advanced age in women confers unique stroke risks that are beyond reproductive factors. Previous reviews and guidelines have largely focused on risk factors specific to women, with a predominant focus on reproductive factors and, therefore, younger to middle-aged women. This review aims to specifically describe stroke risk factors in elderly women, the population of women where the majority of strokes occur, with a focus on atrial fibrillation, hormone therapy, psychosocial risk factors, and cognitive impairment. Our review suggests that prevention and management of stroke risks that are unique or more prevalent in elderly women needs a coordinated system of care from general physicians, general neurologists, vascular and cognitive neurologists, psychologists, cardiologists, patients, and their caretakers. Early identification and management of the elderly woman-specific and traditional stroke risk factors is key for decreasing stroke burden in elderly women. Increased education among elderly women regarding stroke risk factors and their identification should be considered, and an update to the guidelines for prevention of stroke in women is strongly encouraged.

Black New Yorkers with Type 2 Diabetes: Afro-Caribbean Immigrants Have Lower BMI and Lower Waist Circumference than African Americans

OBJECTIVE

Using the 2013/2014 New York City (NYC) Health and Nutrition Examination Survey (NYCHANES) data, this exploratory study examined whether (a) type 2 diabetes (diabetes) prevalence differed between NYC Afro-Caribbeans and African Americans; (b) anthropometric, biochemical, and sociodemographic diabetes profiles differed between and within groups; and (c) diabetes odds differed between and within groups.

METHODS

Diabetes was defined as prior diagnosis, HbA1c ≥ 6.5% (7.8 mmol/L), or fasting glucose ≥ 126 mg/dL. Weighted logistic regression estimated diabetes odds by nativity and either waist circumference (WC) (cm) or BMI (kg/m²). All regression models controlled for age, hypertension, gender, education, income, marital status, physical activity, and smoking.

RESULTS

Among Afro-Caribbeans (n = 81, 65% female, age (mean ± SE) 49 ± 2 years, BMI 29.2 ± 0.7 kg/m²) and African Americans (n = 118, 50% female, age 47 ± 2 years, BMI 30.3 ± 0.9 kg/m²), Afro-Caribbeans with diabetes had lower BMI (29.9 ± 0.8 kg/m² vs. 34.6 ± 1.7 kg/m², P = 0.01) and lower WC (102 ± 2 cm vs. 114 ± 3 cm, P = 0.002) than African Americans with diabetes. Afro-Caribbeans with diabetes had lower prevalence of obesity (33.2% vs. 74.7%) and higher prevalence of overweight (57.2% vs. 13.5%) (P = 0.02) than African Americans with diabetes. Odds of diabetes did not differ between Afro-Caribbeans and African Americans. In models predicting the effect of WC, diabetes odds increased with WC (OR = 1.07 (95% CI 1.02, 1.11), P = 0.003) and age (OR = 1.09 (95% CI 1.03-1.15), P = 0.003) for African Americans only. In models predicting the effect of BMI, diabetes odds increased for Afro-Caribbeans with age (OR = 1.06 (1.01, 1.11)*, P = 0.04) and hypertension (OR = 5.62 (95% CI 1.04, 30.42), P = 0.045), whereas for African Americans, only age predicted higher diabetes odds (OR = 1.08 (95% CI 1.03, 1.14), P = 0.003).

CONCLUSIONS

In NYC, Afro-Caribbeans with diabetes have lower BMI and lower WC than African Americans with diabetes, but odds of diabetes do not differ. Combining African-descent populations into one group obscures clinical differences and generalizes diabetes risk.

Association of Arterial Stiffness Indices with Framingham Cardiovascular Disease Risk Score

Purpose

The new non-invasive arterial stiffness indices, arterial velocity pulse index (AVI) and arterial pressure volume index (API) are known to be associated with cardiovascular disease risk. The present study aimed to examine the "dose-response" associations between AVI, API and Framingham cardiovascular disease risk score (FCVRS).

Methods

This survey included individuals with arterial stiffness indices collected at age 18 years and older. We used Pearson's correlation coefficients and multivariate linear analyses to evaluate associations of AVI and API to other variables. The associations between FCVRS and AVI, API were analyzed by restrictive cubic spline.

Results

4311 people were included in the full study population, including 2091 males and 2220 females. In restricted cubic spline regression models, AVI or API had significant U-shaped associations with FCVRS, with the lowest risk score of cardiovascular disease was 8 units or 18 units, respectively. After AVI increased to 12 units, FCVRS increased rapidly until AVI was 27 units, and the FCVRS increased relatively flat afterward. For API, results were similar. When API increased to 23 units, the FCVRS increased rapidly, and after API was 52 units, FCVRS increased relatively flat.

Conclusions

AVI or API had U-shaped associations with FCVRS. The associations may provide a new perspective for early treatment or lifestyle modifications to prevent cardiovascular diseases.

Development, validation and comparison of multivariable risk scores for prediction of total stroke and stroke types in Chinese adults: a prospective study of 0.5 million adults

BACKGROUND AND PURPOSE

Low-income and middle-income countries have the greatest stroke burden, yet remain understudied. This study compared the utility of Framingham versus novel risk scores for prediction of total stroke and stroke types in Chinese adults.

METHODS

China Kadoorie Biobank (CKB) is a prospective study of 512 726 adults, aged 30-79 years, recruited from 10 areas in China in 2004-2008. By 1 January 2018, 43 234 incident first stroke cases (36 310 ischaemic stroke (IS); 8865 haemorrhagic stroke (HS)) were recorded in 503 842 participants with no history of stroke at baseline. We compared the predictive utility of the Framingham Stroke Risk Profile (FSRP) with novel CKB stroke risk scores and included recalibration, refitting, stratifying by study area and addition of other risk factors. Discrimination was assessed using area under the receiver operating characteristic curve (AUC) and calibration was assessed using Greenwood-Nam-D'Agostino χ² statistics.

RESULTS

Incidence of total stroke varied fivefold by area in China. The FSRP had good discrimination for total stroke (AUC (95% CI); men: 0.78 (0.77 to 0.79), women: 0.77 (95% CI 0.76 to 0.78)), but poor calibration (χ²; men: 1,825, women: 3,053), substantially underestimating absolute risks. Recalibration reduced χ² by >80%, but did not improve discrimination. Refitting the FSRP did not materially improve discrimination, but further improved calibration. Stratification by area improved discrimination (AUC; men: 0.82 (0.82 to 0.83); women: 0.82 (0.82 to 0.83)), but not calibration. Adding other risk factors yielded modest, but statistically significant, improvements in the AUCs. The findings for IS and HS were similar to those for total stroke.

CONCLUSIONS

The FSRP reliably differentiated Chinese adults with incident stroke, but substantially underestimated the absolute risks of stroke. Novel local risk prediction equations that took account of differences in stroke incidence within China enhanced risk prediction of total stroke and major stroke pathological types.

Oral Microbiota, Its Equilibrium and Implications in the Pathophysiology of Human Diseases: A Systematic Review

Imbalances of the oral microbiota and dysbiosis have traditionally been linked to the occurrence of teeth and oral diseases. However, recent findings indicate that this microbiota exerts relevant influence in systemic health. Dysbiosis of the oral microbiota is implicated in the apparition and progression of cardiovascular, neurodegenerative and other major human diseases. In fact, the oral microbiota are the second most diverse and largely populated microbiota of the human body and its relationships with systemic health, although widely explored, they still lack of proper integration. The purpose of this systematic review is thus to widely examine the implications of oral microbiota in oral, cardiovascular and neurodegenerative diseases to offer integrative and up-to-date interpretations. To achieve that aim, we identified a total of 121 studies curated in PUBMED from the time interval January 2003–April 2022, which after careful screening resulted in 79 studies included. The reviewed scientific literature provides plausible vias of implication of dysbiotic oral microbiota in systemic human diseases, and encourages further research to continue elucidating the highly relevant and still poorly understood implications of this niche microbiota in systemic health. PROSPERO Registration Number: CRD42022299692. This systematic review follows relevant PRISMA guidelines.

Behavioral Counseling Interventions to Promote a Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Cardiovascular Disease Risk Factors: US Preventive Services Task Force Recommendation Statement

IMPORTANCE

Cardiovascular disease (CVD), which includes heart disease, myocardial infarction, and stroke, is the leading cause of death in the US. A large proportion of CVD cases can be prevented by addressing modifiable risk factors, including smoking, obesity, diabetes, elevated blood pressure or hypertension, dyslipidemia, lack of physical activity, and unhealthy diet. Adults who adhere to national guidelines for a healthy diet and physical activity have lower rates of cardiovascular morbidity and mortality than those who do not; however, most US adults do not consume healthy diets or engage in physical activity at recommended levels.

OBJECTIVE

To update its 2017 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a review of the evidence on the benefits and harms of behavioral counseling interventions to promote healthy behaviors in adults without CVD risk factors.

POPULATION

Adults 18 years or older without known CVD risk factors, which include hypertension or elevated blood pressure, dyslipidemia, impaired fasting glucose or glucose tolerance, or mixed or multiple risk factors such as metabolic syndrome or an estimated 10-year CVD risk of 7.5% or greater.

EVIDENCE ASSESSMENT

The USPSTF concludes with moderate certainty that behavioral counseling interventions have a small net benefit on CVD risk in adults without CVD risk factors.

RECOMMENDATION

The USPSTF recommends that clinicians individualize the decision to offer or refer adults without CVD risk factors to behavioral counseling interventions to promote a healthy diet and physical activity. (C recommendation).

Measuring Stroke Quality: Methodological Considerations in Selecting, Defining, and Analyzing Quality Measures

Knowledge about stroke and its management is growing rapidly and stroke systems of care must adapt to deliver evidence-based care. Quality improvement initiatives are essential for translating knowledge from clinical trials and recommendations in guidelines into routine clinical practice. This review focuses on issues central to the measurement of the quality of stroke care, including selection and definition of quality measures, identification of the eligible patient cohorts, optimization of data quality, and considerations for data analysis and interpretation.

Aspirin for Primary Prevention of Cardiovascular Diseases: "WALTZ" with the Evidence

PURPOSE OF REVIEW

In this review article, a detailed analysis of the current literature is provided, along with a "glimpse" into what the future holds for aspirin in the context of primary prevention.

RECENT FINDINGS

The role of aspirin in primary prevention of cardiovascular diseases (CVD) has been extensively evaluated; however, the results provided over the years have been controversial. Identification of individual subgroups who may benefit from aspirin administration at an acceptable risk of bleeding complications is of paramount importance. Additionally, questions emerge at everyday clinical practice regarding the optimal use of aspirin in different phenotypes of patients due to age, sex, obesity status, frailty and diabetes mellitus. Until further data become available, the effective management of the well-established CV risk factors constitutes the milestone in the primary prevention of CVD. Moreover, based on the available evidence, the beneficial addition of aspirin in the modern era of lifestyle and pharmacological interventions for primary CVD prevention remains largely undetermined and further research is needed.

Efficacy and Safety of Dapagliflozin According to Background Use of Cardiovascular Medications in Patients With Type 2 Diabetes: A Prespecified Secondary Analysis of a Randomized Clinical Trial

Importance

Dapagliflozin was shown to reduce the cardiovascular (CV) and kidney outcomes in patients with type 2 diabetes. However, data are limited on the relationship of the effect and safety with the concurrent use of CV medications in patients with type 2 diabetes.

Objective

To assess whether the cardiorenal efficacy and safety of dapagliflozin were consistent with and without background use of CV medications commonly used for heart failure (HF) and kidney disease in patients with type 2 diabetes.

Design, Setting, and Participants

This study is a prespecified secondary analysis of DECLARE-TIMI 58, which was a randomized trial of dapagliflozin vs placebo in 17 160 patients with type 2 diabetes and either atherosclerotic disease or multiple risk factors for CV disease. Patients were stratified by baseline use of the following CV medications: angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers (ACEI/ARBs), β-blockers, diuretics, and mineralocorticoid receptor antagonists (MRAs). The study was conducted from May 2013 to September 2018, and data were evaluated for this analysis from February 2021 to May 2022.

Interventions

Dapagliflozin or placebo.

Main Outcomes and Measures

The outcomes of interest were the composite of CV death or hospitalization for HF (HHF), HHF alone, and a kidney-specific composite outcome (persistent ≥40% decrease in estimated glomerular filtration rate [eGFR], end-stage kidney disease, or kidney-related death).

Results

Among 17 160 patients, 13 950 (81%) used ACEI/ARBs, 9030 (53%) used β-blockers, 6205 (36%) used diuretics, and 762 (4%) used MRAs at baseline. Changes in blood pressure and eGFR at 48 months with dapagliflozin compared with placebo did not differ regardless of concurrent therapy (placebo-corrected change, -1.6 mm Hg [95% CI, -4.2 to 1.0] to -2.6 mm Hg [95% CI, -3.3 to -2.9]; P > .05 for each interaction). Dapagliflozin consistently reduced the risk of CV death/HHF, HHF alone, and the kidney-specific composite outcome regardless of background use of selected medications (hazard ratio [HR] range: HR, 0.50; 95% CI, 0.39-0.63; to HR, 0.82; 95% CI, 0.72-0.95; P > .05 for each interaction). In patients receiving ACEI/ARBs + β-blockers + diuretics (n = 4243), dapagliflozin reduced the risk of CV death/HHF and of the kidney-specific outcome by 24% (HR, 0.76; 95% CI, 0.62-0.93) and 38% (HR, 0.62; 95% CI, 0.44-0.87), respectively. There were no significant treatment interactions with the concomitant CV medications for adverse events of volume depletion, acute kidney injury, or hyperkalemia (range: HR, 0.12; 95% CI, 0.02-0.99; to HR, 1.04; 95% CI, 0.83-1.32; P > .05 for each interaction).

Conclusions and Relevance

Dapagliflozin consistently reduced the risk of CV and kidney outcomes irrespective of background use of various CV medications without any treatment interaction for key safety events. These data show the clinical benefit and safety of dapagliflozin in a broad range of patients with type 2 diabetes regardless of background therapy.

Trial Registration

ClinicalTrials.gov Identifier: NCT01730534.