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

High-sensitivity C-reactive Protein in Atherosclerotic Cardiovascular Disease: To Measure or Not to Measure?

Inflammation and dyslipidemia are central to the pathogenesis of atherosclerotic cardiovascular disease (ASCVD). While lipid-lowering therapies are the cornerstone of ASCVD prevention and treatment, there are other emerging targets, including inflammation (which has been dubbed the 'residual inflammatory risk'), that can be addressed after LDL cholesterol thresholds have been reached. Research over the past 20 years has identified C-reactive protein (CRP) as a key marker of inflammation with atherosclerosis. The association of more sensitive measures of CRP (high- sensitivity C-reactive protein [hsCRP]) with ASCVD risk in epidemiological studies has also led to its incorporation as a risk enhancer in primary prevention guidelines and its incorporation into risk stratification tools. While there are no formal recommendations related to measurement of hsCRP in secondary prevention, consideration should be given to an individualized approach that addresses inflammatory risk in those with major adverse cardiovascular events, despite maximal lipid-lowering therapy and well-controlled LDL cholesterol levels. The aim of this review is to discuss the role of inflammation in ASCVD, the use of hsCRP as a tool to assess residual inflammatory risk to target upstream pathways such as glucose intolerance and obesity, and to consider use of additional anti-inflammatory medications for ASCVD risk reduction. The authors provide clinical context around when to measure hsCRP in clinical practice and how to address residual inflammatory risk in ASCVD.

Impact of anti-inflammatory diets on cardiovascular disease risk factors: a systematic review and meta-analysis

Introduction

Chronic inflammation, via multiple pathways, influences blood pressure and lipid profiles, serving as a significant risk factor for the onset of cardiovascular disease (CVD). Anti-inflammatory dietary patterns may ameliorate CVD risk factors through the modulation of inflammatory mediators and metabolic factors, potentially leading to improved cardiovascular outcomes. Current findings regarding the relationship between dietary habits and CVD risk factors, such as blood pressure and lipid levels, exhibit considerable variability. We performed a comprehensive systematic review and meta-analysis to explore the possible association between anti-inflammatory dietary patterns (such as the Mediterranean diet, DASH diet, Nordic diet, Ketogenic diet, and Vegetarian diet) and CVD risk factors.

Methods

We conducted a comprehensive search across five databases: PubMed, Web of Science, Cochrane Library, Embase, and China National Knowledge Infrastructure (CNKI). Ultimately, we identified 18 eligible randomized controlled trials (including randomized crossover trials), which were subjected to meta-analysis utilizing RevMan 5 and Stata 18.

Results

A comprehensive meta-analysis of these studies conducted based on random effects model indicated that, in comparison to an Omnivorous diet, interventions centered on anti-inflammatory diets were linked to significant reductions in Systolic Blood Pressure (SBP) (MD: -3.99, 95% CI: -6.01 to -1.97; p = 0.0001), Diastolic Blood Pressure (DBP) (MD: -1.81, 95% CI: -2.73 to -0.88; p = 0.0001), Low Density Lipoprotein Cholesterol (LDL-C) (SMD: -0.23, 95% CI: -0.39 to -0.07; p = 0.004), Total Cholesterol (TC) (SMD: -0.31, 95% CI: -0.43 to -0.18; p < 0.00001) and High-sensitivity C-reactive Protein (hs-CRP) (SMD: -0.16, 95% CI: -0.31 to -0.00; p = 0.04). No notable correlations were identified between High Density Lipoprotein Cholesterol (HDL-C) and Triglycerides (TG).

Discussion

The findings indicate that anti-inflammatory diets may lower serum hs-CRP levels and positively influence the reduction of CVD risk factors, such as blood pressure and lipid profiles, thereby contributing to the prevention and progression of cardiovascular conditions. Most of the outcome indicators had low heterogeneity; sensitivity analyses were subsequently conducted on outcome measures demonstrating substantial heterogeneity, revealing that the findings remained consistent.

Dietary branched-chain amino acids intake and coronary artery calcium progression: insights from the coronary artery risk development in young adults (CARDIA) study

OBJECTIVE

Branched-chain amino acids (BCAA) have been implicated in the risk of cardiovascular disease. However, it is unclear whether dietary BCAA intake, specifically isoleucine, leucine, and valine are associated with coronary artery calcium (CAC) progression.

METHODS

We included the participants from the Coronary Artery Risk Development in Young Adults (CARDIA) study cohort for the analysis. Dietary intake of BCAA was assessed at year 7 of the study. CAC was measured using standardized computed tomography scans at years 15, 20, and 25. CAC progression was defined as follows: for participants with a baseline CAC of 0, progression was defined as CAC > 0 at follow-up; for those with 0 < baseline CAC < 100, progression was defined as an annualized change of ≥ 10; and for those with baseline CAC ≥ 100, progression was defined as an annualized percent change of ≥ 10%. Multivariate adjusted Cox regression models were utilized to examine the associations between BCAA intake and CAC progression.

RESULTS

Among 2381 included participants (average age 40.4 ± 3.5 years, 44.9% men), 629 participants (26.4%) exhibited CAC progression during a follow-up period of 8.90 ± 2.03 years. In the fully adjusted model, high intake of total BCAA, and its individual components, isoleucine, leucine, and valine were associated with an increased risk of CAC progression by 35.6% (HR, 1.356 [95% CI, 1.040-1.769]), 30.5% (HR, 1.305 [95% CI, 1.001-1.701]), 30.9% (HR, 1.309 [95% CI, 1.003-1.706]), and 33.9% (HR, 1.339 [95% CI, 1.026-1.747]), respectively, compared to their corresponding low intake groups. The associations were consistent across various subgroups, including age, sex, race, and body mass index, but were stronger in participants without baseline CAC (interaction P < 0.001). These results remained robust in a series of sensitivity analyses.

CONCLUSIONS

High dietary intake of BCAA, including isoleucine, leucine, and valine, were independently associated with an increased risk of CAC progression. The findings may implication for dietary modifications in primary prevention of subclinical atherosclerosis.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov ; Unique identifier: NCT00005130.

Genetic Susceptibility to Type 2 Diabetes, Television Viewing, and Atherosclerotic Cardiovascular Disease Risk

BACKGROUND

Type 2 diabetes (T2D) is a major risk factor for atherosclerotic cardiovascular disease (ASCVD). This study examined the interplay between watching television and T2D genetic risk for risk of ASCVD.

METHODS

We included 346 916 White British individuals from UK Biobank. A weighted polygenic risk score for T2D was calculated on the basis of 138 genetic variants associated with T2D. Time spent watching television was self-reported and categorized into 2 groups: ≤1 h/d and ≥2 h/d. Over a median 13.8-year follow-up, 21 265 incident ASCVD events were identified. Models using Cox regression with age as the underlying time scale adjusted for potential confounders (demographic, anthropometric, lifestyle factors, and medication use) were fit.

RESULTS

Compared with watching television for ≤1 h/d, watching ≥2 h/d was associated with 12% (95% CI, 1.07-1.16) higher hazards of ASCVD, independently of T2D genetic risk. Joint analyses (with low T2D genetic risk and ≤1 h/d of television viewing as reference) indicated that medium and high T2D genetic risk was not associated with higher hazards of ASCVD as long as television viewing was ≤1 h/d. The P values for multiplicative and additive interactions between T2D genetic risk and television viewing were 0.050 and 0.038, respectively. The 10-year absolute risk of ASCVD was lower for high T2D genetic risk combined with ≤1 h/d of television viewing (2.13%) than for low T2D genetic risk combined with ≥2 h/d of television viewing (2.46%).

CONCLUSIONS

Future clinical trials of lifestyle-modification interventions targeting specific types of screen-based sedentary activities could be implemented to individuals at high genetic risk of T2D for primary prevention of ASCVD.

Impact of Sex Differences on Lipids and Statin Utilization

PURPOSE OF THE REVIEW

Hypercholesterolemia is a significant and modifiable risk factor for cardiovascular disease (CVD), with Low-Density Lipoprotein Cholesterol (LDL-C) being the primary target for lipid-lowering therapies in both primary and secondary prevention. This review aims to explore the efficacy of statin therapy in women, its safety and application during pregnancy, and treatment disparities that contribute to undertreatment of dyslipidemia in women.

RECENT FINDINGS

Statins has demonstrated efficacy in reducing LDL-C and CVD risk in women. However, women are less likely to achieve LDL-C targets compared to men, largely due to undertreatment and delays in initiating therapy, often influenced by sex-specific factors. The unique considerations of lipid management during pregnancy, including suspension of statin therapy, present additional challenges in achieving optimal lipid control in high-risk women. Evidence also points to systemic disparities in healthcare delivery and treatment allocation, further exacerbating undertreatment of dyslipidemia among women. While LDL-C lowering remains a cornerstone of CVD prevention, women face distinct challenges in achieving lipid goals due to biological, clinical, and healthcare disparities. Addressing these barriers, including improving timely initiation of statins and addressing gaps in care during pregnancy, is essential to enhance the dyslipidemia management and reduce CVD risk in women.

Clinical Considerations for Competitive Sports Participation for Athletes With Cardiovascular Abnormalities: A Scientific Statement From the American Heart Association and American College of Cardiology

COLLABORATORS

Larry A. Allen, MD, MHS, FAHA, FACC; Mats Börjesson, MD, PhD, FACC; Alan C. Braverman, MD, FACC; Julie A. Brothers, MD; Silvia Castelletti, MD, MSc, FESC; Eugene H. Chung, MD, MPH, FHRS, FAHA, FACC; Timothy W. Churchill, MD, FACC; Guido Claessen, MD, PhD; Flavio D'Ascenzi, MD, PhD; Douglas Darden, MD; Peter N. Dean, MD, FACC; Neal W. Dickert, MD, PhD, FACC; Jonathan A. Drezner, MD; Katherine E. Economy, MD, MPH; Thijs M.H. Eijsvogels, PhD; Michael S. Emery, MD, MS, FACC; Susan P. Etheridge, MD, FHRS, FAHA, FACC; Sabiha Gati, BSc (Hons), MBBS, PhD, MRCP, FESC; Belinda Gray, BSc (Med), MBBS, PhD; Martin Halle, MD; Kimberly G. Harmon, MD; Jeffrey J. Hsu, MD, PhD, FAHA, FACC; Richard J. Kovacs, MD, FAHA, MACC; Sheela Krishnan, MD, FACC; Mark S. Link, MD, FHRS, FAHA, FACC; Martin Maron, MD; Silvana Molossi, MD, PhD, FACC; Antonio Pelliccia, MD; Jack C. Salerno, MD, FACC, FHRS; Ankit B. Shah, MD, MPH, FACC; Sanjay Sharma, BSc (Hons), MBChB, MRCP (UK), MD; Tamanna K. Singh, MD, FACC; Katie M. Stewart, NP, MS; Paul D. Thompson, MD, FAHA, FACC; Meagan M. Wasfy, MD, MPH, FACC; Matthias Wilhelm, MD.

This American Heart Association/American College of Cardiology scientific statement on clinical considerations for competitive sports participation for athletes with cardiovascular abnormalities or diseases is organized into 11 distinct sections focused on sports-specific topics or disease processes that are relevant when considering the potential risks of adverse cardiovascular events, including sudden cardiac arrest, during competitive sports participation. Task forces comprising international experts in sports cardiology and the respective topics covered were assigned to each section and prepared specific clinical considerations tables for practitioners to reference. Comprehensive literature review and an emphasis on shared decision-making were integral in the writing of all clinical considerations presented.

Triglyceride/high density lipoprotein cholesterol index and future cardiovascular events in diabetic patients without known cardiovascular disease

The triglyceride/high-density lipoprotein cholesterol (TG/HDL-C) index, calculated as TG divided by HDL-C, has been suggested as a predictor of cardiovascular disease (CVD). We investigated the association between the TG/HDL-C index and CVD events in type 2 diabetes mellitus (T2DM) patients with retinopathy and hyperlipidemia but no known CVD, enrolled in the EMPATHY study, which compared intensive and standard statin therapy (targeting LDL-C levels < 70 mg/dL and ≥ 100 to < 120 mg/dL, respectively). A total of 4665 patients were divided into high (TG/HDL-C ≥ 2.5, n = 2013) and low (TG/HDL-C < 2.5, n = 2652) TG/HDL-C index groups. During a median follow-up of 36.8 months, 260 CVD events occurred. The high TG/HDL-C index group had higher CVD risk than the low group (HR 1.89, 95% CI 1.45-2.47, p < 0.001). This association remained consistent across subgroups. A trend toward interaction between TG/HDL-C index and statin treatment allocation for CVD risk was observed (p for interaction = 0.062). Intensive statin treatment reduced CVD risk in the high TG/HDL-C group but not in the low group. In conclusion, a TG/HDL-C index ≥ 2.5 was associated with higher CVD risk in T2DM patients with retinopathy and hyperlipidemia without a history of CVD. The TG/HDL-C index may identify patients who benefit from intensive statin treatment.

Statins for primary prevention of cardiovascular disease in Germany: benefits and costs

BACKGROUND

The reduction of LDL cholesterol lowers the risk of coronary and cerebrovascular events in individuals without manifest cardiovascular diseases. In Germany, statins at the expense of statutory health insurance had only been permitted for patients with atherosclerosis-related diseases or those at high cardiovascular risk (over 20 percent event probability within the next 10 years, calculated using one of the "available risk calculators"). However, international guidelines recommend lower risk thresholds for the use of statins.

METHODS

The health and economic impacts of different risk thresholds for statin use in primary prevention within the German population are estimated for thresholds of 7.5, 10, and 15 percent over 10 years, based on the US Pooled Cohort Equation (PCE) which is valid for Germany, using Markov models.

FINDINGS

Cost-effectiveness increases with a rising risk threshold, while individual benefit decreases with age at the start of treatment. The use of statins at a risk of 7.5 percent or more is cost-effective at any age (cost per QALY between 410 and 2100 Euros). In none of the examined scenarios does the proportion of the population qualifying for statin therapy exceed 25 percent.

INTERPRETATION

Lowering the threshold for statin therapy to a risk of 7.5 percent of either non-fatal myocardial infarction, coronary heart disease death, non-fatal or fatal stroke would align statin prescription in Germany with international standards. There is no urgent rationale for applying age-stratified risk thresholds.

Identifying a Heterogeneous Effect of Atrial Fibrillation Screening in Older Adults: A Secondary Analysis of the VITAL-AF Trial

Background

One-time atrial fibrillation (AF) screening trials have produced mixed results; we sought a subset for whom screening is effective.

Methods

We conducted a secondary analysis of VITAL-AF, a randomized trial of one-time, brief, single-lead ECG screening during primary care visits. We tested two approaches to identify a subgroup where screening is effective. First, we developed an effect-based model using a T-learner. Specifically, we separately predicted the likelihood of AF diagnosis under screening and usual care conditions; the difference in probabilities was the predicted screening effectiveness. Second, we used a validated AF risk model to test for heterogeneous screening effectiveness.

Results

In the effect-based analysis, in the highest quartile of predicted screening effectiveness, AF diagnosis rates were higher in the screening group (4.00 vs. 2.88 per 100 person-years, rate difference 1.12, 95% CI 0.11 to 2.13). In the risk-based analysis, in the highest quartile of baseline AF risk, AF diagnosis rates were also higher in the screening group (5.55 vs. 4.23 per 100 person-years, rate difference 1.32, 95% CI 0.14 to 2.50). Predicted screening effectiveness and predicted baseline AF risk were weakly correlated (Spearman correlation coefficient 0.23). Patients with low primary care use, using rate control medications, females, and Black patients were overrepresented in the high-effectiveness group even when they were not at high risk of developing AF.

Conclusions

In a secondary analysis of VITAL-AF, we identified subgroups where one-time screening was associated with increased AF diagnoses using both effect-based and risk-based approaches. In this study, predicted AF risk was only a partial proxy for predicted screening effectiveness. Even when individuals are not in the high-risk subset, features like low primary care use and rate control medication use can identify individuals for whom AF screening has a large impact. Future AF screening efforts should focus on screening both "high-risk" and "high-effectiveness" individuals.

What is Known

Because trials testing office-based screening for atrial fibrillation have produced mixed results, some have suggested we focus screening efforts on high-risk individuals.Newer methods allow us to test for screening heterogeneity using risk-based analyses and separately effect-based analyses, which disentangle screening effects from baseline disease risk.

What the Study Adds

Both the risk-based analysis and the effect-based analysis identified "high-risk" and "high-effectiveness" subgroups, respectively, where one-time AF screening was effective."High-risk" and "high-effectiveness" groups only partially overlap; even when individuals are not in the high-risk subset, features like low primary care use and rate control medication use an identify individuals for whom AF screening has a large impact.Future AF screening efforts should focus on screening both "high-risk" and "high-effectiveness" people.

Validity and reliability study of the Turkish version of the multidimensional outcome expectations for exercise scale (MOEES) in patients with cardiovascular diseases

Outcome expectations are a multidimensional construct encompassing physical, social, and self-evaluative components, significantly influencing adults' exercise behaviors. The study aimed to develop and validate a Turkish version of the 'Multidimensional Outcome Expectations for Exercise Scale' (MOEES) and assess its reliability in adults with cardiovascular disease (CVD). This cross-sectional validation included 150 participants. The MOEES was translated into Turkish, ensuring cultural and linguistic appropriateness, and reviewed by 15 healthcare professionals. Participants' demographic data were collected, and they completed the MOEES, International Physical Activity Questionnaire (IPAQ), and Tampa Scale for Kinesiophobia-Heart (TSK-H) twice, 15 days apart. The internal consistency of the MOEES was excellent, with a Cronbach's Alpha of 0.919. Test-retest reliability showed high intraclass correlation coefficients (ICC) for the physical (0.924), self-evaluative (0.921), and social (0.929) subscales. Confirmatory factor analysis (CFA) indicated an excellent fit (X2/df = 1.782, GFI = 0.908, AGFI = 0.856, CFI = 0.962, RMSEA = 0.072, NFI = 0.918, SRMR = 0.052). Strong correlations were found between MOEES sub-dimensions and IPAQ total and TSK-H scores (p < 0.01), confirming the scale's validity. The Turkish MOEES is a reliable tool for evaluating physical, social, and self-evaluative outcome expectations regarding exercise in CVD patients, making it suitable for clinical and research applications.

Impact of combined high-intensity bodyweight interval training and breathing exercise on cardiometabolic health in normal-weight middle-aged adults with hypertension

BACKGROUND

High-intensity interval training and breathing exercises alone have well-documented health benefits in people with hypertension. This study aimed to investigated the effects of combining the two methods on physical health among adults with hypertension.

METHODS

Ninety-six adults (59.4 ± 9.1 years; 84% female; BMI 22.7 ± 1.6 kg/m2) with hypertension were randomized into one of four groups: Breathing Exercise (BE), High-Intensity Bodyweight Interval Training (HIBIT), Combined Exercise (CE), or a Non-Exercise Control (CON) group. The intervention lasted 10 weeks, with all exercise groups having the same total training time of 3 days per week (BE: 30 min/day; HIBIT: 60 min/day; CE: BE 30 min/day plus HIBIT 60 min/day). Resting heart rate, resting blood pressure, hand grip strength, cardiorespiratory fitness assessed using 6-Minute Walking Test (6MWT) and blood lipids were measured pre- and post-intervention.

RESULTS

The BE group showed the greatest reduction in systolic blood pressure (SBP) compared to CON, although differences among the exercise groups were not statistically significant. The increase in 6MWT values in the combined exercise group differed significantly compared to the other three groups (p = 0.000 and effect size = 0.296). The combined exercise group showed significant reductions in total cholesterol, LDL and triglyceride levels compared to the control group. The average reduction in total cholesterol levels was 20.8 mg/dL (95% C: -41.9 - 0.4) with an effect size of 0.103. Meanwhile, the decrease in LDL and triglyceride levels was 20.1 mg/dL (95% CI: -37.6--2.5; p = 0.014) and -40.4 mg/dL (95% CI: -82.1-1.3; p = 0.04) with effect sizes of 0.118 and 0.101.

CONCLUSIONS

In conclusion combined exercise for 10 weeks could lower systolic and diastolic blood pressure, increase CRF, and improved lipid profile. As a clinical implication, the results of this study can be an alternative or complementary approach to treatment for hypertension, potentially reducing the need for medications and their associated side effects.

TRIAL REGISTRATION

TCTR20230707003 ( http://www.

CLINICALTRIALS

in.th/ ) registered on 28 January 2023.

Trends in Preventive Aspirin Use by Atherosclerotic Cardiovascular Risk

This study uses National Health and Nutrition Examination Survey data to examine national trends in preventive aspirin use among populations at low and high atherosclerotic cardiovascular disease (ASCVD) risk and with existing ASCVD.

Remnant cholesterol, lipid ratios, and the severity of coronary artery lesions: a retrospective cohort study in patients with coronary heart disease

Background

Emerging genetic and observational evidence indicates that remnant cholesterol (RC) is a significant residual risk factor for cardiovascular diseases. However, there is a relative paucity of evidence exploring the correlation among RC, lipid ratios, and atherosclerotic lesion severity. This study aimed to investigate the predictive value of RC and lipid ratios alone or in combination for the severity of coronary artery stenosis in patients with coronary heart disease (CHD).

Methods

The Gensini score was used to assess the severity of coronary atherosclerotic lesions. CHD patients were categorized into mild stenosis and moderate-to-severe stenosis groups. Logistic regression was used to evaluate the risk of a high Gensini score associated with RC and lipid ratios. Our study also examined the relationship between inconsistencies in RC and non-high-density lipoprotein cholesterol (non-HDL-C) levels and the severity of coronary artery stenosis. Receiver operating characteristic (ROC) curves were used to assess the predictive power of RC and lipid ratios alone or in combination for moderate to severe coronary artery lesions.

Results

Multivariate regression models suggested that RC was a strong predictor of moderate to severe coronary artery stenosis [odds ratio (OR): 5.44, P < 0.001]. When grouped by curve-fitting inflection points, the group with inconsistent high RC/low non-HDL-C, rather than the low RC/high non-HDL-C group, was associated with an increased risk of moderate to severe coronary stenosis compared with the consistent low RC group (OR: 2.72, P < 0.001). ROC curves showed that RC predicted an area under the curve (AUC) of 0.715 for coronary stenosis severity, improving the predictive efficacy of the combined predictors comprising lipid ratios (AUC: 0.723 vs. 0.703, P < 0.05).

Conclusions

RC and various lipid ratios [triglyceride/HDL-C, total cholesterol/HDL-C, low-density lipoprotein cholesterol/HDL-C, and apoloprotein (apo)B/apoA] correlated with the degree of coronary artery stenosis in patients with CHD, suggesting that RC has potential value as a biomarker reflecting the degree of coronary artery stenosis independent of the traditional risk factors and the levels of non-HDL-C. This could enhance the predictive efficacy based on the lipid ratio model and had better predictive value for moderate to severe coronary artery lesions.

Can cardiovascular health and its modifiable healthy lifestyle offset the increased risk of all-cause and cardiovascular deaths associated with insulin resistance?

BACKGROUND

Insulin resistance(IR) is associated with an increased risk of all-cause and cardiovascular death, and modifiable healthy lifestyles play an active role in the improvement of IR and the reduction of all-cause and cardiovascular death. Whether cardiovascular health (CVH) and modifiable healthy lifestyles within it can attenuate or even offset the heightened perils of both all-cause and cardiovascular deaths associated with insulin resistance remains unclear.

METHODS

The study encompassed 14,172 healthy participants from the 2005-2018 NHANES programme. Insulin resistance was evaluated using the TyG index, TyG-WC, and TyG-WHtR, while CVH was assessed employing the LE8 score, in addition to the LE4 index redefined according to four health behaviours. Weighted multifactor Cox regression models were used to assess the association of IR and CVH with all-cause and cardiovascular mortality, and dose-response relationships were assessed using restricted cubic spline. Furthermore, subjects were grouped according to IR and CVH scores, and generalised linear models were used to estimate the weighted mortality and risk of death for each group and to calculate the absolute risk difference. Finally, the predicted probability of all-cause and cardiovascular mortality risk as a function of IR was computed, and the complex relationship between the three was visualised using two-dimensional grouped scatter plots and three-dimensional surface plots.

RESULTS

Among the 14,172 healthy participants included in the study, 1534 deaths occurred over a mean follow-up period of 7.6 years (382 of these deaths were due to cardiovascular causes). The weighted Cox regression analysis indicated that elevated TyG-WC and TyG-WHtR correlated with a greater likelihood of mortality from all causes and cardiovascular events, whereas cardiovascular health was inversely associated with these risks. Additional stratification revealed a notable reduction in the likelihood of mortality from all causes and cardiovascular events as cardiovascular health improved, irrespective of the presence of insulin resistance. Additionally, participants with high insulin resistance but moderate or high cardiovascular health did not have significantly increased risks compared with those with low insulin resistance. Stratified scatter plots and 3D surface plots revealed that cardiovascular health and modifiable healthy lifestyles significantly reduced the risk of insulin resistance-related death, with greater reductions observed at higher insulin resistance levels.

CONCLUSIONS

In this cohort study, improving cardiovascular health and modifiable health behaviors significantly reduced the risk of insulin resistance-related all-cause and cardiovascular deaths. Maintaining cardiovascular health at moderate or high levels (LE8 ≥ 50) could offset the increased risks caused by insulin resistance.

Influencing factors of health promotion behaviour in patients with aortic dissection: a qualitative study using the COM-B model

OBJECTIVES

This study aimed to understand influencing factors of health promotion behaviour in patients with aortic dissection (AD) using the capability, opportunity, motivation, behaviour (COM-B) model of behaviour.

DESIGN

A descriptive qualitative design was adopted. Data were collected using face-to-face semi-structured interviews and analysed using directed content analysis.

SETTING

Fujian Medical University Union Hospital.

PARTICIPANTS

A purposive sample of 16 patients with AD.

RESULTS

The following themes and subthemes were identified. Psychological capability: (1) lack of disease knowledge; physical capability: (1) physical function limitation; (2) fatigue; physical opportunity: (1) limited access to disease knowledge; (2) communication between providers and patients; (3) objective condition restriction; social opportunity: (1) stigma; (2) social support; reflective motivation: (1) self-efficacy; (2) perceived benefits; (3) personal and family responsibilities; automatic motivation: (1) post-traumatic growth; (2) fear of disease progression.

CONCLUSION

This study adopted a novel approach to understanding factors affecting health promotion behaviour among patients with AD. Interventions can be implemented using the Behaviour Change Wheel framework and study findings to improve health promotion behaviour in this patient population.

Association between behavioural risk factors for hypertension and concordance with the Dietary Approaches to Stop Hypertension dietary pattern among South Asians in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study

South Asians are among the fastest-growing immigrant population group in the United States (U.S.) with a unique disease risk profile. Due in part to immigration and acculturation factors, South Asians engage differently with behavioural risk factors (e.g. smoking, alcohol intake, physical activity, sedentary behaviour, and diet) for hypertension, which may be modified for the primary prevention of cardiovascular disease. Using data from the Mediators of Atherosclerosis in South Asians Living in America cohort, we conducted a cross-sectional analysis to evaluate the association between behavioural risk factors for cardiovascular disease and diet. We created a behavioural risk factor score based on smoking status, alcohol consumption, physical activity, and TV watching. We also calculated a Dietary Approaches to Stop Hypertension (DASH) dietary score based on inclusion of relevant dietary components. We used both scores to examine the association between engaging with risk factors for hypertension and the DASH diet among a cohort of South Asian adults. We found that participants with 3-4 behavioural risk factors had a DASH diet score that was 3 units lower than those with no behavioural risk factors (aβ: -3.25; 95% CI: -4.28, -2.21) and were 86% less likely to have a DASH diet score in the highest category compared to the lowest DASH diet score category (aOR: 0.14; 95% CI: 0.05, 0.37) in the fully adjusted models. These findings highlight the relationship between behavioural risk factors for hypertension among South Asians in the U.S.

Artificial intelligence-derived electrocardiographic aging and risk of atrial fibrillation: a multi-national study

BACKGROUND AND AIMS

Artificial intelligence (AI) algorithms in 12-lead electrocardiogram (ECG) provides promising age prediction methods. This study investigated whether the discrepancy between ECG-derived AI-predicted age (AI-ECG age) and chronological age, termed electrocardiographic aging (ECG aging), is associated with atrial fibrillation (AF) risk.

METHODS

An AI-ECG age prediction model was developed using a large-scale dataset (1 533 042 ECGs from 689 639 participants) and validated with six independent and multi-national datasets (737 133 ECGs from 330 794 participants). The AI-ECG age gap was calculated across two South Korean cohorts [mean (standard deviation) follow-up: 4.1 (4.3) years for 111 483 participants and 6.1 (3.8) years for 37 517 participants], one UK cohort [3.0 (1.6) years; 40 973 participants], and one US cohort [12.9 (8.6) years; 90 639 participants]. Participants were classified into two groups: normal group (age gap < 7 years) and ECG-aged group (age gap ≥ 7 years). The predictive capability of ECG aging for new- and early-onset AF risk was assessed.

RESULTS

The mean AI-ECG ages were 51.9 (16.2), 47.4 (12.5), 68.4 (7.8), and 56.7 (14.6) years with age gaps of .0 (6.8), -.1 (6.0), 4.7 (8.7), and -1.4 (8.9) years in the two South Korean, UK, and US cohorts, respectively. In the ECG-aged group, increased risks of new-onset AF were observed with hazard ratios (95% confidence intervals) of 2.50 (2.24-2.78), 1.89 (1.46-2.43), 1.90 (1.55-2.33), and 1.76 (1.67-1.86) in the two South Korean, UK, and US cohorts, respectively. For early-onset AF, odds ratios were 2.89 (2.47-3.37), 1.94 (1.39-2.70), 1.58 (1.06-2.35), and 1.79 (1.62-1.97) in these cohorts compared with the normal group.

CONCLUSIONS

The AI-derived ECG aging was associated with the risk of new- and early-onset AF, suggesting its potential utility to identify individuals for AF prevention across diverse populations.

Cognitive ability in offspring conscripts and cardiovascular disease risk in extended family members: assessing the impact of modifiable risk factors on familial risk

BACKGROUND

Previous studies have demonstrated an inverse association between cognitive ability (CA) and risk of cardiovascular diseases (CVDs). This study aims to investigate the associations between CA in offspring and CVD mortality in relatives of the parental generation (ie, parents, aunts/uncles (A/U) and the partners of A/U) and assesses the role of modifiable risk factors on these associations.

METHODS

This longitudinal study included nearly 3 million adults who were followed up from age 45 until death. Data for participants were obtained through the linkage of various Norwegian surveys and registries. HRs for CVD mortality among the parental generation in relation to offspring CA were estimated using Cox proportional hazards regression.

RESULTS

One standard deviation increase in CA was associated with a 23%, 17%, 9% and 9% CVD mortality reduction in mothers (HR: 0.77, 95% CI (0.74, 0.81)), fathers (0.83, (0.81, 0.86)), A/U (0.91, (0.87, 0.94)) and A/U partners (0.91, (0.89, 0.94)), respectively. Accounting for modifiable risk factors in the parental generation attenuated the association in mothers from 23% to 9% (0.91, (0.87, 0.96)), fathers from 17% to 7% (0.93, (0.91, 0.96)), A/U from 9% to 1% (0.99, (0.96, 1.03)) and A/U partners from 9% to 2% (0.98, (0.95, 1.01)).

CONCLUSIONS

We observed an inverse CA-CVD association in all familial relationships including non-genetically related duos (offspring-A/U partners). CA and CVD probably have shared causes such as genetic and environmental components common to the family members. These associations were largely accounted for by modifiable risk factors.

Comparison of chest computed tomography in Turbo FLASH mode with conventional mode for coronary artery disease screening: radiation dose, image quality, and calcium scoring performance

Background

Currently, the traditional chest computed tomography (CT) scan mode presents certain limitations in evaluating the coronary artery calcification score (CACS). Therefore, this study aimed to investigate the impact of using the Turbo FLASH mode to optimize chest CT on radiation dose, image quality, and CACS.

Methods

In this cross-sectional study, a total of 968 patients who simultaneously underwent routine chest CT (using the Turbo FLASH mode or the conventional mode) and cardiac CT [coronary calcium scan (CCS) and coronary CT angiography] were retrospectively collected. A comparative analysis was performed between the FLASH mode (n=493) and the conventional mode (n=475) in terms of radiation dose and image quality. CACS analysis was carried out using a semi-automatic software based on CCS, chest CT (FLASH), and chest CT (conventional). Using the CCS-CACS as a reference, the correlation, consistency, and concordance rate of risk categories based on CACS from the two chest CT modes were independently calculated.

Results

Chest CT (FLASH) reduced the mean radiation dose by 36.47 mGy·cm (11.1%) and exhibited fewer motion artifacts, albeit with a worse signal-to-noise ratio (SNR) (all P<0.05). For CACS quantification, chest CT (FLASH) showed a stronger linear correlation (r, 0.998 vs. 0.941) and higher consistency (mean difference, -5.653 vs. 7.142) compared to chest CT (conventional). For risk categories, chest CT (FLASH) set also demonstrated a higher concordance rate [91.3% (450/493) vs. 84% (399/475)]. Specifically, category 1 (CACS 1-10) exhibited the most significant improvement (78.5% vs. 53.5%). Additionally, chest CT (FLASH) had a lower false-negative rate [1% (5/493) vs. 4.6% (22/475)].

Conclusions

The Turbo FLASH mode of chest CT excels in detecting microcalcifications, reducing false negatives, and improving the accuracy of risk categories. It also lowers radiation exposure, but it may compromise the SNR of images.

Cardiometabolic deaths in black and white men: Tracing the risks from early- to mid-adulthood

Objective

This study aimed to estimate and compare cardiometabolic disease (CMD) mortality in U.S. Black and White men during the transition from early adulthood to middle age.

Methods

Using 2022 National Vital Statistics System data and standard period life table methods, we estimated the risk of CMD death in hypothetical cohorts of Black and White men from age 25 to 45 years. We estimated cumulative risk, excess mortality, years of lost life (YLL), and proportion of deaths due to CMD, stratifying by metabolic and cardiovascular disease.

Results

Of the 325,134 Black men aged 25 years in the initial cohort, the cumulative risk of cardiometabolic death before age 45 was one in 63 individuals or 1.58 %. For White men, the risks were markedly lower. Of the 1,185,384 White men aged 25 years in the initial cohort, the cumulative risk of cardiometabolic death before age 45 was one in 158 individuals or 0.63 %. The study also found that of the 5141 expected CMD deaths in the Black cohort, 3090 or 60.10 % were excess deaths relative to the White cohort. Additionally, the proportion of all deaths due to CMD among Black men was 19.15 % rising from 6.02 % at age 25 to 38.00 % at age 45, compared with 11.10 % among White men, increasing from 4.57 % at age 25 to 19.79 % at age 45. The YLL for Black men averaged 6.72 months per person while White men averaged 2.94 months.

Conclusions

This investigation shows profound racial disparities in CMD mortality from early to mid-adulthood.

Regular Use of Oral Nonsteroidal Anti-inflammatory Drugs in a Population of Polish Seniors: Findings from the PolSenior2 Cross-Sectional Survey

INTRODUCTION

Older adults represent a growing proportion of the general population. Nonsteroidal anti-inflammatory drugs (NSAIDs) constitute a group of medicines that are both necessary, owing to their anti-inflammatory, analgesic, and cardioprotective abilities, and potentially harmful, owing to their side effects.

OBJECTIVES

This study provides a comprehensive analysis of NSAID usage patterns among Polish adults aged 60 years and older. It focused on the regular use (≥ three times per week) of two types of NSAIDs: acetylsalicylic acid (ASA) and non-ASA NSAIDs, examining consumption on the basis of age, sex, educational level, and place of residence.

METHODS

Data were collected from the PolSenior2 study, a national cross-sectional survey of 5987 Polish individuals aged 60-106 years, conducted from 2018 to 2019.

RESULTS

The study found that 30.7% [95% confidence interval (CI) 28.8-32.7)]of Polish seniors regularly used NSAIDs, with 26.2% (95% CI 24.5-28.0) regularly using ASA, 6.3% (95% CI 5.3-7.2) regularly using non-ASA NSAIDs, and 1.9% (95% CI 1.4-2.3) reporting regular use of both. An age-related increase in regular NSAID use, including ASA, was observed. Women were more likely than men to use non-ASA NSAIDs regularly, whereas men in the 70-79 age group were more likely to use ASA. A lower level of education was associated with more frequent NSAID use.

CONCLUSIONS

The findings have implications for healthcare practitioners and policymakers, emphasizing the need for careful management of NSAID use. The study contributes to a more nuanced understanding of NSAID usage and underscores the necessity for tailored healthcare strategies to ensure safe and effective medication use among older adults.

The relationship between continuation of exercise habit for three years and endothelial function in patients with hypertension

The aim of this study was to evaluate the relationship between continuation of exercise habit for a long period and endothelial function assessed by flow-mediated vasodilation (FMD) in patients with hypertension. This study was a multicenter retrospective observational study. A total of 639 patients with hypertension were enrolled in this study. The subjects were divided into two groups based on information on exercise habit: a regular exercise group and a non-regular exercise group (control group). The regular exercise group was defined as patients who had an exercise habit during a 3-year follow-up period. There was no significant difference in FMD at baseline between the regular exercise group and control group. The change in FMD examined by the Wilcoxon signed rank test was significantly larger in the regular exercise group than in the control group (0.4 (-1.4, 2.0) % vs. -0.1 (-2.2, 1.4) %, p = 0.008). After adjustment for confounding factors for FMD, the odds ratio for increase in FMD was significantly larger in the regular exercise group than in the control groups. (OR: 1.59, 95% CI: 1.14-2.21, p = 0.006) A cubic spline curve revealed that even subjects with regular exercise who had a mean exercise intensity of less than 20 Mets・hour/week a had higher odds ratio for increase in endothelial function compared to the control group. These findings suggest that patients with hypertension who engage in regular exercise exhibited better endothelial function compared to those who do not exercise. Clinical Trial Registry Information: http://www.umin.ac.jp (UMIN000012951).

Coronary artery calcium in a 20-year-old South Asian patient - pushing the limits of detecting "early disease"

Coronary artery calcium (CAC) assessment has long been reserved for intermediate-risk individuals in mid- to older-adult populations. However, a growing body of evidence supports expanding CAC measurement to younger adults who exhibit multiple risk factors or other risk-enhancing features. We describe a case of a very young, 20-year-old, South Asian man with a CAC score of 15.7 Agatston Units. Despite his age and lack of overt symptoms, his CAC score placed him at the 99th percentile for his age and sex, underscoring the limitations of relying solely on traditional risk algorithms. Early CAC detection in such patients has potential for significant clinical impact, allowing timely implementation of intensive lifestyle modification and the most aggressive possible pharmacotherapy for cardiovascular risk reduction. Evidence indicates that even minimal CAC in very young individuals can progress exponentially, markedly increasing the risk of future atherosclerotic cardiovascular disease. Nonetheless, current guidelines do not recommend CAC testing in this population, creating a missed opportunity to detect and intervene in high-risk individuals during early adulthood. These observations underscore the need for more precise risk stratification strategies in select high-risk populations. Incorporating CAC measurements into care for young, high-risk individuals-alongside newer tools such as polygenic risk scores and low-radiation coronary CT angiography-could revolutionize preventive cardiology. Further research is needed to refine the cost-effectiveness and implementation strategies for early CAC measurement, develop more inclusive guidelines, and ensure a specialized workforce capable of delivering comprehensive preventive care.

Investigating the effect of occupational noise exposure in the risk of atrial fibrillation: a case study among Chinese occupational populations

PURPOSE

This study examines the link between high occupational noise exposure and atrial fibrillation (AF), given the limited existing evidence.

METHODS

We conducted a cross-sectional study among participants from a large heavy industry enterprise in China. High noise exposure was defined as an equivalent A-weighted sound level (LAeq, 8 h) of ≥ 80 dB(A) during an 8 h workday. Statistical analyses included univariate analysis to assess relationships between high noise exposure, cardiovascular risk factors, and AF. Mediation analysis identified potential mediators between high noise exposure and AF. Propensity score matching (PSM) and multivariable analysis were used to evaluate the independent association between high noise exposure and AF.

RESULTS

A total of 4530 participants were included, with 1526 experiencing high noise exposure, and 167 diagnosed with AF. Adjusted mediation analysis revealed that sleep disorders, hypertension, dyslipidemia, and dietary quality were the primary mediators for AF among those exposed to high noise, accounting for 12.4%, 9.6%, 8.9%, and 6.7% of the effect, respectively. PSM analysis showed a significantly higher proportion of AF in individuals with high noise exposure compared to those with low exposure (5.4% vs. 3.0%, P = 0.003). Multivariable analysis indicated that the risk of AF was doubled in individuals with high noise exposure (OR = 1.99, 95% CI 1.38-2.88, P < 0.001).

CONCLUSION

High occupational noise exposure increases the risk of AF in the working population, acting both as an independent risk factor and through mediation effects. Sleep disorders, hypertension, dyslipidemia, and dietary quality are the main mediators. These findings highlight the importance of integrating noise control with cardiovascular health management in workplace safety policies to prevent AF among industrial workers.

TRIAL REGISTRATION NUMBER

ChiCTR2300077951, registered on November 24, 2023, in the Chinese Clinical Trial Registry.

Accuracy analysis of cholesterol analyzer in detecting dyslipidemia in truck drivers

Cardiovascular diseases (CVD) are a leading cause of mortality and morbidity worldwide. Rapid diagnostic tools are crucial for timely intervention, especially in high-risk groups such as truck drivers. In Brazil, the Mission® test uniquely offers test strips for simultaneous measurement of total cholesterol (TC), high-density lipoprotein (HDL), triglycerides (TG), and low-density lipoprotein (LDL). This study evaluates the accuracy of the Mission® analyzer compared to laboratory testing for HDL-C, TG, and TC in truck drivers. A blinded cross-sectional study was conducted among truck drivers aged 30-64 in Campo Grande, Mato Grosso do Sul, Brazil. Spearman correlation, linear regression, and the Bland-Altman analyses were employed to compare lipid profile results between the Mission® analyzer and laboratory methods. A total of 108 samples were analyzed. For HDL, the Mission® analyzer showed a sensitivity of 0.88, a specificity of 0.67, and an area under the curve (AUC) of 0.77 (95% CI: 0.68-0.86). For TG, sensitivity and specificity were 0.96 and 0.98, respectively, with an AUC of 0.97 (95% CI: 0.93-1.0). For TC, the AUC was 0.87 (95% CI: 0.79-0.95). Bland-Altman analysis revealed biases of -4.5 for HDL, 12.4 for TC, and -42.8 for TG between Mission® and laboratory results. The Mission® analyzer demonstrates good accuracy for rapid dyslipidemia diagnosis and Framingham Global Risk Score calculation. It is a valuable tool for initial screening and risk assessment, confirmation with laboratory testing is recommended for definitive diagnosis and treatment planning.

Use of Aspirin and Initial Cardiovascular and Bleeding Risk in Patients with Chronic Kidney Disease

Key Points

The association between aspirin use and risk of the first cardiovascular event was NS in patients with CKD. Compared with nonusers, aspirin users had an increased risk of significant bleeding events. Aspirin prescription for the primary prevention of cardiovascular disease in patients with CKD needs careful consideration.

Background

Despite the high cardiovascular risk in patients with CKD, the role of aspirin in primary prevention remains unclear. This study aimed to investigate the association between aspirin initiation in adults with CKD without prior cardiovascular disease (CVD) and the first cardiovascular and bleeding events using Korean nationwide cohort data.

Methods

Among individuals aged 40–79 years with an eGFR between 15 and 59 ml/min per 1.73 m2 who underwent routine health examinations between 2011 and 2016, 15,861 individuals who were newly prescribed aspirin at a dose of 100 mg/d were matched with 79,305 aspirin non-users by propensity score matching. The primary efficacy outcome was a composite of nonfatal atherosclerotic CVD or cardiovascular death. The primary safety outcome was hospitalization due to intracranial or gastrointestinal bleeding.

Results

During a mean follow-up of 6.9±2.9 years, the incidence rates for the primary efficacy outcome in aspirin users and nonusers were 8.0 and 9.0 per 1000 person-years, respectively. Aspirin therapy initiation was not associated with the primary efficacy outcome (hazard ratio, 0.93; 95% confidence intervals, 0.86 to 1.04). However, the primary safety outcome of major bleeding was more frequent in aspirin users than in nonusers (6.7 versus 4.7 per 1000 person-years). The hazard ratio for this outcome in aspirin users versus nonusers was 1.45 (95% confidence intervals, 1.32 to 1.59).

Conclusions

No association was observed between aspirin use and the risk of nonfatal atherosclerotic CVD or cardiovascular death in patients with CKD stages G3 and G4 without prior CVD. Aspirin use was associated with higher risk of major bleeding.

Kidney outcomes of malignant hypertension-associated thrombotic microangiopathy in patients with and without IgA nephropathy: a propensity score-matched analysis

Background

IgA nephropathy (IgAN) can cause hypertension, and severe hypertension can exacerbate the progression of IgAN. However, the long-term kidney outcome of malignant hypertension (mHTN)-associated thrombotic microangiopathy (TMA) with IgAN is not well defined.

Methods

A total of 292 individuals with mHTN-associated TMA confirmed by kidney biopsy were included. Propensity score matching (PSM) analysis was performed to adjust for clinical characteristics in the comparison between cases with and without IgAN. Cox regression analysis was utilized to identify risk factors associated with long-term kidney outcome.

Results

A total of 86 mHTN-associated TMA with IgAN patients were compared with 206 mHTN-associated TMA with non-IgAN patients. After PSM, 61 pairs of patients with mHTN-associated TMA were matched. The mHTN-associated TMA with IgAN patients exhibited significantly lower serum albumin, higher 24-hour proteinuria, and a higher ratio of global sclerosis than those with non-IgAN. mHTN-associated TMA with IgAN was independently associated with impaired kidney function recovery [hazard ratio (HR), 0.48; 95% confidence interval (CI), 0.24-0.96, P = .038] compared with non-IgAN. This association remained significant after PSM (HR, 0.41; 95% CI, 0.17-0.99, P = .047). In addition, mHTN-associated TMA with IgAN was independently associated with kidney replacement therapy (KRT) compared with non-IgAN (HR, 2.31; 95% CI, 1.38-3.88; P = .002). This difference remained significant after PSM comparison (HR, 2.38; 95%CI, 1.14-4.99; P = .021). In addition, mHTN-associated TMA with IgAN patients had a higher incidence of receiving KRT and a lower incidence of kidney function recovery with a 25% reduction in creatinine levels than in non-IgAN patients, regardless of intensive blood pressure control.

Conclusions

The long-term kidney outcomes for mHTN-associated TMA patients with concomitant IgAN are significantly poorer than that of patients with non-IgAN. Monitoring kidney pathological characteristics will aid management and risk assessment at an early stage.

Comparison of pharmacokinetics of a fixed-dose combination of atorvastatin/ezetimibe 5 mg/10 mg versus separate tablets in healthy subjects

The 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors are well-established treatment options for dyslipidemia. For patients not meeting low-density lipoprotein cholesterol targets with monotherapy, combination therapy with another lipid-lowering agent including ezetimibe, is recommended. This study compared the pharmacokinetics (PKs) and safety of a fixed-dose combination (FDC) of atorvastatin/ezetimibe 5 mg/10 mg with the individual components in healthy Korean subjects. A randomized, open-label, single-dose, 2-treatment, 2-sequence, crossover study was conducted in 60 healthy subjects. An FDC of atorvastatin/ezetimibe 5 mg/10 mg or the corresponding individual components was administered in the first period, and the alternative in the second period after a 14-day washout. Serial blood samples were collected up to 72 hours post-dose to calculate PK parameters such as maximum plasma concentration (Cmax) and the area under the plasma concentration-time curve to the last measurable concentration (AUClast). The geometric mean ratios (GMRs) and 90% confidence intervals (CIs) of the Cmax and AUClast for the atorvastatin and total ezetimibe were estimated compared to the individual components. Adverse events (AEs) and other safety variables were monitored to evaluate safety and tolerability profile. Sixty subjects were enrolled and 58 subjects completed the study. For atorvastatin, the GMRs (90% CIs) for Cmax and AUClast were 1.18 (1.04-1.33) and 1.04 (1.00-1.08), respectively, and the corresponding values were 1.37 (1.26-1.50) and 0.98 (0.93-1.03) for total ezetimibe. No clinically significant treatment-emergent AEs were observed with either formulations. The FDC of atorvastatin/ezetimibe 5 mg/10 mg was safe and showed similar exposure to those of the individual components.

Trial Registration

ClinicalTrials.gov Identifier: NCT05202405.

Cardio-oncology rehabilitation and exercise: evidence, priorities, and research standards from the ICOS-CORE working group

The aim of this whitepaper is to review the current state of the literature on the effects of cardio-oncology rehabilitation and exercise (CORE) programmes and provide a roadmap for improving the evidence-based to support the implementation of CORE. There is an urgent need to reinforce and extend the evidence informing the cardiovascular care of cancer survivors. CORE is an attractive model that is potentially scalable to improve the cardiovascular health of cancer survivors as it leverages many of the existing frameworks developed through decades of delivery of cardiac rehabilitation. However, there are several challenges within this burgeoning field, including limited evidence of the efficacy of this approach in patients with cancer. In this paper, a multidisciplinary team of international experts highlights priorities for future research in this field and recommends standards for the conduct of research.

Preservation of Vascular Endothelial Function in Late-Onset Postmenopausal Women

BACKGROUND

Postmenopausal women (PMW) who complete menopause at a late age (55+ years) have lower cardiovascular disease risk than PMW who complete menopause at a normal age (45-54 years). However, the influence of late-onset menopause on vascular endothelial dysfunction is unknown. Moreover, the mechanisms by which a later age at menopause may modulate endothelial function remain to be determined.

METHODS

We measured endothelial function (brachial artery flow-mediated dilation [FMDBA]) in age-matched late- and normal-onset PMW and a young premenopausal reference group. We determined mitochondrial reactive oxygen species (mitoROS)-related suppression of endothelial function (change in FMDBA with an acute dose of the mitochondria-targeted antioxidant MitoQ; ΔFMDBA, MTQ) in PMW. The effects of serum from late- and normal-onset PMW and premenopausal women on mitoROS bioactivity in human aortic endothelial cells in culture were assessed. Metabolomics analyses in combination with serum metabolite level normalization and human aortic endothelial cell serum exposure experiments were performed to identify the circulating factors contributing to the serum effects on endothelial cell mitoROS bioactivity.

RESULTS

FMDBA in PMW was lower than in premenopausal women. However, FMDBA was >50% higher in late- versus normal-onset PMW and positively related to age at menopause. ΔFMDBA, MTQ was >50% lower in late- versus normal-onset PMW. Serum from normal-onset PMW but not late-onset PMW induced higher mitoROS bioactivity in human aortic endothelial cells compared with serum from premenopausal women. MitoROS bioactivity was negatively related to FMDBA and age at menopause. Seventeen metabolites significantly differed between late- and normal-onset PMW; 15 were lipid specific; 8 were triglyceride derived. TG(16:0) was most strongly correlated with mitoROS bioactivity. Normalization of TG(16:0) concentrations in serum from premenopausal women and late-onset PMW to match serum levels in normal-onset PMW abrogated differences in mitoROS bioactivity in serum-treated human aortic endothelial cells.

CONCLUSIONS

Late-onset menopause is associated with preservation of endothelial function, which is mediated by lower mitoROS-associated oxidative stress. A more favorable profile of circulating lipid metabolites, specifically triglyceride-derived metabolites, contributes to lower endothelial cell mitoROS in late-onset PMW. These findings provide new insight into the possible mechanisms of reduced cardiovascular disease risk in late-onset menopause.

Ten-year atherosclerotic cardiovascular disease risk score in post-menopausal women with low bone mineral density

BACKGROUND

Reports on the association between cardiovascular disease (CVD) risk and bone mineral density (BMD) remain inconsistent and hence more population-based studies on this subject are needed.

AIMS

This cross-sectional study aimed to evaluate the association between bone mineral density (BMD) at the lumbar spine (L1-L4) and femoral neck (right and left) with 10-year atherosclerotic cardiovascular disease (ASCVD) risk scores in Saudi postmenopausal women.

METHODS

A cohort of 1,450 postmenopausal women with risk factors for bone loss were analyzed using the data from the Chair for Biomarkers of Chronic Diseases (CBCD) Osteoporosis database. BMD at the lumbar spine and femoral neck was assessed using dual-energy X-ray absorptiometry (DXA). Anthropometric and biochemical parameters, including fasting glucose and lipid profiles, were measured. ASCVD risk scores were calculated using the ASCVD Risk Estimator Plus tool. BMD tertiles were analyzed for their association with ASCVD risk.

RESULTS

Women with osteoporosis had significantly lower BMI, waist and hip circumferences, and metabolic dysfunction markers compared to those with normal BMD. Significant negative correlations were observed between ASCVD risk scores and BMD at femoral neck sites in women with osteopenia and osteoporosis. Multivariate logistic regression indicated that women in the lowest BMD tertiles had significantly higher odds of intermediate to high ASCVD risk scores, with adjusted odds ratios of 1.90 for the lumbar spine, 2.19 for the right femoral neck, and 2.04 for the left femoral neck.

CONCLUSIONS

The study identified significant associations between lower BMD at the lumbar spine and femoral neck sites and elevated 10-year ASCVD risk scores in postmenopausal women, particularly among those with osteopenia and osteoporosis. These findings demonstrate the importance of assessing cardiovascular risk in women with low BMD to enable early prevention and management strategies.

A New Legal Standard for Medical Malpractice

Importance

Patients in the US have persistent needs for safe, evidence-based care. Physicians in the US report fear of liability risk and the need to practice "defensive medicine." In 2024, the American Law Institute revised the legal standard for assessing medical negligence. Understanding the implications of this change is crucial for balancing patient safety, physician autonomy, and the legal system's role in health care.

Observations

The updated standard from the American Law Institute shifts away from the traditional reliance on customary practice toward a more patient-centered concept of reasonable medical care. Although this revised standard still includes elements of prevailing medical practice, it defines reasonable care as the skill and knowledge regarded as competent among similar medical clinicians under comparable circumstances and acknowledges that, in some cases, juries can override customary practices if they fall short of contemporary standards. The restatement also embraces evidence-based practice guidelines, while leaving questions open about the variations in the quality of those guidelines. The restatement makes additional recommendations regarding informed consent and other aspects of physician-patient communication.

Conclusions and Relevance

The new standard of care from the American Law Institute represents a shift away from strict reliance on medical custom and invites courts to incorporate evidence-based medicine into malpractice law. Although states may adopt the recommendations from the American Law Institute at different times and to varying degrees, the restatement offers health professionals and the organizations in which they practice an opportunity to reconsider how medical negligence will be assessed, and to focus more directly on promoting patient safety and improving care delivery. Nonetheless, physicians should recognize that, at least for now, many courts will continue to rely significantly on prevailing practice in assessing medical liability.

2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2025 AHA Statistical Update is the product of a full year's worth of effort in 2024 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. This year's edition includes a continued focus on health equity across several key domains and enhanced global data that reflect improved methods and incorporation of ≈3000 new data sources since last year's Statistical Update.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Dietary Cholesterol and Myocardial Infarction in the Million Veteran Program

BACKGROUND

Coronary artery disease is a leading cause of morbidity and mortality in the United States. Coronary artery disease can lead to major complications including myocardial infarction (MI). The association of dietary cholesterol with coronary artery disease remains inconsistent. We examined the relation of dietary cholesterol with the incidence of MI among participants of the Million Veteran Program.

METHODS AND RESULTS

The Million Veteran Program is a prospective cohort database collecting genetic and nongenetic factors influencing chronic diseases. We analyzed data from 180 156 veterans with complete information on relevant dietary intake. The association between dietary cholesterol and MI risk was assessed using both linear and nonlinear models. Statistical significance was determined using the Wald test for linear trends and the likelihood ratio test for nonlinearity, alongside comparisons between high (≥300 mg/d) and low (<300 mg/d) cholesterol intake groups. In this study of 180 156 veterans with mean follow-up of 3.5 years, we observed a linear, dose-response association between dietary cholesterol intake and risk of MI, with every 100-mg/d increment in cholesterol intake associated with a 5% higher MI risk (relative risk [RR], 1.05 [95% CI, 1.02-1.08]). Subjects consuming >300 mg/d of cholesterol had a 15% increased MI risk compared with those consuming less (RR, 1.15 [95% CI, 1.06-1.25]).

CONCLUSIONS

We found that dietary cholesterol intake was linearly associated with greater risk of MI. These findings contribute to the growing literature highlighting the impact dietary cholesterol has on cardiovascular health. Reductions in cholesterol intake, which can be achieved by decreasing the intake of meat and eggs, may reduce the risk of incident MI.

Coronary artery and retinal vascularization by optical coherence tomography angiography: are eyes the window to the heart?

PURPOSE

Coronary artery disease (CAD) is the leading cause of death in the United States and its assessment still relies on invasive diagnostic procedures requiring contrast, such as coronary angiography (CAG) or computed tomography angiography (CCTA). The retinal vasculature is the only microvascular site in the human body that can be assessed non-invasively, and it has been described as a promising method for predicting cardiovascular risk since the classification of hypertensive retinopathy in the 19th century. Unfortunately, most classifications still rely on qualitative findings, which exhibit high rates of interobserver and intraobserver variability. With advances in ophthalmology exams, particularly the advent of optical coherence tomography angiography (OCTA), the capability of quantitatively assessing retinal vasculature can enable a more reliable non-invasive exam that could aid in estimating cardiovascular risk and assessing coronary lesions. This review aims to provide an extensive overview of the available evidence establishing the correlation of retinal and choroidal microvascular damage observed in OCTA and parameters such as coronary stenosis grade, number of affected vessels and scores like Gensini and SYNTAX evaluated via CAG or CCTA.

METHODS

Review of the literature published until December 2024 on PubMed/MEDLINE, SCOPUS and EMBASE by searching "optical coherence tomography angiography" or "OCTA" AND "Coronary artery disease" or "Coronary heart disease".

RESULTS

Findings from sixteen studies suggest a potential correlation between vascular parameters in OCTA and results from coronary exams. Reductions in vessel density analysis of the retinal plexus, especially the superficial capillary plexus (SCP), could improve patient selection and diagnostic yield for more invasive diagnostic procedures, such as CAG and CCTA.

CONCLUSION

OCTA is a non-invasive technology that can provide visualization and quantification of retinal microvascular disfunction that may correlate with macrovascular disease, particularly in the coronary circulation. Longitudinal assessment of quantitative OCTA parameters may provide biomarkers for monitoring CAD patients over time.

Comparison of magnetocardiography and coronary computed tomographic angiography for detection of coronary artery stenosis and the influence of calcium

OBJECTIVES

This study aimed to compare the diagnostic performance of magnetocardiography (MCG) and coronary computed tomography angiography (CCTA) in detecting coronary artery stenosis in relation to coronary calcification.

METHODS

A total of 587 patients who underwent invasive coronary angiography (ICA) with both CCTA and MCG between September 1, 2022, and August 31, 2023, were included. The patients were divided into three subgroups based on their coronary artery calcium score (CACS), namely less than 100, 100-400, and 400 and above, as determined by the Agatston score. The diagnostic sensitivity, specificity, accuracy, and the area under the receiver operating characteristic curve (ROC) of MCG, CCTA, and the combined diagnostic model (CCTA + MCG) were compared across all CACS subgroups.

RESULTS

According to ICA, 481 out of 587 patients (81.94%) had ischemia. The area under the ROC curve (AUC) of MCG for detecting ischemia was 0.80, with a sensitivity of 74.64% and specificity of 84.91% for all patients. In the different CACS subgroups, the diagnostic specificity of CCTA notably decreased (78.57% vs 24.13% vs 17.46%), while that of MCG remained stable (92.86% vs 86.21% vs 82.54%). The diagnostic accuracy of MCG and the combined diagnostic model was better than that of CCTA when CACS was ≥ 400 (77.22% vs 67.22% vs 58.89%). The AUC values of MCG, CCTA, and the combined model in the CACS ≥ 400 subgroups were 0.78, 0.49, and 0.71, respectively.

CONCLUSIONS

The diagnostic performance of MCG is less affected by CACS than that of CCTA. MCG and the combined model demonstrate better performance than CCTA alone in detecting coronary artery stenosis, particularly in cases with CACS ≥ 400.

KEY POINTS

Question How does the diagnostic performance of MCG compare with coronary computed tomographic angiography (CCTA) at different levels of calcification scores (CACS)? Findings MCG demonstrated better performance than CCTA in detecting coronary artery stenosis, particularly in patients with high CACS. Clinical relevance MCG or the MCG and CCTA combined model can be used to improve the noninvasive imaging diagnostic performance for detecting coronary artery stenosis and reduce unnecessary ICA, especially for patients with high calcification scores.

Effects of incorporating green leafy vegetables with meals on starch and lipid digestibility under simulated gastrointestinal digestion

Green leafy vegetables (GLV) are known for their cardiovascular health benefits. However, the effects of their serving size on delaying carbohydrate and lipid digestion remain unclear. This study investigated the impact of varying MyPlate-recommended GLV serving sizes on the digestibility of carbohydrates and lipids and antioxidant activity during in vitro gastrointestinal digestion. Eight GLV including Asteraceae (cos, green oak, red oak, loose-leaf) and Brassicaceae (cabbage, cauliflower, broccoli, Chinese cabbage) vegetables were incorporated into mixed meals at 0.5, 1.0, and 1.5 times the MyPlate recommendation. The results showed that the total phenolic content (TPC) ranged from 5.77 to 9.46 mg GAE/g extract. Nitrate accumulation exhibited a higher content in Asteraceae (590.90-1155.04 mg NO3-NE/g extract) than in Brassicaceae families (244.96-726.20 mg NO3-NE/g extract). Incorporating ≥ 1 serving of all GLV significantly decreased rapidly and slowly digestible starch fractions, while undigestible starch significantly increased, resulting in delaying glucose release. Antioxidant activity was significantly enhanced with ≥ 1 serving and free fatty acid concentrations decreased with higher vegetable servings. Post-digestion nitrate concentrations ranged from 127.3 to 188.5 µg NO3-N/mL, positively correlating with GLV serving size. These effects were dose-dependent and varied across species. These findings suggest that incorporating GLV at or above the MyPlate recommendation may have protective effects on cardiovascular health.

Development and validation of a multivariable Prediction Model for Pre-diabetes and Diabetes using Easily Obtainable Clinical Data

Importance

In the US, pre-diabetes and diabetes are increasing in prevalence alongside other chronic diseases. Hemoglobin A1c is the most common diagnostic test for diabetes performed in the US, but it has known inaccuracies in the setting of other chronic diseases.

Objective

To determine if easily obtained clinical data could be used to improve the diagnosis of pre-diabetes and diabetes compared to hemoglobin A1c alone.

Design Setting and Participants

This cross-sectional study analyzed nationally representative data obtained from six 2-year cycles (2005 to 2006 through 2015 to 2016) of the National Health and Nutrition Examination Survey in the US. We excluded participants without hemoglobin A1c, oral glucose tolerance test, or sample weight data. The sample comprised 13,800 survey participants. Data analyses were performed from May 1, 2024 to February 9, 2025.

Main Outcomes and Measures

We estimated 2-hour glucose from a gradient boosted machine decision tree machine learning model to diagnose pre-diabetes and diabetes as defined by oral glucose tolerance test 2-hour glucose of greater than or equal to 140 mg/dL but less than 200 mg/dL and greater than or equal to 200 mg/dL, respectively. We compared the area-under-the-receiver-operating-curve (AUROC), the calibration, positive predictive value, and the net benefit by decision curve analysis to hemoglobin A1C alone.

Results

A 20-feature Model outperformed the hemoglobin A1c and fasting plasma glucose for diagnosis, with AUROC improvement from 0.66/0.71 to 0.77 for pre-diabetes and from 0.87/0.88 to 0.91 for diabetes. The Model also had improved positive predictive value compared to the A1c for diagnosis and for net benefit on decision curve analysis. Main features that improved diagnosis of pre-diabetes and diabetes were the standard vitals: age, height, weight, waist circumference, blood pressure, pulse, the fasting labs plasma glucose, insulin, triglycerides, and iron, the non-fasting labs cholesterol, gamma-glutamyl transferase, creatinine, platelet count, segmented neutrophil percentage, urine albumin, and urine creatinine, and the social determinant of health factor Poverty Ratio.

Conclusions and Relevance

In this cross-sectional study of NHANES participants, we identified risk factors that could be incorporated into the electronic medical record to identify patients with potentially undiagnosed pre-diabetes and diabetes. Implementation could improve diagnosis and lead to earlier intervention on disease before it becomes severe and complications develop.

Key Points

Question: Can readily-available clinical data improve diagnosis of pre-diabetes and diabetes compared to hemoglobin A1c testing alone?Findings: In this cross-sectional study of 13,800 adults with paired hemoglobin A1c and oral glucose tolerance testing in the National Health and Nutrition Examination Survey, the rate of pre-diabetes undiagnosed by 8.6% and rate of diabetes undiagnosed by the hemoglobin A1c was 3.5%. A novel multivariable prediction model that included fasting plasma glucose, insulin, basic body measurements, and routinely available dyslipidemia and hepatic function labs for was significantly more accurate (AUROC 0.66/0.71 to 0.77 for pre-diabetes, 0.87/0.88 to 0.91 for diabetes) than hemoglobin A1C or fasting plasma glucose alone.Meaning: Incorporation of easily obtainable clinical data can improve diagnosis of pre-diabetes and diabetes compared to hemoglobin A1C alone.

Nicotine dependence is associated with an increased risk of developing chronic, non-communicable inflammatory disease: a large-scale retrospective cohort study

Introduction

Chronic, non-communicable inflammatory diseases (CIDs) affect a large portion of the population, imposing a significant morbidity, encompassing a substantial mortality. Thus, they are a major medical burden with a high unmet need. CIDs develop over the span of several years, and the risk of developing CIDs has been linked to genetic and environmental factors. Thus, modification of environmental factors is a promising approach for the prevention of CIDs. Among modifiable environmental factors that have been linked to the CID risk is nicotine dependence. However, for only few CIDs, compelling evidence suggests that nicotine dependence increases (e.g., rheumatoid arthritis and asthma) or decreases (e.g., pemphigus) the CID risk. For most CIDs, there are inconsistent, scant, or no reports on the risk of CID associated with nicotine dependence.

Methods

To address this gap, we leveraged TriNetX, analyzing data from over 120 million electronic health records (EHRs). Using propensity score matching (PSM) to control for age, sex, ethnicity, and other CID risk factors, we contrasted the risk of developing any or any of the 38 CIDs in 881,192 EHRs from individuals with nicotine dependence to PSM-matched unexposed counterparts.

Results

The analytical pipeline was validated by demonstrating an increased risk of individuals exposed to nicotine dependence for subsequent diagnosis of myocardial infarction, malignant neoplasm of the lung, and chronic obstructive pulmonary disease. Overall, 16.8% of individuals with nicotine dependence developed CIDs, compared to 9.6% of individuals not exposed to nicotine dependence (hazard ratio 2.12, confidence interval 2.10-2.14, p < 0.0001). Investigating single CIDs, nicotine dependence imposed increased risks for 23 of the 38 investigated diseases, i.e., dermatomyositis, granulomatosis with polyangiitis, pyoderma gangrenosum, and immune thrombocytopenic purpura. The sex-stratified analysis revealed few sex-specific differences in CID risk.

Discussion

Our study emphasizes the importance of preventive measures targeting nicotine addiction to reduce the global burden of CIDs.

Telemedicine Use and Hypertension Control in an Urban Community Health Center Cohort

BACKGROUND

Real-time or synchronous telemedicine can be a valuable adjunctive strategy for chronic disease management, but few studies have assessed its impact on hypertension control among safety-net populations.

OBJECTIVE

To evaluate whether telemedicine is associated with blood pressure (BP) control.

DESIGN

Retrospective cohort study. Mixed-effects logistic regression models clustered by the patient estimated associations between telemedicine and BP control after adjusting for patient factors and neighborhood context.

PARTICIPANTS

Patients seeking care at an urban, multisite community health center with hypertension and ≥1 BP measurement between 2020 and 2022 (3663 patient-year observations across 2086 unique patients).

MAIN MEASURES

The primary outcome was BP control defined as a binary variable. We used the Centers for Medicare & Medicaid Services' Controlling High Blood Pressure quality measure criteria of systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg in the most recent recording in the measurement year.

KEY RESULTS

Among the 2086 patients with hypertension in our sample, there were 1257 (60.3%) Latinx and 425 (20.4%) Black patients. Over 90% lived in a neighborhood of high deprivation as categorized by the social deprivation index. Telemedicine visits, compared to none, were not associated with blood pressure control (1-2 telemedicine visits aOR, 1.05 [95% CI, 0.86-1.28]; ≥3 telemedicine visits aOR, 0.86 [95% CI, 0.68-1.09]). One in-person visit per year, compared to 2-3, was associated with lower odds of BP control (aOR, 0.72 [95% CI, 0.55-0.94]). Black patients, compared to Latinx patients, were less likely of having BP control (aOR, 0.64 [95% CI, 0.48-0.87]).

CONCLUSIONS

In this community health center cohort of patients with hypertension, telemedicine did not compromise blood pressure control. Persistent racial disparities in blood pressure control underscore the need for equity-centered strategies for hypertension management in safety-net primary care settings.

Safety assessment of rosuvastatin-fenofibrate combination in the treatment of hyperlipidemia based on FDA's adverse event reporting system database

Background

With the improvement of living standards, an increasing number of patients are presenting with mixed hyperlipidemia. In addition to cholesterol reduction, it is imperative to lower triglyceride levels. The combination of statin and fibrate for reducing lipid levels has commonly been applied in clinical therapy. However, the combination of drugs also increases the risk of adverse events (AEs). In this study, we analyzed the safety signals of rosuvastatin-fenofibrate combination by assessing the publicly available US Food and Drug Administration Adverse Event Reporting System (FAERS), so as to provide a reference for rational clinical use of rosuvastatin and fenofibrate, and reduce the occurrence of related AEs.

Methods

Reports to the FAERS from 1 January 2004 to 19 March 2020 were analyzed. The proportional report ratio (PRR), reporting odds ratio (ROR), and Bayesian Confidence Propagation Neural Network (BCPNN) analysis were used to extract data from FAERS for suspected signals referring to the combination of rosuvastatin and fenofibrate.

Results

A total of 68 safety signals were detected from the top 250 AEs in 3,587 reports, of which 28 signals were not included in the drug labels. All the detected AEs were associated with 12 System Organ Classes (SOC), such as gastrointestinal, musculoskeletal and connective tissue, general diseases, investigations and nervous system. The most frequent AEs were analyzed, and it was found that women generally have a higher susceptibility to experiencing AEs, including pain, nausea, fatigue, myalgia, diarrhea, dyspnea, headache, weakness, and dizziness.

Conclusion

Clinicians should pay more attention to the AEs of gastrointestinal and muscular system during combination therapy, and it is recommended to strengthen pharmaceutical care during clinical application.

Call for a consensual definition of dyslipidemia in coronary angiography trials

Dyslipidemia is extensively analyzed in clinical trials investigating its role as a risk factor for coronary artery disease (CAD). However, its definition varies vastly among studies, leading to different attributions to the variable dyslipidemia. The objectives of this study are to verify the hypothesis of a lack of a consensual definition of dyslipidemia in coronary angiography studies and to propose a consensual definition of dyslipidemia, considering the influence of each serum lipid parameter on mortality. A systematic search of coronary angiography studies focusing on dyslipidemia was conducted. We listed definitions and their references in the 258 articles the research found. Out of the 258 articles retrieved in the search, 52 studies (20%) provided a definition of dyslipidemia, and 20 (8%) mentioned the source. We identified 39 different definitions. To mitigate misinterpretations of cardiovascular risk factors, we propose the use of the "lipid triad" components to define dyslipidemia: LDL-cholesterol >3.0 mmol/L for primary prevention and >2.6 mmol/L or >1.4 mmol/L for secondary prevention in patients over/under 75 years old, respectively; or HDL-cholesterol <1.3 mmol/L (women) and <1.0 mmol/L (men); or triglycerides >1.7 mmol/L.

Revealing the limitations of 10-year MACE observations: 20-year observed total cardiovascular burden in the EPIC-Norfolk study

BACKGROUND

Primary prevention strategies for cardiovascular disease (CVD) conventionally rely on 10-year risk estimates of major adverse cardiovascular events (MACE). However, communicating longer-term total CVD risk may better facilitate informed preventive decisions. Therefore, we aimed to quantify how well 10-year observed incidence reflects 20-year observed incidence and how MACE reflects total CVD events across demographic groups, using observations in long-term prospective data.

METHODS

In individuals aged 40-79 without CVD or diabetes from the population-based EPIC-Norfolk cohort, we compared the first occurrence of 10 and 20 years (1) 3-point MACE events (non-fatal myocardial infarction+non-fatal stroke+fatal CVD) and (2) total CVD events (all non-fatal and fatal CVD events leading to hospitalisation), stratified by sex and age.

RESULTS

Among 22 569 participants (57% women), incident 10-year and 20-year 3-point MACE was 5.3% and 15.5%, respectively, yielding 20/10 year ratios from 2.2 (in older men) to 4.5 (in younger women). Total CVD increased from 10.5% at 10 years to 26.9% at 20 years, with ratios ranging from 1.9 (older men) to 3.9 (younger women). Ratios between 10-year MACE and 20-year total CVD varied substantially, ranging from 3-fold in (older men) to 10-fold (younger women).

CONCLUSIONS

The observed incidence of CVD roughly triples from 10 to 20 years of follow-up, with 10-year MACE observations underestimating 20-year total CVD burden by a factor ranging from 3 (older men) to 10 (younger women). These findings highlight the limitations of communicating 10-year MACE risk assessments to facilitate informed decisions in longer-term CVD prevention-particularly in younger women.

Cardiac adverse events associated with statins in myocardial infarction patients: a pharmacovigilance analysis of the FDA Adverse Event Reporting System

BACKGROUND

Despite the advent of new pharmacotherapies, statins remain a cornerstone in the secondary prevention of myocardial infarction (MI). However, the cardiac adverse events (AEs) linked to statins are not well-documented.

AIM

This pharmacovigilance study used data from the FDA Adverse Event Reporting System (FAERS) to investigate the association between statin use and cardiac AEs in MI patients.

METHOD

Reports from the FAERS database (2004-2023) identifying statins as the primary suspect in MI patients were analyzed. The study evaluated seven types of statins: atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, and simvastatin. Disproportionality analysis using four major indices, Reporting Odds Ratio (ROR), Proportional Reporting Ratio (PRR), Bayesian Confidence Propagation Neural Network (BCPNN), and Multi-Item Gamma-Poisson Shrinker (MGPS), was conducted to detect signals of statin-related cardiac AEs.

RESULTS

Of the 20,346,289 reports reviewed, 150 identified statins as the primary suspect drug in MI patients. The most common cardiac AEs were recurrent MI (50 reports), acute MI (14 reports), followed by tachycardia (10), angina pectoris (8), coronary artery occlusion (6), cardiac failure (6), and arrhythmia (6). The analysis revealed no significant signals of statin-induced cardiac AEs.

CONCLUSION

The findings confirm that statin use in MI patients does not significantly increase the risk of cardiac adverse effects, supporting their safety profile in this context.

Microbiota-derived 3-Methyl-L-histidine mediates the proatherogenic effect of high chicken protein diet

Diet rich in chicken protein has gained a widespread popularity for its profound effect on weight loss and glycemic control; however, its long-term effect on cardiovascular health and the underlying mechanisms remains obscure. Here, we demonstrated that higher intake of chicken protein was an independent risk factor for sub-clinical atherosclerosis. Adherence to high chicken protein diet (HCD) alleviated excessive weight gain and glycemic control regardless of the presence of gut microbiota in apolipoprotein E-deficient mice. In contrast, long-term HCD administration enhanced intestinal cholesterol absorption and accelerated atherosclerotic plaque formation in a gut microbiota-dependent manner. Integrative analysis of 16S rDNA sequencing and metabolomics profiling identified 3-Methyl-L-histidine (3-MH), resulting from an enrichment of Lachnospiraceae, as the key microbial effector to the atherogenic effect of HCD. Mechanistically, 3-MH facilitated the binding of hepatocyte nuclear factor 1A (HNF1A) to the promoter of NPC1-like intracellular cholesterol transporter 1 (NPC1L1), whereas inhibition of HNF1A-NPC1L1 axis abolished the atherogenic effect of 3-MH. Our findings uncovered a novel link between microbiota-derived 3-MH and disturbed cholesterol homeostasis, which ultimately accelerated atherosclerosis, and argued against the recommendation of HCD as weight loss regimens considering its adverse role in vascular health.

Random Survival Forest Machine Learning for the Prediction of Cardiovascular Events Among Patients With a Measured Lipoprotein(a) Level: A Model Development Study

BACKGROUND

Established risk models may not be applicable to patients at higher cardiovascular risk with a measured Lp(a) (lipoprotein[a]) level, a causal risk factor for atherosclerotic cardiovascular disease.

METHODS

This was a model development study. The data source was the Nashville Biosciences Lp(a) data set, which includes clinical data from the Vanderbilt University Health System. We included patients with an Lp(a) measured between 1989 and 2022 and who had at least 1 year of electronic health record data before measurement of an Lp(a) level. The end point of interest was time to first myocardial infarction, stroke/TIA, or coronary revascularization. A random survival forest model was derived and compared with a Cox proportional hazards model derived from traditional cardiovascular risk factors (ie, the variables used to estimate the Pooled Cohort Equations for the primary prevention population and the variables used to estimate the Second Manifestations of Arterial Disease and Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention scores for the secondary prevention population). Model discrimination was evaluated using Harrell's C-index.

RESULTS

A total of 4369 patients were included in the study (49.5% were female, mean age was 51 [SD 18] years, and mean Lp(a) level was 33.6 [38.6] mg/dL, of whom 23.7% had a prior cardiovascular event). The random survival forest model outperformed the traditional risk factor models in the test set (c-index, 0.82 [random forest model] versus 0.69 [primary prevention model] versus 0.80 [secondary prevention model]). These results were similar when restricted to a primary prevention population and under various strategies to handle competing risk. A Cox proportional hazard model based on the top 25 variables from the random forest model had a c-index of 0.80.

CONCLUSIONS

A random survival forest model outperformed a model using traditional risk factors for predicting cardiovascular events in patients with a measured Lp(a) level.

Concordance Between DASH Diet and Coronary Artery Calcification: Results From the Mediators of Atherosclerosis in South Asians Living in America (MASALA) Prospective Cohort Study

Introduction

South Asian adults are at high risk for atherosclerotic cardiovascular disease, for which coronary artery calcification is an early predictor. Adherence to the Dietary Approaches to Stop Hypertension diet is a modifiable risk factor that may mitigate the progression of coronary artery calcification and atherosclerotic cardiovascular disease.

Methods

Using data from the Mediators of Atherosclerosis in South Asians Living in America cohort, the authors calculated a Dietary Approaches to Stop Hypertension dietary score (categorized as low, moderate, and high) to examine the associations of Dietary Approaches to Stop Hypertension diet adherence with coronary artery calcification after a 5-year follow up.

Results

The authors found that participants in the high Dietary Approaches to Stop Hypertension category were 41% less likely to have coronary artery calcification score >100 (age-adjusted incidence rate ratio=0.59; 95% CI=0.36, 0.95) than those in the low category; this association was attenuated in multivariable models. Differences were observed by sex. Men in the high Dietary Approaches to Stop Hypertension category were 51% less likely to have coronary artery calcification score >100 (adjusted incidence rate ratio=0.49; 95% CI=0.26, 0.95) and experienced 0.46-fold coronary artery calcification change (fold change=0.46; 95% CI=0.18, 0.90) in multivariable models.

Conclusions

The findings indicate a relationship between Dietary Approaches to Stop Hypertension diet and early predictors of atherosclerotic cardiovascular disease risk among South Asians living in the U.S., particularly men.

Perimenopausal combined hormonal contraception: focus on sexual function

Age alone should not be an absolute contraindication for any contraceptive methods. However, medical eligibility criteria for combined hormonal contraception (CHC) use must be taken into consideration when choosing an appropriate contraceptive method. Women should be counseled on the benefits and risks of CHC while in their 40s. If there are no contraindications, women may use CHC for contraception up until the age of 50 years. Loss of libido is a common symptom during the late 40s. While women associate this with hormone levels, libido is multifactorial and is influenced by family and work stress, tiredness, self-image, medications and the physical changes in their partner. During this stage, women might experience urogenital issues such as vaginal dryness, dyspareunia and bladder problems, which can further affect the woman's sexual function. Before attributing the cause of sexual dysfunction to CHC use, a complete gynecologic examination and a full biopsychosocial assessment of the woman and her partner should be conducted to define other potential causes. When CHC-related female sexual dysfunction is suspected, using an oral CHC with a higher estrogen dose, a vaginal contraceptive ring or a transdermal contraceptive patch, or switching to a progesterone-only pill or non-hormonal method, might be suggested.