Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

Obesity is associated with impaired long-term prognosis in patients undergoing coronary angiography: Results from a large-scaled single centre registry

BACKGROUND

The study investigates the prognostic value of body mass index (BMI) in a large cohort of unselected patients undergoing invasive coronary angiography (CA). More than one third of the world population is overweight or obese with increasing prevalence. Obesity is an established risk factor for the development of coronary artery disease (CAD), but its impact on outcomes in patients undergoing CA remains controversial.

METHODS

Consecutive patients undergoing invasive CA were included at one institution from 2016 to 2022. Patients were stratified by BMI on admission according to the current WHO definition into the following subgroups: BMI 18.5- < 25 kg/m2, 25- < 30 kg/m2, 30- < 35 kg/m2 and ≥ 35 kg/m2. The prognostic value of BMI was investigated with regard to the primary endpoint rehospitalization for heart failure (HF) at 36 months and the secondary endpoints acute myocardial infarction (AMI) and coronary revascularization at 36 months.

RESULTS

From 2016 to 2022, 6583 patients undergoing CA were included with a median BMI of 27.5 kg/m2 (mean: 28.3 kg/m2). Patients with a BMI of 25- < 30 kg/m2 had the highest prevalence of CAD (71.1 %) and 3-vessel CAD (30.5 %), whereas patients with a BMI ≥ 35 kg/m2 had the lowest prevalence (61.4 % and 20.1 %, respectively). After multivariable adjustment, patients with a BMI ≥ 35 kg/m2 had the highest risk of HF-related rehospitalization at 36 months compared to those with a BMI in the normal range (adjusted HR = 1.210; 95 % CI: 1.011-1.448; p = 0.038).

CONCLUSION

In patients undergoing CA, a BMI ≥35 kg/m2 was associated with the highest risk of HF-related rehospitalization at 36 months.

Evaluation of machine learning methods for prediction of heart failure mortality and readmission: meta-analysis

BACKGROUND

Heart failure (HF) impacts nearly 6 million individuals in the U.S., with a projected 46% increase by 2030, is creating significant healthcare burdens. Predictive models, particularly machine learning (ML)-based models, offer promising solutions to identify patients at greater risk of adverse outcomes, such as mortality and hospital readmission. This review aims to assess the effectiveness of ML models in predicting HF-related outcomes, with a focus on their potential to improve patient care and clinical decision-making. We aim to assess how effectively machine learning models predict mortality and readmission in heart failure patients to improve clinical outcomes.

METHOD

The study followed PRISMA 2020 guidelines and was registered in the PROSPERO database (CRD42023481167). We conducted a systematic search in PubMed, Scopus, and Web of Science databases using specific keywords related to heart failure, machine learning, mortality and readmission. Extracted data focused on study characteristics, machine learning details, and outcomes, with AUC or c-index used as the primary outcomes for pooling analysis. The PROBAST tool was used to assess bias risk, evaluating models based on participants, predictors, outcomes, and statistical analysis. The meta-analysis pooled AUCs for different machine learning models predicting mortality and readmission. Prediction accuracy data was categorized by timeframes, with high heterogeneity determined by an I² value above 50%, leading to a random-effects model when applicable. Publication bias was assessed using Egger's and Begg's tests, with a p-value below 0.05 considered significant RESULT: A total of 4,505 studies were identified, and after screening, 64 were included in the final analysis, covering 943,941 patients. Of these, 40 studies focused on mortality, 17 on readmission, and 7 on both outcomes. In total, 346 machine learning models were evaluated, with the most common algorithms being random forest, logistic regression, and gradient boosting. The neural network model achieved the highest overall AUC for mortality prediction (0.808), while the support vector machine performed best for readmission prediction (AUC 0.733). The analysis revealed a significant risk of bias, primarily due to reliance on retrospective data and inadequate sample size justification.

CONCLUSION

In conclusion, this review emphasizes the strong potential of ML models in predicting HF readmission and mortality. ML algorithms show promise in improving prognostic accuracy and enabling personalized patient care. However, challenges like model interpretability, generalizability, and clinical integration persist. Overcoming these requires refined ML techniques and a robust regulatory framework to enhance HF outcomes.

Risk factors and clinical outcome of postoperative hyperglycemia after cardiac surgery with cardiopulmonary bypass

Background

There is a high incidence of postoperative hyperglycemia (PHG) in cardiac surgery with cardiopulmonary bypass (CPB), as well as increased morbidity and mortality. The purpose of this study was to evaluate the incidence of PHG after cardiac surgery with CPB, the independent risk factors, and its association with clinical outcomes.

Methods

This was a retrospective, observational study of patients who underwent cardiac surgery with CPB between January 2023 and March 2024 in West China Hospital of Sichuan University. A total of 1,008 consecutive postoperative cardiac surgery patients admitted to the cardiac surgery intensive care unit (ICU) were divided into a non-PHG group and a PHG group. Patients' blood glucose levels were evaluated immediately after cardiac surgery and every 3-4 h daily for 10days, until discharge from the ICU. For patients with PHG, intravenous insulin infusion was performed according to the institution's protocol, and perioperative risk factors for hyperglycemia and clinical outcomes were assessed.

Results

PHG, defined as random blood glucose ≥10.0 mmol/L (180 mg/dl) on two occasions within 24 h, occurred in 65.28% of cardiac surgery patients. Multivariable logistic regression analysis identified that age [odds ratio (OR) 1.054, 95% confidence interval (CI) 1.040-1.069; p < 0.001], female sex (OR 1.380, 95% CI 1.023-1.864; p = 0.035), diabetes (OR 13.101, 95% CI 4.057-42.310; p < 0.001), pulmonary infection (OR 1.918, 95% CI 1.129-3.258; p = 0.016), aortic cross-clamp time (OR 1.007, 95% CI 1.003-1.010; p < 0.001), and intraoperative highest glucose (OR 1.515, 95% CI 1.370-1.675; p < 0.001) emerged as independent risk factors for PHG. Moreover, PHG had higher rates of acute kidney injury (12.61% vs. 4.00%; p < 0.001), delirium (9.57% vs. 3.43%; p < 0.001), pulmonary infection (12.01% vs. 5.14%; p < 0.001), longer duration of mechanical ventilation (19 vs. 14 h; p < 0.001), length of ICU stay (74 vs. 58 h; p < 0.001), length of hospitalization (13 vs. 11 days; p < 0.001), and higher rate of self-discharge or death (3.95% vs. 0.57%; p = 0.002) compared with patients with non-PHG.

Conclusions

PHG occurs frequently in patients after cardiac surgery. Age, female, diabetes, pulmonary infection, aortic cross-clamp time, and intraoperative highest glucose were independent risk factors for PHG. PHG is associated with worse clinical outcomes, including a higher rate of acute kidney injury, delirium, and pulmonary infection, greater duration of mechanical ventilation, length of ICU stay, length of hospitalization, and higher rate of automatic discharge or death.

Genetic and Lifestyle Risks for Coronary Artery Disease and Long-Term Risk of Incident Dementia Subtypes

BACKGROUND

Shared genetic and lifestyle risk factors may underlie the development of both coronary artery disease (CAD) and dementia. We examined whether an increased genetic risk for CAD is associated with long-term risk of developing all-cause, Alzheimer's, or vascular dementia, and investigated whether differences in potentially modifiable lifestyle factors in the mid- to late-life period may attenuate this risk.

METHODS

A prospective cohort study of 365 782 participants free from dementia for at least 5 years after baseline assessment was conducted within the UK Biobank cohort. Genetic risk was assessed using a genomewide polygenic risk score (PRS) for CAD and lifestyle risk using a modified version of the American Heart Association's Life's Essential 8 Lifestyle Risk Score (LRS). Higher values for both scores were deemed to represent increased risk. Primary outcomes were incident all-cause, Alzheimer's, and vascular dementia diagnoses obtained from electronic health records. Secondary outcomes were neuroimaging phenotypes measured in 32 028 participants recalled for magnetic resonance imaging. Sensitivity analyses were conducted to test the extent by which biological and behavioral risk factors contributed to observed associations.

RESULTS

A total of 8870 cases of all-cause dementia were observed over a median 13.9-year follow-up. Both genetic (PRS) and lifestyle (LRS) risk scores for CAD were associated with a modestly elevated risk of all-cause dementia (subhazard ratio per SD increase, 1.10 [1.08, 1.12], P<0.001, for PRS and 1.04 [1.02, 1.06], P=0.006, for LRS). This risk appeared largely attributable to underlying vascular dementia diagnoses (subhazard ratio, 1.16 [1.11, 1.21], P<0.001 for PRS and 1.15 [1.09, 1.22], P<0.001, for LRS), because Alzheimer's disease was found to demonstrate moderate associations with PRS alone (subhazard ratio, 1.09 [1.06, 1.13]; P<0.001). LRS was found to have an additive rather than interactive effect with PRS, with individuals in the highest tertiles for both genetic and lifestyle risk for CAD ≈70% more likely to develop vascular dementia during follow-up compared with those in the lowest tertiles for both (subhazard ratio, 1.71 [1.39, 2.11]; P<0.001). This was substantially attenuated in those with a low LRS at baseline, however, regardless of underlying genetic risk (40% to 50% reduction for low versus high LRS tertile regardless of PRS tertile; P<0.001 for all). In a subset of individuals recalled for neuroimaging assessments, those in the highest tertiles for genetic and lifestyle risk for CAD demonstrated a ≈25% greater volume of white matter hyperintensities than those in the lowest risk tertiles, but showed little difference in gray matter or hippocampal volumes. Sensitivity analyses identified associations between both biological and behavioral risk scores with white matter hyperintensity burden and vascular dementia, whereas some Alzheimer's dementia associations showed seemingly paradoxical relationships.

CONCLUSIONS

Individuals who are genetically predisposed to developing CAD also face an increased risk of developing dementia in old age. This risk is reduced in those demonstrating healthy lifestyle profiles earlier in the lifespan, particularly in those who may be at an increased risk of developing dementia caused by an underlying vascular pathology.

Effect of Home-Based Virtual Reality Training on Upper Extremity Recovery in Patients With Stroke: Systematic Review

BACKGROUND

Stroke is a leading cause of long-term disability, often resulting in upper extremity dysfunction. Traditional rehabilitation methods often face challenges such as limited patient access to resources and lack of sustained motivation. Home-based virtual reality (VR) training is gaining traction as an innovative, sustainable, and interactive alternative. However, the effect of home-based VR, specifically for upper extremity recovery in patients with stroke, remains insufficiently explored.

OBJECTIVE

This systematic review aims to synthesize existing evidence to evaluate the impact of home-based VR interventions on upper extremity function recovery in patients with stroke.

METHODS

This systematic review followed the guidelines of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). A comprehensive literature search was conducted across PubMed, Web of Science, Scopus, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) Ultimate databases, targeting English-language randomized controlled trials (RCTs) published up to June 30, 2024. Eligible studies involved patients with stroke with upper extremity dysfunction who received home-based VR interventions. Data extraction was performed by 2 independent reviewers, and study quality was assessed using the Physiotherapy Evidence Database scale. Due to heterogeneity in study designs and outcome measures, a narrative synthesis was performed instead of a meta-analysis.

RESULTS

A total of 8 RCTs with 392 participants were included. This review shows that home-based VR training positively affects upper extremity function recovery in patients with stroke, especially in motor control improvement. Customized VR systems were more effective than commercial VR systems in patients with moderate to severe disorders. Although studies generally showed positive results, differences in intervention protocols and small sample sizes limited the validity of results. The effect of VR therapy also varied based on the VR system type, intervention intensity, and the functional level of patients.

CONCLUSIONS

This systematic review shows that home-based VR training has a positive impact on upper extremity rehabilitation for patients with stroke, particularly in those with varying degrees of dysfunction. However, heterogeneity in study design and differences in outcome measures affect the reliability of the current conclusions. Future studies should include larger, standardized RCTs with long-term follow-up to assess their continued effects. Future research should explore how VR technology can be integrated into comprehensive rehabilitation programs, focusing on patient-centered approaches that incorporate sustainable, personalized technology, and support services to optimize recovery outcomes.

TRIAL REGISTRATION

PROSPERO CRD42024526650; https://tinyurl.com/5dny5bhp.

Real-world family planning and pregnancy practices in women with homozygous familial hypercholesterolemia

BACKGROUND AND AIMS

Homozygous familial hypercholesterolemia (HoFH) is characterized by extremely high plasma low-density lipoprotein cholesterol (LDL-C) levels and high premature atherosclerotic cardiovascular disease risk. During pregnancy LDL-C levels increase, while limited therapeutic options are available. This international study documented current approaches of healthcare professionals (HCPs) to family planning, pregnancy, and breastfeeding in HoFH.

METHODS

An online HCP survey was distributed among the HoFH International Clinical Collaborators (HICC, NCT04815005). Responses were analyzed according to HCPs' gender, medical specialty, country income status, and world region.

RESULTS

In total, 87 HCPs (39.1 % women) from 48 countries participated (64.4 % practicing in high-income countries). Most HCPs (79.3 %) always discuss family planning with patients with HoFH. Most (72.4 %) recommend contraception, with intrauterine devices (50.8 %) and oral contraceptives (49.2 %) being most commonly recommended. One in three HCPs would advise against pregnancy if ASCVD risks were deemed too high. Except for lipoprotein apheresis and colesevelam, most HCPs would recommend discontinuing LLT during the conception, pregnancy, and breastfeeding periods. However, approximately 30 % advise continuation or reinitiation of statins and/or ezetimibe during pregnancy and breastfeeding despite labelled restrictions on use during pregnancy and breastfeeding. Nearly half (48.3 %) of HCPs would recommend that women with HoFH shorten the breastfeeding period to resume LLT earlier, with HCPs from high-income countries significantly more likely to do so (51.8 % vs. 41.9 %; p = 0.008).

CONCLUSIONS

This study highlights significant variability in the management of HoFH in women of childbearing age, especially concerning LLT use during conception, pregnancy, and breastfeeding. The findings underscore the need for further research to establish global evidence-based guidelines tailored to individual needs, to improve cardiovascular risk management and reproductive health outcomes for women with HoFH worldwide.

Modifiable risk factors for stroke, dementia and late-life depression: a systematic review and DALY-weighted risk factors for a composite outcome

BACKGROUND

At least 60% of stroke, 40% of dementia and 35% of late-life depression (LLD) are attributable to modifiable risk factors, with great overlap due to shared pathophysiology. This study aims to systematically identify overlapping risk factors for these diseases and calculate their relative impact on a composite outcome.

METHODS

A systematic literature review was performed in PubMed, Embase and PsycInfo, between January 2000 and September 2023. We included meta-analyses reporting effect sizes of modifiable risk factors on the incidence of stroke, dementia and/or LLD. The most relevant meta-analyses were selected, and disability-adjusted life year (DALY) weighted beta (β)-coefficients were calculated for a composite outcome. The β-coefficients were normalised to assess relative impact.

RESULTS

Our search yielded 182 meta-analyses meeting the inclusion criteria, of which 59 were selected to calculate DALY-weighted risk factors for a composite outcome. Identified risk factors included alcohol (normalised β-coefficient highest category: -34), blood pressure (130), body mass index (70), fasting plasma glucose (94), total cholesterol (22), leisure time cognitive activity (-91), depressive symptoms (57), diet (51), hearing loss (60), kidney function (101), pain (42), physical activity (-56), purpose in life (-50), sleep (76), smoking (91), social engagement (53) and stress (55).

CONCLUSIONS

This study identified overlapping modifiable risk factors and calculated the relative impact of these factors on the risk of a composite outcome of stroke, dementia and LLD. These findings could guide preventative strategies and serve as an empirical foundation for future development of tools that can empower people to reduce their risk of these diseases.

PROSPERO REGISTRATION NUMBER

CRD42023476939.

The Impact of Folic Acid Deficiency on Ischemic Stroke: Role of Inflammation and Long Noncoding RNA H19

It has been validated that folic acid deficiency (FD) is associated with an increased risk of stroke and a worse prognosis. However, the specific mechanisms by which FD exerts its detrimental effects on ischemic stroke (IS) have not been fully understood. The results of this case-control study indicated that patients with IS had a decreased serum folate level, along with up-regulated long non-coding RNA H19 (lncRNA H19) and enhanced inflammatory responses. Meanwhile, it was corroborated that the serum folate level was negatively correlated with H19 expression and the systemic immune-inflammation index (SII). Similarly, FD was demonstrated to exacerbate neurological injury in the middle cerebral artery occlusion/reperfusion (MCAO/R) rats by up-regulating the expression of inflammatory cytokines and H19 in both peripheral blood and brain tissue. Notably, the alterations in the expression of these factors in peripheral blood were consistent with those observed in brain tissue. Additionally, in a co-culture of N2a neurons and BV2 microglia, FD promoted the transition of BV2 cells towards a pro-inflammatory state by up-regulating the expression of H19, which aggravated neuronal injury. Moreover, blocking H19 in BV2 cells mitigated inflammation and partially reversed the injury in N2a cells exacerbated by FD after the treatment with oxygen-glucose deprivation and reperfusion (OGD/R). These findings provide a more in-depth insight into the regulatory role of H19-mediated systemic inflammatory responses in the context of FD, suggesting the potential clinical utility of folic acid in managing ischemic brain injury.

Associations of Gla-rich protein and interleukin-1β with coronary artery calcification risk in patients with suspected coronary artery disease

Background

Gla-rich protein (GRP) and interleukin-1β (IL-1β) are recognized as reliable biomarkers for evaluating inflammation and are effective predictors of cardiovascular disease. However, the relationship between GRP, IL-1β, and coronary artery calcification (CAC) in patients with suspected coronary artery disease (CAD) remains unclear. Therefore, we investigated the association between these inflammatory biomarkers (GRP and IL-1β) and CAC in patients with suspected CAD.

Methods

This prospective study included patients with suspected CAD who underwent coronary computed tomography angiography (CTA). Fasting venous blood samples were collected at admission, and GRP and IL-1β levels were quantified using enzyme-linked immunosorbent assays (ELISA). The Agatston score was calculated to assess coronary artery calcification (CAC) based on coronary CTA findings.

Results

A total of 120 patients were included in this study. Multivariate logistic regression analysis revealed that GRP [odds ratio (OR), 1.202; 95% confidence interval (CI), 1.065-1.356; p = 0.003] and IL-1β (OR, 1.011; 95% CI, 1.002-1.020; p = 0.015) were independent risk factors for CAC severity. Receiver operating characteristic (ROC) curve analysis demonstrated that GRP had a predictive ability for CAC, with an area under the curve (AUC) of 0.830 [95% CI (0.755, 0.904)]. IL-1β exhibited an AUC of 0.753 [95% CI (0.660, 0.847)]. The combination of GRP and IL-1β in a predictive model improved the AUC to 0.835. Additionally, GRP and IL-1β levels showed a strong positive correlation (r = 0.6861, p < 0.05), and GRP was significantly associated with CAC severity (r = 0.5018, p < 0.05).

Conclusions

Elevated levels of GRP and IL-1β, as inflammatory biomarkers, were associated with CAC in patients with suspected CAD. These biomarkers may provide valuable insights into the pathophysiology of coronary artery calcification and contribute to improved risk stratification in this patient population.

Impact of coincident lower extremity deep vein thrombosis on symptomatic and incidental pulmonary embolism outcomes. A single-center prospective cohort study

BACKGROUND

The prognostic implications of co-incident DVT at the time of PE diagnosis remains unclear.

OBJECTIVES

Study aims were to assess the impact of co-incident lower extremity (LE) deep vein thrombosis (DVT) on clinical outcomes of pulmonary embolism (PE) including venous thromboembolism (VTE) recurrence and mortality.

METHODS

Consecutive patients with confirmed acute symptomatic or incidental PE (March 1, 2013 to June 30, 2021) who underwent ultrasound imaging were divided into two groups depending on the presence or absence of LE DVT. Patients were followed prospectively for VTE recurrence, bleeding, and all-cause mortality.

RESULTS

Over the study period, 1907 patients with PE were stratified into groups based on the presence (n = 920) or absence (n = 987) of LE DVT. Patients with co-incident LE DVT were older, heavier, and had a significantly greater frequency of trauma, confinement, thrombophilia, and VTE. Those without LE DVT had a higher prevalence of active cancer, metastatic disease, and active systemic therapy use. All-cause mortality rates (per 100 person-years) were significantly higher for patients without vs with co-incident LE DVT (42.4/100 person-years vs 29.6/100 person- years; P < .001) with no differences in VTE recurrence or bleeding outcomes. After stratification by cancer status, mortality in those without vs. with co-incident DVT only remained significant among noncancer patients (15.2/100 person-years vs 12.1/100 person-years, P = .046).

CONCLUSIONS

Among patients with acute PE, the absence of co-incident lower extremity DVT is associated with significantly higher mortality rates. Mortality rate differences were only observed for those without cancer. No differences in VTE recurrence or bleeding were observed.

Evaluation and Management of Arrhythmias in Ischemic Cardiomyopathy

Atrial and ventricular arrhythmias are highly comorbid with ischemic cardiomyopathy (ICM) and are associated with worsening symptoms, morbidity, and mortality. This review will discuss the pathophysiology, evaluation, and treatment of each arrhythmia in ICM with a focus on novel evaluation strategies and catheter-directed interventions. For atrial fibrillation /atrial flutter, recent studies have demonstrated mortality and symptom benefit with early rhythm control with catheter ablation. With respect to ventricular tachycardia, scar characterization is being investigated to change primary prevention and novel ablation technologies and strategies are being explored.

Engagement in Hypertension and Diabetes Clinical Trials at Federally Qualified Health Centers: A Systematic Review

Importance

Federally qualified community health centers (FQHCs) are potential partners in the quest to increase diversity in clinical trials. Despite this opportunity, there is limited knowledge about FQHC engagement in clinical trials.

Objective

To assess levels of FQHC engagement in hypertension and type 2 diabetes (T2D) clinical trials and identify FQHC characteristics associated with engagement in the US.

Evidence Review

Six literature databases were searched for protocols and reports of clinical trials addressing hypertension or T2D among adults at FQHCs in the US, published between January 1, 2013, and November 6, 2023. Guided by a framework on community-engaged research, 4 levels of FQHC engagement in clinical trials were defined, ranging from level 1 (FQHC informed) to level 4 (FQHC driven). An ordinal regression analysis was conducted to investigate the association between FQHC organizational and patient demographic characteristics and levels of engagement in hypertension and T2D clinical trials using the publicly available data from Uniform Data System (UDS) for all identifiable FQHCs.

Findings

The initial literature search identified 4552 articles. Following deduplication, title and abstract screening, full-text review, data extraction, and matching with available information in UDS, a total of 33 clinical trials were included. Together, these clinical trials engaged 67 FQHCs. In most cases, FQHC engagement occurred at level 1 (15 clinical trials engaging 19 FQHCs) or level 2 (8 clinical trials engaging 38 FQHCs). A higher ratio of full-time equivalent physicians to patients was associated with 54% (odds ratio [OR], 1.54; 95% CI, 1.06-2.23) higher odds of having a higher level of FQHC engagement in hypertension and T2D clinical trials. A higher ratio of full-time community and patient education specialists to patients was associated with 41% (OR, 1.41; 95% CI, 1.03-1.94) higher odds of having a higher level of FQHC engagement in hypertension and T2D clinical trials.

Conclusions and Relevance

In this systematic review of FQHC engagement in clinical trials, lower levels of engagement in hypertension and T2D clinical trials were found. Further research is required to identify clinical trial design and implementation strategies that promote FQHC participation in clinical trials and research capacity building.

Lack of Racial Disparities in Cangrelor Therapy in Patients Presenting With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

BACKGROUND

Cangrelor is an intravenous P2Y12 receptor antagonist that exerts rapid and potent antiplatelet effects. It is associated with a reduction in the indcidence of ischemic events in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI).

AIMS

The aim of our study was to investigate the racial disparities and their impact on outcomes among patients with ACS who were treated with cangrelor during PCI.

METHODS

We reviewed the data of patients with ACS who were treated with cangrelor during PCI at our center from 2018 to 2023 and divided between African American (AA) and Caucasian patients. The primary safety outcome was in-hospital thrombolysis in myocardial infarction (TIMI) major bleeding. The primary efficacy outcome was in-hospital major adverse cardiac events (MACE), defined as a composite of cardiac death, MI, or stroke. Multivariate regression analysis was performed to assess the primary outcomes after controlling for differences in baseline characteristics.

RESULTS

The study included 1181 patients who received cangrelor during PCI for ACS, including 616 AA and 565 Caucasian patients. AA patients were significantly younger (61 ± 13 vs. 64 ± 12 years; p < 0.001) and had higher rates of hypertension, diabetes mellitus, and end-stage renal disease requiring dialysis. There were no significant differences between AA and Caucasian patients regarding in-hospital TIMI major bleeding (odds ratio [OR]: 0.55; 95% confidence interval [CI]: 0.16-1.88; p = 0.343) and in-hospital MACE (OR: 1.82; 95% CI: 0.71-4.69; p = 0.212) after controlling for relevant baseline differences.

CONCLUSION

No racial disparities were observed with regard to the administration of cangrelor during PCI in patients presenting with ACS, and cangrelor was not associated with increased bleeding for AA patients as compared to Caucasian patients.

Evaluating the appropriateness and the factors associated with sodium-glucose co-transporter 2 inhibitors prescribing in a Middle Eastern country: a cross-sectional study

BACKGROUND

Sodium glucose co-transporter 2 inhibitors (SGLT2is) are a novel class of oral antidiabetic drugs (ADDs). Studies evaluating the appropriateness of SGLT2is prescribing, and the factors associated with their initiation in the Middle East region are lacking.

AIM

This study aimed to evaluate the appropriateness of prescribing SGLT2is based on indication, dosing, and contraindication and determine the factors associated with their initial prescribing.

METHOD

In this cross-sectional study, a cohort of 650 patients newly prescribed SGLT2is (n = 400) and/or any other oral ADDs (n = 250) during 2020 were included. Data were extracted from an electronic medical record system. Multivariate logistic regression was conducted to investigate factors associated with prescribing SGLT2is.

RESULTS

SGLT2is were prescribed for appropriate indication in 400 patients (100%), while inappropriately prescribed in relation to contraindication and dosing in 14 patients (3.5%). Male patients were more likely to be prescribed SGLT2is (odds ratio [OR], 1.69; 95% confidence interval [CI], 1.02-2.82). Patients with a baseline glycated hemoglobin (HbA1c) above 7% and atherosclerotic cardiovascular disease (ASCVD) were more likely to be prescribed SGLT2is (OR, 3.22; 95% CI, 1.84-5.64) and (OR, 2.18; 95% CI, 1.05-4.52), respectively. Patients receiving metformin (OR, 7.56; 95% CI, 4.46-12.80), sulfonylureas (OR, 2.30; 95% CI, 1.16-4.56), and dipeptidyl peptidase 4 inhibitors (OR, 3.43; 95% CI, 2.00-5.87) were more likely to be prescribed SGLT2is.

CONCLUSION

SGLT2is were found to be typically prescribed for the appropriate indication. Among the most important factors associated with prescribing SGLT2is are having uncontrolled HbA1c, history of ASCVD, and using other ADDs.

Future of factor XI inhibitors in cardiovascular practice

Anticoagulation is indicated for treatment and prevention of arterial and venous thrombosis. Targeting different steps of the coagulation process, currently available anticoagulants entail an increased risk of bleeding, which detrimentally impacts on prognosis and hinders the administration of an effective antithrombotic regimen. Factor XI (FXI) inhibition has emerged as a strategy to uncouple prevention of thrombosis from bleeding. Indeed, while FXI is crucial for the amplification phase in pathological thrombosis, it is ancillary in physiological hemostasis. A comprehensive search in several scientific databases has been performed to identify relevant studies in the field. In addition, ongoing trials have been searched for in proper datasets to provide an updated and comprehensive assessment of the current state of investigations on FXI inhibition. Many compounds have been tested to inhibit FXI at different stages (i.e., synthesis, activation, or interactions with target molecules and coagulation factors). These include antisense oligonucleotides, monoclonal antibodies, small molecules, natural peptides and aptamers. In phase 2 studies, FXI inhibitors reduced thrombotic complications without any corresponding increase in bleeding. FXI inhibitors were noninferior and potentially superior to low-molecular-weight heparin in orthopedic surgery and reduced bleeding compared to apixaban in patients with atrial fibrillation. FXI inhibition is also under testing in other conditions, including end-stage renal disease, cancer, or noncardioembolic stroke. FXI inhibition represents a promising and rapidly emerging approach for a number of clinical indications. This article reviews the rationale, evidence, pharmacology, and future applications of FXI inhibition.

Association between cardiometabolic index and myocardial Infarction: based on NHANES database

BACKGROUND

The cardiometabolic index (CMI) combines abdominal obesity and abnormal blood lipid indices, representing a good predictive indicator of risk in cardiovascular diseases (CVDs). However, the association between CMI and myocardial infarction (MI) is not clear.

OBJECTIVE

The present project was designed to explore the linkage between CMI and MI.

METHODS

Data from the National Health and Nutrition Examination Survey (NHANES) 2005-2018 were employed in this project, with CMI as the independent variable and MI as the dependent variable. Weighted logistic regression was applied in the association analysis between CMI and MI. Restricted cubic spline (RCS), subgroup analysis, and interaction tests were employed to elucidate the non-linear relationship and stability of CMI and MI's link. Moreover, to verify the robustness of the results, sensitivity analysis was conducted, with the MI status of subjects taking lipid-lowering drugs as the outcome variable.

RESULTS

A total of 13,923 participants were gathered in this project, with 605 cases of MI, accounting for 3.5%. In the weighted logistic regression model, a positive linkage was observed between CMI and the risk of MI (OR: 1.41, 95% CI: 1.18-1.68, p < 0.001). The RCS curves indicated a linear relationship between CMI and MI (P-non-linear = 0.146). Subgroup analysis manifested that CMI was positively linked with MI risk in males, individuals with BMI > 30kg/m2, and alcohol drinkers (p < 0.05). In addition, the interaction results demonstrated that there was no heterogeneity in the association between CMI and MI risk in the subgroups (p > 0.05). The sensitivity analysis showed that after adjusting for all confounding factors in the model, there was still a significant positive correlation (p < 0.01) between CMI and MI in the population taking lipid-lowering drugs.

CONCLUSION

There is a significant positive linkage of CMI with MI risk, which is particularly significant in males, those with a BMI greater than 30 kg/m2, and those who have drinking habits. Even after considering the impact of lipid-lowering drug therapy, the positive correlation between CMI and MI remains robust, supporting CMI as a promising tool for assessing MI risk and guiding clinical prevention. Further research is required to probe into the application of CMI in different populations and its role in the prevention of CVDs.

Abnormal blood biomarkers and trajectories of depressive symptoms among Chinese middle-aged and older adults

OBJECTIVE

Although previous studies have demonstrated allostatic load (AL) predicts depressive symptoms, few studies have considered the association between AL and trajectories of depressive symptoms. This study aims to systematically examine the associations of abnormal blood biomarkers in the three biological systems with trajectories of depressive symptoms.

METHODS

A total of 6251 participants aged 45+ from the China Health and Retirement Longitudinal Study (CHARLS). Depressive symptoms were assessed using the 10-item Center for Epidemiological Studies Depression Scale (CESD-10) in five visits (waves 2011, 2013, 2015, 2018, and 2020). Biomarkers in three biological systems were evaluated based on standard criteria, including C-reactive protein in the inflammation system; systolic and diastolic blood pressures in the cardiovascular system; and high-density lipoprotein cholesterol (HDLC), total cholesterol/HDL-C ratio, and glycosylated hemoglobin (HbA1c) in the metabolic system. The trajectories of depressive symptoms were measured using group-based trajectory modelling (GBTM). Multinomial logistic regression models were conducted to examine the association between the number of abnormal biological systems and trajectories of depressive symptoms.

RESULTS

Four different trajectories of depressive symptoms were identified: mild (44.22 %), moderate (42.09 %), increasing (9.39 %), and severe (4.30 %). Compared to participants with normal values of biomarkers in all three systems, those with abnormal values of biomarkers in three systems had a 2.26-fold risk of developing the severe depressive symptoms trajectory.

CONCLUSIONS

Our findings highlight the importance of monitoring multiple biological systems to prevent long-term accelerated severe depressive symptoms trajectory.

Periendoscopic management of antithrombotic drugs: Is cold snare polypectomy the answer?

Patients undergoing colonoscopy are increasingly taking antithrombotic medication. These patients, who are generally older, also have a higher prevalence of colon polyps. Therefore, it is general practice to modify or discontinue antithrombotic treatment before colonoscopy, to reduce the risk of post-polypectomy bleeding (PPB). However, this modification increases the risk of thrombotic events. Currently, the main clinical guidelines recommend cold-snare resection for polyps smaller than 10mm because of its better safety profile, especially in reducing post-polypectomy bleeding. This reduced PPB rate could open the door to maintaining antithrombotic drugs in patients undergoing colonoscopy. This review aims to evaluate the evidence available so far that may support a modification of current guidelines on the management of antithrombotic drugs in the periendoscopic period.

Exosomes and exosomal miRNAs mediate the beneficial effects of exercise in ischemic stroke

Ischemic stroke is an acute cerebrovascular disease that is one of the leading causes of death and neurological disorders worldwide. Exosomes are a novel class of intercellular signaling regulators containing cell-specific proteins, lipids, and nucleic acids that transmit messages between cells and tissues. MicroRNAs are regulatory non-coding ribonucleic acids that are usually present in exosomes as signaling molecules. Studies have shown that exosomes and exosomal microRNAs can improve the prognosis of ischemic stroke by inhibiting the inflammatory response, reducing apoptosis, improving the imbalance of oxidative and antioxidant systems, and regulating cellular autophagy, among other processes. Previous studies have shown that exercise training can exert neuroprotective effects on ischemic stroke by promoting the release of exosomes and regulating the expression of exosomal microRNAs, which in turn regulate multiple signaling pathways. Exosomes and exosomal microRNAs may be key targets for exercise to promote cerebrovascular health. Therefore, the study of exercise-mediated exosomes and their microRNAs may provide new perspectives for exploring the mechanism of exercise intervention in the prevention and treatment of ischemic stroke.

Bifurcation Percutaneous Coronary Intervention in Patients Aged ≥80 Years: Insights from the Prospective Global Registry for the Study of Bifurcation Lesion Interventions Registry

The outcomes of bifurcation percutaneous coronary intervention (PCI) in patients aged ≥80 and ≥90 years have received limited study. We compared the procedural characteristics and outcomes of bifurcation PCIs in patients aged ≥80 years and those aged <80 years in a multicenter registry. Of 1,253 patients who underwent 1,262 bifurcation PCIs between 2014 and 2024 at 6 centers, 194 (15%) were aged ≥80 and ≥90 years. These patients were more likely to have atrial fibrillation (30 vs 12%, p <0.001) and heart failure (39 vs 19%, p <0.001) than were younger patients. They were more likely to have bifurcation lesions with greater angiographic complexity, including severe calcification (38% vs 14%, p <0.001) and left main coronary artery (30% vs 0%, p <0.001) and left anterior descending artery (80% vs 70%, p <0.001) stenoses. Patients aged ≥80 years had lower procedural success (87% vs 92%, p = 0.026) and greater incidence of in-hospital major adverse cardiovascular events (MACE, 8.3% vs 3.4%, p = 0.002) and death (3.1% vs 1%, p = 0.035). During a median follow-up of 903 days, patients aged ≥80 years had greater follow-up MACE (47.3% vs 28.1%, p <0.001), mortality (38.4% vs 10.9%, p <0.001), and stroke (6.8% vs 2.9%, p = 0.018) than did younger patients. In multivariable analysis, follow-up MACE was independently associated with age ≥80 years (hazard ratio 1.46, 95% confidence intervals 1.05 to 2.04, p = 0.026). In conclusion, success rates were lower than those in younger patients and the risk of complications greater in patients aged ≥80 years who underwent bifurcation PCI.

Utilizing 12-lead electrocardiogram and machine learning to retrospectively estimate and prospectively predict atrial fibrillation and stroke risk

BACKGROUND

The stroke risk in patients with subclinical atrial fibrillation (AF) is underestimated. By identifying patients at high risk of embolic stroke, health-care professionals can make more informed decisions regarding anticoagulation treatment to prevent stroke. The main aim of this study was to forecast the risk of AF both retrospectively and prospectively.

METHODS

The research used a dataset of patients who had received a standard 12-lead electrocardiogram (ECG) at the seven branches of Chang Gung Memorial Hospital between October 2007 and December 2019. Using convolutional neural network (CNN) ECG models, the study classified the risk of AF development both retrospectively and prospectively in 1,776,968 patients by analyzing their 12-lead ECG. The study also examined the risk of stroke, hospitalization for heart failure (HF), myocardial infarction (MI), and death among patients with predicted AF versus that of those with normal sinus rhythm.

RESULTS

The CNN models could be used to accurately diagnose AF, assess the risk of past AF episodes, and predict the risk of future AF episodes with high accuracy, as shown by areas under the receiver operating characteristic curve of 0.99, 0.86, and 0.85, respectively. Patients who were estimated to have had past AF or predicted to have future AF were at a higher risk of developing stroke, HF hospitalization, MI, and mortality. The ECGs of patients with predicted AF tended to exhibit lower R-wave amplitudes and flattened T waves. Additionally, we observed that the QRS complexes in leads V1, aVL, and aVR were highly weighted in predicting AF in the CNN models.

CONCLUSIONS

The CNN models were effective for estimating the past and future risk of AF by analyzing 12-lead ECG. Patients with predicted AF had a higher risk of developing stroke, hospitalization for HF, MI, and death. By using this AF prediction model, physicians may be able to identify patients who should be screened for AF and taking action to prevent stroke and manage cardiovascular risk.

Cardiometabolic risk factors in women: what's sauce for the goose is not sauce for the gander

PURPOSE OF REVIEW

The aim of this review was to discuss cardiometabolic risk factors that affect women.

RECENT FINDINGS

Recent calls to action to address cardiometabolic risk factors specific to women relate to increasing evidence of sex-specific differences in patient-related, drug-related, and socio-demographic factors leading to sub-optimal care of women.

SUMMARY

Certain aspects of common modifiable cardiovascular risk factors (e.g. smoking, hypertension, dyslipidaemia and diabetes) affect female individuals more adversely. Additionally, there are risk factors or enhancers that particularly affect cardiometabolic health in women [e.g. premature menopause, polycystic ovarian syndrome (PCOS), familial partial lipodystrophy, socio-cultural factors]. Understanding these risk factors may provide insight on how to improve cardiometabolic outcomes in women.

Shared Decision-Making for Patients with Stroke in Neurocritical Care: A Qualitative Meta-Synthesis

Decision-making for patients with stroke in neurocritical care is uniquely challenging because of the gravity and high preference sensitivity of these decisions. Shared decision-making (SDM) is recommended to align decisions with patient values. However, limited evidence exists on the experiences and perceptions of key stakeholders involved in SDM for neurocritical patients with stroke. This review aims to address this gap by providing a comprehensive analysis of the experiences and perspectives of those involved in SDM for neurocritical stroke care to inform best practices in this context. A qualitative meta-synthesis was conducted following the methodological guidelines of the Joanna Briggs Institute (JBI), using the thematic synthesis approach outlined by Thomas and Harden. Database searches covered PubMed, CIHAHL, EMBASE, PsycINFO, and Web of Science from inception to July 2023, supplemented by manual searches. After screening, quality appraisal was performed using the JBI Appraisal Checklist. Data analysis comprised line-by-line coding, development of descriptive themes, and creation of analytical themes using NVivo 12 software. The initial search yielded 7,492 articles, with 94 undergoing full-text screening. Eighteen articles from five countries, published between 2010 and 2023, were included in the meta-synthesis. These studies focused on the SDM process, covering life-sustaining treatments (LSTs), palliative care, and end-of-life care, with LST decisions being most common. Four analytical themes, encompassing ten descriptive themes, emerged: prognostic uncertainty, multifaceted balancing act, tripartite role dynamics and information exchange, and influences of sociocultural context. These themes form the basis for a conceptual model offering deeper insights into the essential elements, relationships, and behaviors that characterize SDM in neurocritical care. This meta-synthesis of 18 primary studies offers a higher-order interpretation and an emerging conceptual understanding of SDM in neurocritical care, with implications for practice and further research. The complex role dynamics among SDM stakeholders require careful consideration, highlighting the need for stroke-specific communication strategies. Expanding the evidence base across diverse sociocultural settings is critical to enhance the understanding of SDM in neurocritical patients with stroke.Trial registration This study is registered with PROSPERO under the registration number CRD42023461608.

The role of long non-coding RNAs in cardiovascular diseases: A comprehensive review

Cardiovascular diseases (CVDs) are the leading cause of morbidity and mortality worldwide, posing significant challenges to healthcare systems. Despite advances in medical interventions, the molecular mechanisms underlying CVDs are not yet fully understood. For decades, protein-coding genes have been the focus of CVD research. However, recent advances in genomics have highlighted the importance of long non-coding RNAs (lncRNAs) in cardiovascular health and disease. Changes in lncRNA expression specific to tissues may result from various internal or external factors, leading to tissue damage, organ dysfunction, and disease. In this review, we provide a comprehensive discussion of the regulatory mechanisms underlying lncRNAs and their roles in the pathogenesis and progression of CVDs, such as coronary heart disease, atherosclerosis, heart failure, arrhythmias, cardiomyopathies, and diabetic cardiomyopathy, to explore their potential as therapeutic targets and diagnostic biomarkers.

Practice-Pattern Variation in Neurocritical Care Blood Pressure Control Reveals Opportunities for Improved Long-Term Hypertension Control

Background and Objectives

Uncontrolled hypertension is a risk factor of heart attack, stroke, dementia, and other conditions. In outpatients with hypertension, blood pressure (BP) may be controlled at only 30%-50% of visits depending on the population studied. Hospital admission is ideal for achieving guideline-directed BP targets, given the resource-intensive environment. We evaluated the relationship between BP control performance during neurocritical care and hospital admission and rates of uncontrolled hypertension at discharge and over the subsequent 2 years.

Methods

This two-center retrospective cohort included adults admitted with any neurologic illness to an neurosciences intensive care unit (NeuroICU) from April 2016 to December 2022, transferred to a neurology general care unit, and then discharged to home or rehabilitation. Hypertension was defined as systolic BP (SBP) ≥140 mm Hg or diastolic BP (DBP) ≥90 mm Hg. The primary outcomes were rates of hypertension at hospital discharge through 2 years after discharge. Multivariable logistic and generalized additive models were developed to assess the association between NeuroICU BP control and persistent hypertension, adjusting for baseline covariates, NeuroICU length of stay, performance measures quantifying BP goals, and antihypertensive medication intensity on transferring from the NeuroICU.

Results

Of 13,711 admissions, 10,836 met inclusion criteria and 3,075 (28.3%) were hypertensive at hospital discharge. Each 10-mm Hg SBP increase at NeuroICU transfer was associated with 1.60-fold increased odds of uncontrolled hypertension at discharge (95% CI 1.56-1.64). In multivariate analysis controlling for covariates, hypertension at transfer remained independently associated with hypertension at discharge (adjusted odds ratio 3.85, 95% CI 3.47-4.28). The association persisted through 24 months after discharge, even among those without a history of hypertension, among those admitted to the hospital normotensive, or when adjusting for antihypertensive therapy intensity. The association persisted across a range of principal diagnoses and across institutions, although practice-pattern variation yielded significant differences between institutions.

Discussion

Hypertension at NeuroICU transfer was independently associated with uncontrolled hypertension through hospital discharge and the subsequent 2 years, independent of patient diagnosis, medical history, institution, and treatment intensity. The initial hospitalization represents an opportunity to achieve and maintain guideline-directed BP targets to reduce secondary cerebrovascular events, dementia, and cardiovascular complications. Further studies are needed to determine whether improving rates of BP control at NeuroICU transfer and discharge leads to long-term improvements in BP control.

Impact of a Clinical Decision Support System on CT Pulmonary Angiography Yield and Utilization in Hospitalized Patients

PURPOSE

The aims of this study were to determine whether point-of-order clinical decision support (CDS) based on the Wells criteria improves CT pulmonary angiography (CTPA) yield and utilization in hospitalized patients in an enterprise-wide health system and to identify yield-related factors.

METHODS

This retrospective, institutional review board-approved, cross-sectional study in an urban, multi-institution health system included hospitalized patients undergoing CTPA 12 months before and after CDS implementation (entire cohort). The χ2 test was used to compare pulmonary embolism (PE) yield in patients in whom providers overrode versus followed CDS alerts after CDS implementation. It was also used to compare utilization and yield before- versus after the intervention. Univariate and multivariable regression analyses were performed on patient factors and post-CDS Wells scores to evaluate yield-related factors.

RESULTS

For 2,429 inpatient CT pulmonary angiographic examinations after the intervention, CTPA yield was significantly higher when CDS recommendations were followed (18.3% [250 of 1,365]) compared with those overridden (14.2% [151 of 1,064]) (P < .01). For 5,372 CT pulmonary angiographic examinations in the entire cohort, there was no difference in PE yield before (448 of 2,943 [15.2%]) versus after (401 of 2,429 [16.5%]) CDS implementation (P = .20). However, in 340,146 admissions over the study period, a 7.4% relative decrease in CTPA utilization (from 17.5 to 16.2 CT pulmonary angiographic examinations per 1,000 admissions before and after CDS, respectively, P = .003) was observed.

CONCLUSIONS

When CDS recommendations were followed, the yield of CTPA was significantly higher than when clinicians overrode CDS alerts. In addition, point-of-order CDS to reduce unnecessary CTPA in hospitalized patients resulted in a significant decrease in CTPA utilization after CDS implementation, with a modest although nonsignificant increase in CTPA yield.

Hypertensive heart disease in older patients: considerations for clinical practice

Appropriate management of older people with hypertension is essential to reduce the burden of hypertensive heart disease and further cardiovascular sequelae but there may be challenges given the presence of concurrent senescent changes, comorbidities and impairment in functionality. It is recommended that frailty level and functional status are assessed periodically to understand patient needs and to guide treatment decisions. Office blood pressure should be measured with an appropriate cuff as per standard guidelines. There should be a high index of suspicion for orthostatic hypotension and white coat/masked hypertension, both common in older individuals. Cardiac imaging often identifies age-related changes that may not result from hypertension alone, including smaller ventricular volumes, a sigmoid septum and non-ischaemic fibrosis. Diastolic dysfunction is common and other pathologies, including cardiac amyloidosis, may need to be considered in the presence of red flags. Screening for atrial fibrillation during blood pressure evaluation is advised. Decisions for blood pressure management should follow current recommendations and take into consideration the patient's age and tolerance. There is limited evidence regarding heart failure management in older patients, however, disease-modifying therapy as per guidelines should be pursued. Sufficient outcome data are lacking for this patient group and a multidisciplinary approach is often needed to design optimal therapy.

Coronary artery event-free or resilient familial hypercholesterolemia: what's in a name?

PURPOSE OF REVIEW

Familial hypercholesterolemia (FH) is an autosomal semi-dominant condition, characterized by excessive circulating low-density lipoprotein cholesterol (LDL-C) from birth that substantially accelerates the onset and progression of atherosclerotic cardiovascular disease (ASCVD), classically coronary artery disease (CAD). Elevated plasma LDL-C integrated over time is unequivocally the major determinant of ASCVD in heterozygous FH (HeFH); however, the wide variation in incidence and progression of ASCVD suggests a role for a wide spectrum of risk modifiers. We reviewed recent evidence describing the features of an ASCVD-free entity referred to as resilient FH among patients with HeFH.

RECENT FINDINGS

Compared with nonresilient FH patients, resilient patients are more likely to be female, and have a lower prevalence of ASCVD comorbidities, higher levels of HDL-C and larger HDL particles, as well as a lower level of lipoprotein(a). A lower SAFEHEART risk score is also an independent predictor of resilient FH. Gene expression studies also demonstrate that resilient FH patients are associated with a less atherogenic gene expression profile in relation to HDL metabolism and immune responses, as reflected by higher expression of ABCA1 and ABCG1, and lower expression of STAT2 and STAT3, respectively.

SUMMARY

A group of HeFH patients, referred as resilient FH, can survive to advance ages without experiencing any ASCVD events. Several key contributors to the event-fee CAD in HeFH patients have been identified. This could not only improve risk stratification and management for FH but also be of major importance for the general population in primary and secondary prevention. However, resilient FH remains an under-investigated area and requires further research.

Reassessing the need for primary prevention implantable cardioverter-defibrillators in contemporary patients with heart failure

The main function of the implantable cardioverter-defibrillator (ICD) is to protect against sudden cardiac death (SCD) due to ventricular tachyarrhythmia (VTA). Current guidelines provide a recommendation to implant a prophylactic ICD for the primary prevention of SCD in individuals having heart failure with reduced ejection fraction (HFrEF) who never experienced a previous sustained VTA. However, these recommendations are based on clinical trials conducted more than 20 years ago and may not be applicable to contemporary patients with HFrEF who have a lower arrhythmic risk as a result of advances in heart failure medical therapies. Thus, there is an unmet need for more appropriate selection of contemporary patients with HFrEF for a primary prevention ICD. In this article, we review data underlying the current clinical equipoise on the need for routine implantation of a primary prevention ICD in patients with HFrEF and the rationale for conducting clinical trials that aim to reassess the role of the ICD in this population.

Bridging hemodynamics, tissue mechanics, and pathophysiology in coronary artery disease: A new agent-based model with tetrahedral mesh integration

We introduce a new multi-physics, multi-scale modeling approach to understand plaque progression during coronary artery disease. Prior works have coupled agent-based models (ABMs) with finite element analysis (FEA) or computational fluid dynamics (CFD) to study the individual contributions of tissue mechanics or hemodynamics to plaque growth. However, these approaches could not simultaneously capture the dynamic interplay between all three domains that drive plaque development. This study aims to present a novel method that merges hemodynamics via CFD, biological processes via ABM, and biomechanics via FEA into a single multi-scale, multi-physics simulation (CAFe). A description of the mechanisms and modeling approaches utilized in the CAFe model is provided, as well as preliminary exploration of the model's capabilities in idealized healthy and stenosed coronary artery models. A volumetric 3D tetrahedral mesh of the artery is shared between CFD, ABM, and FEA to simulate geometrical and biological changes with continuity and consistency. The CFD and FEA modules, implemented with FEBio, calculate the wall shear stress and structural stress and strain, respectively. These biomechanical values are passed to the ABM, implemented in MATLAB, which simulates vascular remodeling using molecular diffusion, cell migration, equations for cellular processes, and volumetric growth to update the geometry. Initial results using CAFe suggest atherosclerotic arteries seek to maintain a hemodynamic threshold through preferential growth and remodeling downstream of a stenosis. The innovative approach described herein marks a significant step forward in predictive modeling of CAD progression and paves the way for powerful coupling of the spatiotemporal-dependent remodeling paradigms exhibited by the disease.

Moderating effect of green space on relationship between atmospheric particulate matter and cardiovascular and cerebrovascular disease mortality in Ningxia, China

OBJECTIVE

This study explores the moderating effect of green space on the association between atmospheric particulate matter (PM) and cardiovascular and cerebrovascular disease (CCVD) mortality.

METHODS

Data on CCVD mortality, PM, meteorological factors, and the Normalized Difference Vegetation Index (NDVI) of green spaces in Ningxia from 2010 to 2020 were collected. A time-series generalized additive mixed-effect model (GAMM) was applied to analyze the exposure-response relationship between PM and CCVD mortality. The moderating effect of green spaces was examined using green space buffers of different radii (300 m, 500 m, 1000 m, and 2000 m) and density.

RESULTS

There were 150,356 CCVD deaths in Ningxia during the study period. The annual mean concentrations of PM2.5 and PM10 were 44.44 μg/m³ and 105.30 μg/m³, respectively, with an annual mean NDVI value of 0.25 within a 500 m radius buffer. An increase of 10 μg/m³ in PM2.5 and PM10 concentrations was significantly associated with an elevated risk of CCVD mortality, with the strongest excess risk (ER) observed at lag07 lag. The ER for PM2.5 was 1.43% (95% CI: 0.97%, 1.89%), and for PM10 was 0.55% (95% CI: 0.38%, 0.72%). The interaction analysis indicated that higher green space density could moderate the association between PM exposure and CCVD mortality risk. and as the green space buffer zone expanded, the interaction on CCVD mortality risk progressively strengthened. The independent moderation analysis indicated that an increase in green space buffer zone was associated with a reduced risk, and as green space density increased from Q1 to Q3, the ER for PM2.5-related CCVD mortality decreased from 1.56% to 0.6%, while the ER for PM10-related CCVD mortality decreased from 0.53% to 0.09%. In conclusion, atmospheric PM is associated with increased CCVD mortality risk, while larger green space buffers and higher green space density significantly moderated this association.

Topology-oriented foreground focusing network for semi-supervised coronary artery segmentation

Automatic coronary artery (CA) segmentation on coronary-computed tomography angiography (CCTA) images is critical for coronary-related disease diagnosis and pre-operative planning. However, such segmentation remains a challenging task due to the difficulty in maintaining the topological consistency of CA, interference from irrelevant tubular structures, and insufficient labeled data. In this study, we propose a novel semi-supervised topology-oriented foreground focusing network (TOFF-Net) to comprehensively address such challenges. Specifically, we first propose an explicit vascular connectivity preservation (VCP) loss to capture the topological information and effectively strengthen vascular connectivity. Then, we propose an irrelevant vessels removal (IVR) module, which aims to integrate local CA details and global CA distribution, thereby eliminating interference of irrelevant vessels. Moreover, we propose a foreground label migration and focusing (FLMF) module with Pioneer-Imitator learning as a semi-supervised strategy to exploit the unlabeled data. The FLMF can effectively guide the attention of TOFF-Net to the foreground. Extensive results on our in-house dataset and two public datasets demonstrate that our TOFF-Net achieves state-of-the-art CA segmentation performance with high topological consistency and few false-positive irrelevant tubular structures. The results also reveal that our TOFF-Net presents considerable potential for parsing other types of vessels.

Hyperactive mTORC1/4EBP1 signaling dysregulates proteostasis and accelerates cardiac aging

The mechanistic target of rapamycin complex 1 (mTORC1) has a major impact on aging by regulation of proteostasis. It is well established that mTORC1 signaling is hyperactivated with aging and age-related diseases. Previous studies have shown that partial inhibition of mTOR signaling by rapamycin reverses age-related deteriorations in cardiac function and structure in old mice. However, the downstream signaling pathways involved in this protection against cardiac aging have not been established. mTORC1 phosphorylates 4E-binding protein 1 (4EBP1) to promote the initiation of cap-dependent translation. The objective of this project is to examine the role of the mTORC1/4EBP1 axis in age-related cardiac dysfunction. We used a whole-body 4EBP1 KO mouse model, which mimics a hyperactive mTORC1/4EBP1/eIF4E axis, to investigate the effects of hyperactive mTORC1/4EBP1 axis in cardiac aging. Echocardiographic measurements of middle-aged 4EBP1 KO mice show impaired diastolic function and myocardial performance compared to age-matched WT mice and these parameters are at similar levels as old WT mice, suggesting that 4EBP1 KO mice experience accelerated cardiac aging. Old 4EBP1 KO mice show further decline in systolic and diastolic function compared to middle-aged counterparts and have worse systolic and diastolic function than age-matched WT mice. Gene expression levels of heart failure markers are not different between 4EBP1 KO and WT hearts. However, ribosomal biogenesis and protein ubiquitination are significantly increased in 4EBP1 KO hearts when compared to WT controls, suggesting dysregulated proteostasis in 4EBP1 KO hearts. Together, these results show that a hyperactive mTORC1/4EBP1 axis accelerates cardiac aging, potentially by dysregulating proteostasis.

Evaluating Percutaneous Coronary Intervention Safety, Quality, and Appropriateness Across Michigan Using Blinded Cross-Institutional Peer Review

BACKGROUND

Several quality improvement initiatives have focused on the quality gap in percutaneous coronary intervention (PCI), yet significant variations in quality persist. Our objective was to use a novel blinded peer review system to evaluate PCI quality, safety, and appropriateness across Michigan.

METHODS

Single-vessel PCI cases were randomly selected from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium registry across Michigan (2018-2020), and anonymized angiograms and pertinent case records were uploaded to a secure server. Cases were reviewed by blinded interventional cardiologists internal and external to the institution, using a standardized peer review form and rated on procedural quality, safety, and appropriateness. We compared appropriateness ratings between reviewers and registry-based appropriateness criteria.

RESULTS

We conducted 1627 independent peer reviews of 961 cases; 23.7% of cases were for non-ST-segment-elevation myocardial infarction, and 36.4% were for ST-segment-elevation myocardial infarction. The majority (96.4%) of reviewers rated angiogram quality as excellent or adequate. Reviewers noted a complication or suboptimal result in 11.1% of reviews; 44.0% of these were deemed avoidable. Most PCI procedures were considered appropriate or may be appropriate, (87.1%) by all those reviewing. Reviewers were less likely to categorize PCI cases as appropriate compared with registry-based appropriate use criteria definitions (73.1% versus 93.3%). The percentage of cases rated as both appropriate/may be appropriate and technically competent ranged from 76.7% to 100% across sites.

CONCLUSIONS

While the overall quality and appropriateness of PCI in Michigan are high, key opportunities to improve care were identified. Additional studies are needed to assess the utility of expanding this approach across the United States.

Gut-derived macrophages link intestinal damage to brain injury after cardiac arrest through TREM1 signaling

Brain injury is the leading cause of death and disability in survivors of cardiac arrest, where neuroinflammation triggered by infiltrating macrophages plays a pivotal role. Here, we seek to elucidate the origin of macrophages infiltrating the brain and their mechanism of action after cardiac arrest/cardiopulmonary resuscitation (CA/CPR). Wild-type or photoconvertible Cd68-Cre:R26-LSL-KikGR mice were subjected to 10-min CA/CPR, and the migration of gut-derived macrophages into brain was assessed. Transcriptome sequencing was performed to identify the key proinflammatory signal of macrophages infiltrating the brain, triggering receptor expressed on myeloid cells 1 (TREM1). Upon drug intervention, the effects of TREM1 on post-CA/CPR brain injury were further evaluated. 16S rRNA sequencing was used to detect gut dysbiosis after CA/CPR. Through photoconversion experiments, we found that small intestine-derived macrophages infiltrated the brain and played a crucial role in triggering secondary brain injury after CA/CPR. The infiltrating peripheral macrophages showed upregulated TREM1 levels, and we further revealed the crucial role of gut-derived TREM1+ macrophages in post-CA/CPR brain injury through a drug intervention targeting TREM1. Moreover, a close correlation between upregulated TREM1 expression and poor neurological outcomes was observed in CA survivors. Mechanistically, CA/CPR caused a substantial expansion of Enterobacter at the early stage, which ignited intestinal TREM1 signaling via the activation of Toll-like receptor 4 on macrophages through the release of lipopolysaccharide. Our findings reveal essential crosstalk between the gut and brain after CA/CPR and underscore the potential of targeting TREM1+ small intestine-derived macrophages as a novel therapeutic strategy for mitigating post-CA/CPR brain injury.

Application of human cardiac organoids in cardiovascular disease research

With the progression of cardiovascular disease (CVD) treatment technologies, conventional animal models face limitations in clinical translation due to interspecies variations. Recently, human cardiac organoids (hCOs) have emerged as an innovative platform for CVD research. This review provides a comprehensive overview of the definition, characteristics, classifications, application and development of hCOs. Furthermore, this review examines the application of hCOs in models of myocardial infarction, heart failure, arrhythmias, and congenital heart diseases, highlighting their significance in replicating disease mechanisms and pathophysiological processes. It also explores their potential utility in drug screening and the development of therapeutic strategies. Although challenges persist regarding technical complexity and the standardization of models, the integration of multi-omics and artificial intelligence (AI) technologies offers a promising avenue for the clinical translation of hCOs.

Repair-associated macrophages increase after early-phase microglia attenuation to promote ischemic stroke recovery

Ischemic stroke recovery involves dynamic interactions between the central nervous system and infiltrating immune cells. Peripheral immune cells compete with resident microglia for spatial niches in the brain, but how modulating this balance affects recovery remains unclear. Here, we use PLX5622 to create spatial niches for peripheral immune cells, altering the competition between infiltrating immune cells and resident microglia in male mice following transient middle cerebral artery occlusion (tMCAO). We find that early-phase microglia attenuation promotes long-term functional recovery. This intervention amplifies a subset of monocyte-derived macrophages (RAMf) with reparative properties, characterized by high expression of GPNMB and CD63, enhanced lipid metabolism, and pro-angiogenic activity. Transplantation of RAMf into stroke-affected mice improves white matter integrity and vascular repair. We identify Mafb as the transcription factor regulating the reparative phenotype of RAMf. These findings highlight strategies to optimize immune cell dynamics for post-stroke rehabilitation.

Leveraging Preexisting Cardiovascular Data to Improve the Detection and Treatment of Hypertension: The NOTIFY-LVH Randomized Clinical Trial

Importance

Hypertension is often underrecognized, leading to preventable morbidity and mortality. Tailored data systems combined with care augmented by trained nonphysicians have the potential to improve cardiovascular care.

Objective

To determine whether previously collected cardiovascular imaging data could be harnessed to improve the detection and treatment of hypertension through a system-level intervention.

Design, Setting, and Participants

The NOTIFY-LVH trial was a 2-arm, pragmatic randomized clinical trial conducted from March 2023 through June 2024 within the Mass General Brigham health care system, a multi-institutional network serving the greater Boston, Massachusetts, area. The study included individuals with a Mass General Brigham primary care affiliation who had left ventricular hypertrophy (LVH) on a prior echocardiogram, had no established cardiomyopathy diagnosis, and were not being treated with antihypertensive medications. Patients were followed for 12 months postintervention.

Intervention

Population health coordinators contacted clinicians of patients randomized to the intervention, notifying them of LVH and offering assistance with follow-up care. A clinical support pathway-including 24-hour ambulatory blood pressure monitoring or cardiology referrals-was provided to aid LVH evaluation.

Main Outcomes and Measures

The primary outcome was the initiation of an antihypertensive medication. Secondary outcomes included new hypertension and cardiomyopathy diagnoses.

Results

A total of 648 patients were randomized-326 to the intervention and 322 to the control. Mean (SD) patient age was 59.4 (10.8) years and 248 patients (38.3%) were female. A total of 102 patients (15.7%) had a baseline diagnosis of hypertension and 109 patients (20.1%) had a mean outpatient blood pressure of 130/80 mm Hg or higher. Over 12 months, 53 patients (16.3%) in the intervention arm were prescribed an antihypertensive medication vs 16 patients (5.0%) in the control arm (adjusted odds ratio [OR], 3.76; 95% CI, 2.09-6.75; P < .001). Individuals in the intervention group were also more likely to be diagnosed with hypertension (adjusted OR, 4.43; 95% CI, 2.36-8.33; P < .001). Cardiomyopathy diagnoses did not significantly differ between groups.

Conclusions and Relevance

In the NOTIFY-LVH randomized clinical trial, a centralized population health coordinator-led notification and clinical support pathway for individuals with LVH on prior echocardiograms increased the initial treatment of hypertension. This work highlights the potential benefit of leveraging preexisting but potentially underutilized cardiovascular data to improve health care delivery through mechanisms augmenting the traditional ambulatory care system.

Trial Registration

ClinicalTrials.gov Identifier: NCT05713916.

Preclinical extracellular matrix-based treatment strategies for myocardial infarction: a systematic review and meta-analysis

BACKGROUND

Administrating extracellular matrix (ECM) to restore cardiac function post-myocardial infarction (MI) shows promise, however study variability obscures its true impact. We therefore conducted a systematic review and meta-analysis of preclinical studies to assess the effects of ECM treatments on cardiac function and tissue homeostasis post-MI.

METHODS

We searched PubMed and SCOPUS from inception to June 28, 2024, for animal studies describing ECM treatment post-MI (pre-registered on PROSPERO, CRD42022368400). Random effects meta-analyses compared ECM treatment to controls regarding left ventricular ejection fraction (LVEF), fractional shortening, infarct size, stroke volume, and left ventricular wall thickness. Subgroup analyses examined the influence of sex, species, ECM source, and administration method. Funnel plots and Egger's regression assessed publication bias.

RESULTS

We identify 88 articles which meet our inclusion criteria. These studies describe the use of rats (51%), mice (38%), and pigs (11%). 44% of studies use males, 34% females, 5% both sexes, and 17% did not report sex. Most studies employ permanent MI models (85%) over ischemia reperfusion models (15%), and deliver ECM via intramyocardial injection (59%), cardiac patch (39%), cardiac sleeve (1%), or osmotic pump (1%). Our meta-analysis demonstrates that ECM treatment significantly improves LVEF (MD: 10.9%, 95% CI: [8.7%;13.0%]; p = 8.057e-24), fractional shortening (MD: 8.2%, 95% CI: [5.6%; 10.9%]; p = 1.751e-09), stroke volume (SMD 0.6, 95% CI: [0.2;1.0], p = 0.004), left ventricular wall thickening (SMD 1.2, 95% CI: [0.9; 1.5], p = 1.321e-17), while reducing infarct size (-11.7%, 95% CI: [-14.7%;-8.6%], p = 3.699e-14). We find no significant differences between the various subgroups and no indication of publication bias.

CONCLUSIONS

ECM-based treatments significantly enhance cardiac function and tissue homeostasis in preclinical post-MI models, supporting further research toward clinical translation.

Effects of a Home-Based Rehabilitation Exercise Program on Cardiorespiratory Performance in Community-Dwelling Adults Who Underwent Heart Surgery: Randomized Controlled Trial

Background

Patients undergoing heart surgery demonstrate impaired cardiorespiratory performance. Phase II cardiac rehabilitation (CR) in people undergoing open heart surgery (OHS) aims to reduce the adverse physical effects of cardiovascular diseases. Virtual reality (VR) exercise is now used in CR.

Objective

This study aimed to explore the effects of VR exercise on functional capacity, pulmonary function, and respiratory muscle strength in patients who underwent OHS and were in phase II CR.

Methods

Forty-nine patients who underwent elective OHS and were in phase II CR were randomized into a VR group (N=24) and a control group (N=25). The VR group completed 8 weeks of a home-based VR exercise program, including chest trunk mobilization and aerobic circuit training for 30 minutes, whereas the control group received an exercise brochure and information regarding the benefits of exercise. Intention-to-treat analysis was conducted, and 2-way mixed ANOVA was performed to compare between- and within-group differences in functional capacity and respiratory performance.

Results

After completing the 8-week program, the VR group showed significant improvement in functional capacity compared to the control group (66.29, SD 25.84 m; P=.01). Inspiratory muscle strength increased in both the VR and control groups compared to baseline (9.46, SD 2.85 and 9.64, SD 2.78 cm H2O, respectively). In addition, after the 8-week intervention, significant improvements were found in expiratory muscle strength (15.79, SD 4.65 cm H2O) and forced expiratory volume in 1 second as a percentage of predicted values (2.96%, SD 1.52%) in the VR group compared to the baseline session.

Conclusions

The home-based VR exercise program significantly improved functional capacity but not respiratory muscle or pulmonary function.

Traditional Chinese medicine injections with Tonifying Qi, equivalent effect of regulating energy metabolism, for acute myocardial infarction: a systematic review and meta-analysis of randomized clinical trials

Background

Traditional Chinese medicine injections for Tonifying Qi (TCMi-TQs), which exhibits comparable effect of regulating energy metabolism, is commonly used as an adjuvant treatment for acute myocardial infarction (AMI) in China.

Objective

A systematic review and meta-analysis was conducted to contrast the effectiveness and safety of four TCMi-TQs in AMI.

Methods

Eight Databases were thoroughly searched before 31 July 2024, for randomized controlled trials (RCTs) focusing on the application of TCMi-TQs combined with conventional treatments (CT) to treat AMI. The primary outcomes were in-hospital mortality and long-term mortality. Secondary outcomes included malignant arrhythmia, left ventricular ejection fraction (LVEF), and adverse events. Stata17.0 and RevMan 5.4.1 software were employed for meta-analysis. The quality of evidence was evaluated using the GRADE approach.

Results

A total of 113 RCTs involving 10,779 patients were included in the analysis, none of which described in-dependent testing of the purity or potency of the TCMi-TQ product used. 51/113 reported random sequence generation. All RCTs lack adequate description of allocation concealment. 112/113 failed to assess blinding. The meta-analysis results demonstrated that the combined application of TCMi-TQ + CT, compared with CT, significantly reduced in-hospital mortality in AMI patients [RR = 0.58, 95% CI (0.51, 0.67), P < 0.05], decreased the incidence of malignant arrhythmia [RR = 0.51, 95%CI(0.42, 0.63), P < 0.05], increased LVEF [MD = 6.52, 95%CI(5.54, 7.50), P < 0.05], and decreased the incidence of adverse events [RR = 0.70, 95%CI(0.60, 0.81), P < 0.05]. The GRADE evidence quality classification indicated that the evidence for in-hospital mortality, malignant arrhythmia, and adverse events was of moderate quality, while the evidence for LVEF was of low quality.

Conclusion

TCMi-TQ demonstrates additional clinical value in reducing mortality, the risk of malignant arrhythmia, and adverse events in patients with AMI. However, further validation of these findings is warranted through high-quality clinical trials due to methodological weaknesses in randomization, blinding, allocation concealment, and insufficient assessment of the purity/potency of botanical drugs and the quantity of active metabolites.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/view/CRD42024573818, identifier PROSPERO (CRD42024573818).

Lactoferrin influences atherosclerotic progression by modulating macrophagic AMPK/mTOR signaling-dependent autophagy

This study aimed to explore the role of lactoferrin (LTF) in atherosclerosis (AS) and its possible mechanisms. Human left coronary artery tissues were collected and divided into control (CON), coronary heart disease (CHD) and sudden coronary death (SCD) groups. Pathologic changes (including changes in the coronary plaque area, necrotic core, collagen fibers, and foam cell content) were observed. The LTF, P62, and 4-hydroxynonenal (4-HNE) expression levels were assessed. The ApoE-/- AS mouse model was established. The pathological changes and related protein levels were analyzed after autophagy inhibition. The foam cell model was constructed using an ox-LDL-induced human monocyte line, THP-1. The LTF, BECN1, LC3-II/I, AMP-activated protein kinase (AMPK)/the mammalian target of rapamycin (mTOR) pathway proteins, B-cell lymphoma-2 (Bcl-2), Bcl-2-associated X protein (Bax), and 4-HNE expressions were then detected after silencing of LTF or BECN1. Plaque stability was significantly lower in the SCD group compared to the non-SCD group (p < 0.05). LTF, P62 and 4-HNE levels in plaques increased as plaque stability decreased, and LTF was significantly correlated with plaque progression and autophagy levels. Autophagy inhibition by U0126 leads to the worsening of aortic luminal stenosis, increased necrotic core and foam cell deposits, decreased autophagosomes, reduced LTF expression, and upregulated P62 expression in AS mice. It was further demonstrated that LTF expression correlates with autophagy. LTF expression was increased in ox-LDL-treated THP-1 cells, and silencing BECN1 and/or LTF increased mTOR phosphorylation and 4-HNE levels, inhibited BECN1 and LC3 II expression and AMPK activation, and simultaneously decreased the Bcl-2/Bax ratio. LTF might alleviate AS pathology through accelerating the AMPK/mTOR pathway, and suggested that LTF may be a potential predictive molecule for AS.

Robotic thread-assisted clot removal for stroke treatment: A comprehensive review

Stroke is the predominant factor of long-term impairment in developed nations and is a major contributor to death globally. Stroke is a life-threatening neurological condition caused by the occlusion or rupture of blood vessels in the brain. Brain clot restricts blood movement by causing obstruction thus, damaging the blood vessels and tissues, which ultimately causes stroke. Thus, stroke requires immediate and efficient treatment to reduce neurological deterioration and increase patient recuperation. Over the last decade, there have been significant breakthroughs in diagnostic and therapeutic interventionsfor stroke. Stroke is typically treated with immediate therapeutic interventions, which may involve thrombolytic medication infusions like tissue plasminogen activator, anti-coagulants like heparin, or surgical clot clearance procedures like thrombectomy. Despite the significant benefits of these treatments, several disadvantages, including restricted therapeutic index, allergic reactions, and adverse effects (such as hypotension, recurrent stroke, hypoglycaemia, and atypical bleeding), highlight the need for far more innovative solutions. In response to these challenges, a novel approach to treating brain clots has emerged. The study investigates a novel approach to treating strokes caused by brain clots through the utilization of a steerable micro-robotic thread guided by real-time imaging to enhance precision in clot removal. This method addresses the limitations of traditional treatments namely thrombolytics and thrombectomy. In this work, we emphasized the innovative approaches in the removal of brain clots, the use and mechanisms of cutting-edge robotic thread technology, and presented specific case studies demonstrating its application.

Stroke with White Matter Lesions: Potential Pathophysiology and Therapeutic Targets

Stroke is one of the most common causes of morbidity and mortality among adults globally. Significant advancements have been made in elucidating its pathophysiology, with stroke categorized into pathological subtypes, such as ischemic stroke (IS) and hemorrhagic stroke. White matter lesions (WMLs) identified on magnetic resonance imaging rank as a hallmark of cerebral small vessel disease and are associated with vascular risk factors. They are linked to adverse outcomes like dementia, depression, and an increased risk of both first-ever and recurrent strokes, independent of other risk factors. Despite the evidence indicating the close link between WMLs and stroke, their underlying pathophysiological relationship remains unclear. This study aims to provide an overview of the current knowledge and recent advances in epidemiology, risk factors, and pathophysiological mechanisms of WMLs and stroke, focusing on their interconnection and emerging therapeutic targets.

Gender correlation between sleep duration and risk of coronary heart disease: a systematic review and meta-analysis

Objective

The influence of extreme sleep duration on coronary heart disease (CHD) risk across genders remains a debated topic.

Methods

This analysis gathers observational studies that explore association between varying sleep durations and CHD risks. Trend estimation employs generalized least squares, converting specific category risk estimates into relative risks (RR) per hour of sleep increase. A two-stage hierarchical regression model evaluates potential linear dose-response relationships. Data analysis utilizes random-effects restricted cubic spline models with four knots.

Results

Involving 17 studies and 906,908 participants, this meta-analysis identifies a pronounced U-shaped nonlinear relationship between sleep duration and CHD risk applicable to both genders (P < 0.01). Notably, shorter sleep durations are linked to higher CHD risks in women, whereas longer durations are more consequential for men. The optimal sleep duration for minimizing CHD risk is between 7.0-8.0 h daily for men and 7.5-8.5 h for women.

Conclusion

The influence of sleep duration on CHD risk differs significantly between genders.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/myprospero, identifier (CRD42023478235).

Prospective Validation and Implementation Pilot Study of an Emergency Department Heart Failure Risk Stratification Tool: STRIDE-HF

BACKGROUND

The STRIDE-HF (Systematic Tool for Risk Identification and Decision-making in Emergency Heart Failure) emergency department (ED) risk tool was previously found to accurately predict the risk of a 30-day serious adverse event (SAE), including 30-day mortality, cardiopulmonary resuscitation, intra-aortic balloon pump insertion, intubation, new dialysis, myocardial infarction, or coronary revascularization.

OBJECTIVES

The aim of this study was to prospectively validate STRIDE-HF across 21 community EDs among patients in the ED with acute heart failure (AHF) from January 1, 2023, to December 31, 2023, and to assess the safety of the real-time use of risk estimates in a 2-ED pilot study.

METHODS

Model area under the receiver operator curve (AUROC) and area under the precision recall curve (AUPRC), sensitivity, specificity, and positive and negative predictive values and likelihood ratios at key clinical thresholds are reported. In the clinical pilot, the rates of 30-day SAEs among patients who were at lower risk by STRIDE-HF and were discharged after ED or observation care were reported.

RESULTS

There were 13,274 patients in the ED in the prospective validation; the median age was 76 years, 50.8% were female, and 44.5% were non-White; and 11.4%, 24.8%, 31.9%, and 31.9% of patients were at very low, low, moderate, and high risk, respectively. The 30-day SAE rates among very-low-risk and low-risk patients were 3.4% and 6.7%, respectively, and the 30-day mortality rates were <1% and <2%, respectively. STRIDE-HF was highly sensitive among low-risk patients (97.6%; 95% CI: 96.8%-98.2%); AUROC was 0.75 (95% CI: 0.74-0.76), and AUPRC was 0.43 (95% CI: 0.39-0.44). There were 845 patients in the pilot study; among patients classified by STRIDE-HF criteria as being at very low risk who were discharged, none experienced a 30-day SAE.

CONCLUSIONS

STRIDE-HF maintained high predictive accuracy for 30-day SAE in prospective validation in this large, diverse, multicenter cohort; the use of risk estimates in real time safely identified low-risk patients appropriate for discharge.

Liver function differences in atherosclerotic cardiovascular disease: a multi-ethnic dual-cohort retrospective study

Background and aims

Liver function plays a pivotal role in the initiation and progression of atherosclerotic cardiovascular disease (ASCVD). Exploring the potential associations between liver function assessment indicators and ASCVD is essential for understanding the liver's involvement in ASCVD pathogenesis. However, the specific relationships between these indicators and ASCVD are still debated. This study aims to conduct an in-depth comparative analysis of variations in various liver function assessment indicators among populations of ASCVD patients.

Methods

A dual-cohort retrospective cross-sectional study design was employed, using data from 15,943 ASCVD patients at the First Hospital of Jilin University and 472 ASCVD patients from the National Health and Nutrition Examination Survey (NHANES) database. Liver function indicators, including enzymatic, protein synthesis, bilirubin metabolism indices, and lipid profile parameters, were analyzed. Inclusion and exclusion criteria were rigorously applied, followed by univariate regression, multivariate regression and stratified subgroup analyses.

Results

Hepatocyte damage indicators (aspartate aminotransferase, alanine aminotransferase, gamma-glutamyl transferase, alkaline phosphatase) and total bilirubin were identified as risk factors for ASCVD. Albumin showed a protective effect. Globulin levels differed significantly between cohorts. Cholinesterase (cohort 1) and total protein, total cholesterol (cohort 2) showed no significant changes in ASCVD patients.

Conclusion

Many liver function indicators are correlated with ASCVD. There are differences in these indicators between ASCVD patients and healthy volunteers. Although some indicators may be weakly correlated due to confounding factors, this study still provides a scientific rationale for developing more precise ASCVD prevention and treatment strategies in the future.

Emergency medicine updates: Cardiopulmonary resuscitation

INTRODUCTION

Cardiac arrest is the loss of functional cardiac activity; emergency clinicians are integral in the management of this condition.

OBJECTIVE

This paper evaluates key evidence-based updates concerning cardiopulmonary resuscitation (CPR).

DISCUSSION

Cardiac arrest includes shockable rhythms (i.e., pulseless ventricular tachycardia and ventricular fibrillation) and non-shockable rhythms (i.e., asystole and pulseless electrical activity). The goal of cardiac arrest management is to achieve survival with a good neurologic outcome, in part by restoring systemic perfusion and obtaining return of spontaneous circulation (ROSC), while seeking to diagnose and treat the underlying etiology of the arrest. CPR includes high-quality chest compressions to optimize coronary and cerebral perfusion pressure. Chest compressions should be centered over the mid-sternum, with the compressor's body weight over the middle of the chest. A compression depth of 5-6 cm is recommended at a rate of 100-120 compressions per minute, while allowing the chest to fully recoil between each compression. Clinicians should seek to minimize any interruptions in compressions. When performed by bystanders, compression-only CPR may be associated with improved survival to hospital discharge when compared to conventional CPR with ventilations. However, in trained personnel, there is likely no difference with compression-only versus conventional CPR. Mechanical approaches for CPR are not associated with improved patient outcomes, including ROSC or survival with good neurologic function, but mechanical compression devices may be beneficial in select circumstances (e.g., few rescuers available, prolonged arrest/transport). Monitoring of chest compressions is not associated with improved ROSC, survival, or neurologic outcomes, but it can improve guideline adherence. Types of monitoring include real-time feedback, a CPR coach, end tidal CO2, arterial line monitoring, regional cerebral tissue oxygenation, and point-of-care ultrasound.

CONCLUSIONS

An understanding of CPR literature updates can improve the ED care of patients in cardiac arrest.

Ultra-Early Blood Pressure Control in Acute Intracerebral Hemorrhage

Acute intracerebral hemorrhage (ICH) remains one of the most devastating neurological emergencies, with blood pressure (BP) management in the early hours playing a pivotal role in determining patient outcomes. Emerging evidence suggests that ultra-early BP control-intervening within minutes to 2 hours of symptom onset-has the potential to reduce secondary brain injury and improve survival. Yet, despite this evidence, current clinical practice is often inconsistent, and there is no universally agreed-upon approach for managing BP in the acute phase of ICH. We advocate for ultra-early BP intervention as a standard of care in ICH, as it offers a clear opportunity to mitigate damage and to enhance recovery. We contend that current BP management protocols are often too conservative and fail to recognize the critical importance of acting swiftly. The first few hours represent a unique window in which targeted interventions, such as continuous infusion intravenous antihypertensives, may limit hematoma expansion and stabilize cerebral perfusion pressure. However, achieving optimal outcomes requires more than just aggressive treatment-it demands a tailored approach to BP control, accounting for individual patient factors, evolving clinical conditions, and operational aspects of care. We advocate for a paradigm shift toward prioritizing ultra-early intervention, supported by clear, evidence-based protocols and real-time decision-making.