2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

Estimates and projections in the economic impacts of fifteen dietary risk factors for two hundred four countries and territories from 2020 to 2050: A health-augmented macroeconomic modeling study

BACKGROUND

Suboptimal diet results in significant health and economic burdens. However, the global economic costs of dietary risks remain unclear.

OBJECTIVES

This study aimed to estimate the macroeconomic burden of 15 dietary risk factors in 204 countries and territories from 2020 to 2050.

METHODS

This health-augmented macroeconomic modeling study assessed the macroeconomic burden that accounted for the decrease in labor supply across different education levels due to mortality and morbidity, as well as the impact of healthcare expenses on investment and savings. Country-specific data were drawn from publicly accessible databases. The cumulative difference in the aggregate output between a realistic scenario without intervention and a counterfactual scenario assuming complete disease elimination was quantified as the macroeconomic burden attributable to diseases. The proportion of disease burden attributed to dietary risk factors was quantified using population-attributable fractions derived from the global burden of disease study 2019, which was integrated into the health-augmented macroeconomic model. Estimates were converted to 2017 international dollars (INT $).

RESULTS

The estimated global macroeconomic burden attributable to dietary risks from 2020 to 2050 was INT $15,491 [uncertainty interval 13078, 18742] billion, representing 0.34% (uncertainty interval 0.29%, 0.41%) of the total gross domestic product. The macroeconomic burden was unevenly distributed across countries, regions, income groups, disease types, and dietary risk factors. The United States (INT $3972 billion), China (INT $2764 billion), and India (INT $1300 billion) had the largest macroeconomic burden. Ischemic heart disease (INT $9384 billion), diabetes (INT $2392 billion), and stroke (INT $1954 billion) accounted for ∼90% of the overall macroeconomic burden. A diet low in whole grains (INT $3808 billion) incurred the highest cost, followed by a diet high in sodium (INT $2812 billion) and red meat (INT $2337 billion).

CONCLUSIONS

The global macroeconomic burden attributable to dietary risks was substantial and varied across countries, regions, income groups, disease types, and individual dietary risk factors.

Depression, Anxiety, and Quality of Life in a Cardiac Rehabilitation Program Without Dedicated Mental Health Resources Post-Myocardial Infarction

Anxiety and depression are common after a myocardial infarction (MI), so psychological and psychiatric mental health (MH) interventions are recommended during Cardiac Rehabilitation Programs (CRP). We aim to evaluate anxiety and depression symptoms and quality of life in MI sufferers followed in a CRP without dedicated MH resources. We prospectively included 164 MI patients in our CRP without dedicated MH resources. Patient Health Questionnaire 2-item (PHQ-2) and Generalized Anxiety Disorder 2-item (GAD-2) questionnaires for depression and anxiety screening (altered if ≥3 points) and the 36-Item Short Form Survey Instrument (SF-36) to analyze four MH components and Mental Component Summary (MCS) were assessed at the beginning and after CRP. The mean age was 61.35 ± 10.76 years, and most patients were male (86.6%). A significant improvement in SF-36 mental components (from +5.94 ± 27.98 to +8.31 ± 25 points, p < 0.001) and SF-36-MCS (+1.85 ± 10.23 points, p = 0.02) was noted, as well as a reduction in depression and anxiety symptoms in PHQ-2 and GAD-2 (p < 0.001). However, 33 (20.1%) patients showed a positive screening for depression and/or anxiety at the end of the program. These patients were younger (56.6 ± 8.05 vs. 62.55 ± 11.05 years, p = 0.004) and showed significantly worse initial scores of SF-36 mental components, PHQ-2, and GAD-2 (p < 0.001). We conclude that a Phase 2 CRP without dedicated MH resources can achieve significant improvements in MH well-being after MI. However, one-fifth of the population had substantial depression and/or anxiety symptoms at the end of the program. This subset, characterized by worse initial MH scores, may benefit from specific MH interventions during CRP.

Fractional Flow Reserve Relates Stronger to Coronary Plaque Burden Than Nonhyperemic Pressure Indexes

BACKGROUND

The relationship between fractional flow reserve (FFR), resting full-cycle ratio (RFR), instantaneous wave-free ratio (iFR), resting distal pressure/aortic pressure (Pd/Pa), and plaque burden as well as phenotype requires further elucidation.

METHODS AND RESULTS

In this single-center cohort study, patients with suspected coronary artery disease who underwent invasive coronary angiography, including routine hyperemic (FFR) and nonhyperemic invasive pressure (Pd/Pa and iFR or RFR) interrogation and computed coronary tomography angiography were prospectively enrolled. Computed coronary tomography angiography was used to assess percentage atheroma volume (PAV), positive remodeling, and low-attenuation plaque.

Among 241 patients with 556 vessels, FFR correlated stronger to PAV compared with Pd/Pa (r=-0.56; versus r=-0.43; P<0.01) and iFR/RFR (r=-0.47; P=0.04). Vessels with FFR and Pd/Pa discordancy showed higher PAV in case of abnormal FFR (34% versus 14%; P<0.01), whereas vessels with FFR and iFR/RFR discordancy showed similar PAV levels. FFR and iFR/RFR, but not Pd/Pa, were independently associated with the presence of low-attenuation plaque (β, -0.03, P<0.01; β, -0.03, P=0.01; and β, -0.02, P=0.10, respectively). None of the invasive pressure measurements was independently associated with positive remodeling. Pressure index discordancy was not associated with positive remodeling or low-attenuation plaque.

CONCLUSIONS

FFR correlated stronger to plaque burden, as defined by PAV, than nonhyperemic pressure indexes. For plaque phenotype, both FFR and iFR/RFR were independently associated with low-attenuation plaque, whereas none of the invasive pressure indexes was associated with positive remodeling.

Association between influenza vaccination and prognosis in patients with ischemic heart disease: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

There is substantial epidemiological evidence demonstrating that influenza contributes to cardiovascular events in patients who already have cardiovascular diseases. However, the efficacy of influenza vaccination on the prognosis of patients with ischemic heart disease (IHD) is unclear.

METHODS

We conducted a systematic search for eligible randomized controlled trials (RCTs) in PubMed, Cochrane, and Embase on September 13, 2024, to investigate the effects of the influenza vaccine on the prognosis of patients with IHD. The effect sizes were combined using random-effects models, and Trial Sequential Analysis (TSA) was used to assess the reliability and validity of the results.

RESULTS

Five RCTs with a total of 5659 patients (median age ranging from 57.1 to 66 years, 67.8% male) with IHD were included. The use of influenza vaccine reduced the risk of major adverse cardiovascular events (risk ratio [RR] = 0.67, 95% confidence interval [CI] 0.52-0.87, number-needed-to-treat [NNT] of 37, high certainty), cardiovascular death (RR = 0.55, 95% CI 0.35-0.87, moderate certainty), all-cause mortality (RR = 0.58, 95% CI 0.40-0.84, high certainty) and myocardial infarction (MI) (RR = 0.66, 95% CI 0.46-0.93, high certainty) in patients with IHD compared with control. The analysis revealed no significant benefit regarding hospitalization for heart failure (HF) (RR = 0.91, 95% CI 0.21-3.99, moderate certainty) and revascularization (RR = 0.59, 95% CI 0.10-3.45, moderate certainty). The NNT to avoid 1 event was 37 for major adverse cardiovascular events, 56 for cardiovascular death, 67 for MI, and 41 for all-cause death. TSA showed that the benefit of influenza vaccine in reducing MACE was conclusive, no more trials were necessary.

CONCLUSION

This study suggests high level of evidence that the use of influenza vaccine reduce the risk of major adverse cardiovascular events in patients with IHD.

Physical Activity and Sedentary Behaviour Thresholds for Secondary Prevention of Coronary Heart Disease: Morbidity Survival Tree Analysis

BACKGROUND

There are no diagnosis-specific guidelines for moderate-to-vigorous physical activity (MVPA) and sedentary behaviour (SB) for coronary heart disease (CHD). This study aimed to identify thresholds of MVPA and SB associated with cardiovascular events.

METHODS

This cohort study included individuals with CHD. MVPA and SB were self-reported, and health registries identified cardiovascular events in the years 2006-2022. Survival tree analyses identified thresholds of time associated with the risk of cardiovascular events. Thresholds were explored with the use of Cox regression models.

RESULTS

There were 40,156 Australians, mean age 70 years, 62% men. Over a median 8.3 years, 3260 nonfatal cardiac events, 5161 total cardiac events, and 14,383 major adverse cardiovascular events (MACE) occurred. Thresholds for MVPA were 122 min/wk for nonfatal cardiac events and 94 min/wk for total cardiac events and MACE. Meeting MVPA thresholds was associated with an 18% lower risk for nonfatal cardiac events, 29% lower risk of total cardiac events, and 23% lower risk of MACE than not reaching the thresholds. Thresholds for SB were 4 and 10 h/d, respectively, for risk of total cardiac events and MACE. SB below thresholds was associated with a 14% lower risk of total cardiac events and an 18% lower risk of MACE. There were sex-specific thresholds for MVPA and SB.

CONCLUSIONS

To lower cardiovascular event risk, identified MVPA thresholds were lower (94-122 min/wk) than the public health guidelines (150 min/wk) in individuals with CHD. The SB thresholds associated with a lower risk of total cardiac events and MACE varied from 4 to 10 h/d.

Imaging of the Acute and Chronic Cardiovascular Complications of Radiation Therapy

Chest radiotherapy (XRT) plays a crucial role in the treatment of a multitude of cancers including breast, lung, esophageal, and lymphoma. Although XRT enhances cancer survival rates, it may also expose healthy bystander tissues to radiation, potentially leading to severe complications. Initially considered relatively resistant to radiation damage, the heart has been shown over the past 4 decades to be susceptible to radiation-induced cardiovascular toxicity and despite advances in XRT which can minimize radiation exposure to heart tissue, no cardiac radiation dose is entirely safe. The clinical spectrum of radiation-induced cardiovascular toxicity is broad, encompassing coronary artery disease, myocardial dysfunction, valvular abnormalities, and pericardial disorders. Radiation-induced cardiovascular toxicity may manifest acutely or many years after XRT, with each condition more likely to present at certain time points post-XRT. Cardiac imaging is a crucial tool in both the screening and diagnosis of radiation-induced cardiovascular toxicity with an understanding of its pathophysiology, incidence, and progression required to implement a comprehensive, multimodality imaging approach to detect and manage these complications effectively.

Pharmacological regression of atherosclerotic plaque in patients with type 2 diabetes

Atherosclerosis of the coronary arteries continues to be one of the major global health burdens and acute coronary syndrome is responsible annually for at least 30 % of all deaths globally. Acute coronary syndrome may be the consequence of thrombus formation after erosion or rupture of obstructive or non-obstructive atherosclerotic plaque. The rupture of plaques is mostly caused by mechanical stress usually called cap fatigue. Vulnerable plaques are characterized by a softer atheromatous core and a thinner fibrous cap, with inflammation and hypercholesterolemia playing a crucial role in the atherothrombotic process. Based on animal studies that extend back to the 1920s, regression of atherosclerotic plaques in humans has just started to be considered and pursued. The idea that the human atherosclerotic plaques could regress at all met an important resistance over the decades; indeed, advanced plaques contain components, such as necrosis, calcification and fibrosis, which are hard to be removed. However, new animal models and imaging technics allowed a more complete and accurate quantitative assessment of plaque volume and are shedding new light on atherosclerosis regression. In this review, we are revisiting the existence of atherosclerosis regression in preclinical and clinical studies, with a focus on the latest mechanistic insights and on the newest pharmacological agents, particularly in patients with diabetes. Interestingly, we suggested that based on literature insights and preclinical studies, a combination of drugs to target hyperglycemia, dyslipidemia and inflammation may be desirable for a fast-track Pharmacological regression of atherosclerotic plaque in patients with type 2 diabetes.

2023 ACC/AHA Chronic Coronary Disease Guideline - An opportunity to reestablish coronary artery bypass recommendations

Coronary artery bypass (CABG) has evolved over the decades, supported by scientific evidence from robust studies. The downgrade of the recommendation for CABG in patients with multivessel coronary artery disease proposed by the 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization and the 2023 ACC/AHA Chronic Coronary Disease Guidelines has brought this discussion to the fore, with prestigious cardiothoracic surgery societies such as AATS and STS not supporting these recommendations. The purpose of this article is to broaden this discussion in light of published studies.

Long-Term Outcomes in Patients With Chronic Total Occlusion and Left Ventricular Systolic Dysfunction - A Single-Center Inverse Probability of Treatment Weighting Analysis

BACKGROUND

The optimal treatment strategy for patients with coronary chronic total occlusion (CTO) and left ventricular systolic dysfunction (LVSD) remains unclear. This study investigated the long-term outcomes of percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), and medical therapy (MT) in this specific patient cohort.

METHODS AND RESULTS

This retrospective cohort study included 987 consecutive patients with CTO and LVSD who met the inclusion criteria and underwent either CTO-PCI (n=277), CTO-CABG (n=222), or CTO-MT (n=488) between 2014 and 2020. The primary outcome was all-cause mortality during follow-up. Secondary endpoints were major adverse cardiac and cerebrovascular events (MACCE) and their components, including cardiovascular mortality, myocardial infarction (MI), stroke, unplanned revascularization, and hospitalization for heart failure. During a median follow-up of 5.3 years, 232 (23.51%) patients died from any cause. In the unadjusted analysis, CTO-MT was associated with worse long-term survival prospects. After inverse probability of treatment weighting and variable adjustment, CTO-PCI and CTO-CABG demonstrated significant reductions in the long-term risks of all-cause and cardiovascular mortality. Notably, CTO-CABG was associated with the lowest long-term risks of MACCE, MI, unplanned revascularization, and hospitalization for heart failure.

CONCLUSIONS

For patients with CTO and LVSD, successful CTO revascularization significantly improved long-term survival compared with CTO-MT. CTO-CABG can be regarded as the optimal treatment modality for better long-term prognosis.

Association between guideline-directed medical therapy and reintervention risk following peripheral vascular interventions in patients with peripheral artery disease

INTRODUCTION

Reintervention following peripheral vascular intervention (PVI) for peripheral artery disease (PAD) is common. Guideline-directed medical therapy (GDMT) is recommended post-PVI, yet its association with reintervention outcomes remains unclear.

METHODS

We analyzed Vascular Quality Initiative registry data linked with Medicare outcome for patients undergoing PVI for PAD (2017-2018). GDMT was defined as the receipt of statin, antiplatelet, and angiotensin-converting enzyme or angiotensin receptor blocker (ACE/ARB) therapy if hypertensive at discharge. Competing risk analyses and conditional risk models assessed the reintervention outcome, and the recurrent reintervention outcomes within 2 years, by GDMT receipt, compliance with each GDMT element, the number of elements received, and GDMT rate across sites and operators in a 1:1 propensity score-matched cohort.

RESULTS

We included 13,244 patients (mean age 72.0 ± 9.9, women 41.0%). The reintervention outcome did not differ by GDMT receipt (cumulative incidence: 43.0% [95% CI 41.0-44.9%] in no GDMT vs 41.2% [95% CI 39.4- 43.0%] in GDMT; subhazard ratio (sHR): 1.03 [95% CI 0.97-1.10]), compliance with GDMT elements, the number of elements received, or site and operator GDMT rates (sHR per 10% increase: 1.00 [95% CI 0.98-1.03] and 1.00 [95% CI 0.98-1.02]) (all p > 0.05). However, a higher operator GDMT rate reduced the recurrent reintervention risk (HR: 0.98 [95% CI 0.97-1.00], p = 0.026).

CONCLUSION

Around 40% of patients undergoing a PVI experience reintervention within 2 years, but the outcome was not reduced with GDMT receipt, and higher GDMT rates by site and operators were not associated with reintervention risk. Future studies should focus on medication adherence, refills, and more granular GDMT data for PAD care surveillance postrevascularization.

Repetition-dependent acutecardiopulmonary responses during intensity-matched squats in males

The 'strength-endurance continuum' is a key concept in strength training (ST). Although cardiopulmonary responses have seldom been reported in conjunction with ST, this repeated-measurement study examined acute blood pressure and haemodynamic responses continuously depending on the number of repetitions but without changing the intensity. Fifteen healthy male participants (21.6 (2.0) years; mean (SD)) performed an incremental exercise test and a 3-repetition maximum test (3-RM) on a Smith machine. They were then randomly assigned to three ST sessions involving 10, 20 and 30 repetitions at 50% of their 3-RM. Blood pressure (vascular unloading technique) and cardiopulmonary responses (spirometry and impedance cardiography) were continuously monitored. Heart rate (121 (10) vs. 139 (22) vs. 153 (13) bpm, P = 0.001, respectively), cardiac output (10.4 (1.9) vs. 13.6 (3.8) vs. 14.6 (3.1) L/min, P = 0.001, respectively) and diastolic blood pressure (113 (8) vs. 116 (21) vs. 135 (22) mmHg, P = 0.001, respectively) increased in the training sessions with higher repetitions. Stroke volume, systolic blood pressure and end-diastolic volume indicated no change in peak values between training sessions. Total peripheral resistance (13.6 (2.8) vs. 11.3 (3.6) vs. 11.2 (3.1) mmHg min/L, P = 0.002, respectively) was significantly lower with 20 and 30 repetitions, while oxygen uptake (V ̇ O 2 ${\dot V_{{{\mathrm{O}}_{\mathrm{2}}}}}$ : 15.5 (1.9) vs. 20.5 (4.1) vs. 20.6 (4.4) mL/min/kg, P = 0.001, respectively) was significantly higher. ST of moderate intensity with an exhausting number (>20) of repetitions induces strong haemodynamic responses, especially high cardiac afterload and a compensatory heart rate acceleration, which may also create a strong stimulus for cardiopulmonary adaptation.

Patient-physician communication of health and risk information in the management of cardiovascular diseases and diabetes: a systematic scoping review

BACKGROUND

The communication of health and risk information is an integral part of patient-physician interaction. Effective communication of risk information for cardiovascular diseases and diabetes has been shown to improve medication adherence, increase physical activity levels, and improve dietary control. Patients who understand their risk profile are better able to work towards modifying their lifestyle behaviours as part of a shared decision-making process with physicians. This scoping review examines the evidence on patient-physician risk communication strategies, approaches and interventions for CVDs and diabetes management in primary care and secondary outpatient settings.

METHODS

A comprehensive database search for quantitative and qualitative studies was conducted in PubMed, Embase, Web of Science, Scopus, CINAHL, PsycINFO, and Cochrane Library from 1st January 2000 to 3rd October 2023. Two reviewers independently performed the screening of articles. Studies that report on patient-physician risk communication processes were included. Data were extracted and analysed using descriptive summaries and narrative synthesis. Results are reported in accordance with PRISMA-ScR guidelines. Included articles were appraised for quality following JBI critical appraisal and MMAT tools.

RESULTS

A total of 8378 articles published between 1st Jan 2000 to 3rd October 2023 were screened. After a full-text review of 88 articles, a total of 30 articles, consisting of 15 qualitative, 14 quantitative and 1 mixed method studies were included. Common areas of inquiry among articles include: (1) understanding and recalling risk information, (2) strategies and approaches used by physicians to communicate risk, and (3) interventions to improve the communication of risk. Studies reveal how physicians use a range of strategies, approaches and interventions to discuss risk with patients. We present and discuss each theme narratively in detail.

CONCLUSIONS

There is a critical need for further research into risk communication strategies for cardiovascular diseases (CVDs) and diabetes, with a focus on developing targeted approaches that enhance patients' understanding of their risk profiles. Evidence-based guidelines should assist healthcare professionals improve risk communication within clinical settings, with the goal of facilitating patient comprehension of health risks that can sustain lifestyle changes. Misalignment in communication may lead to dissatisfaction and confusion, which may impede the effective management of chronic conditions.

Titanium-nitride-oxide-coated vs. drug-eluting stents in acute coronary syndromes: an individual patient data meta-analysis

BACKGROUND AND AIMS

In acute coronary syndromes (ACS), vascular healing at the site of implantation of drug-eluting stents (DES) can be delayed. Titanium-nitride-oxide-coated stents (TiNOS) demonstrate faster strut coverage without the excessive intimal hyperplasia observed with bare metal stents. The 5-year outcomes of patients presenting with ACS, randomized to receive either TiNOS or DES, were compared.

METHODS

A systematic review and individual participant data meta-analysis of trials comparing TiNOS with DES for the treatment of ACS was conducted (PROSPERO: CRD42024514342). The primary endpoint was major adverse cardiac events (MACE) at 5 years, a composite of cardiac death (CD), myocardial infarction (MI), and ischaemia-driven target lesion revascularization (TLR). Pre-specified secondary endpoints included CD, MI, TLR, and stent thrombosis. Data were pooled using a mixed-effects Cox regression model with random slope and stratified baseline hazards.

RESULTS

Patient-level data (n = 2743) were obtained from three randomized controlled trials (TiNOS: n = 1620 vs. DES: n = 1123). After a median follow-up of 4.93 years, there was no significant difference in the primary endpoint between TiNOS and DES (12.6% vs. 16.2%; hazard ratio [HR] .82, 95% confidence interval [CI] .67-1.00, P = .051), mainly due to a similar rate of TLR (8.0% vs. 8.1%; HR 1.05, 95% CI .80-1.38, P = .733). However, TiNOS was associated with significantly lower rates of CD (1.5% vs. 3.7%; HR .46, 95% CI .26-.81, P = .007), MI (5.2% vs. 9.6%; HR .56, 95% CI .42-.75, P < .001), and stent thrombosis (1.1% vs. 3.8%; HR .30, 95% CI .17-.53, P < .001).

CONCLUSIONS

In ACS patients, TiNOS was associated with similar rates of MACE and TLR as compared with DES but significantly lower rates of CD, MI, and stent thrombosis.

Dietary Branched-Chain Amino Acids Modify Postinfarct Cardiac Remodeling and Function in the Murine Heart

BACKGROUND

Branched-chain amino acids (BCAAs), which are derived from the diet, are markedly elevated in cardiac tissue following myocardial infarction (MI). Nevertheless, it remains unclear whether dietary BCAA levels influence post-MI remodeling.

METHODS

To investigate the impact of dietary BCAAs on cardiac remodeling and function after MI, we fed mice a low or a high BCAA diet for 2 weeks before MI and for 4 weeks after MI. Cardiac structural and functional changes were evaluated by echocardiography, gravimetry, and histopathological analyses. Immunoblotting was used to evaluate the effects of BCAAs on isolated cardiac myofibroblast differentiation.

RESULTS

The low BCAA diet decreased circulating BCAA concentrations by >2-fold when compared with the high BCAA diet. Although neither body weights nor heart masses were different in female mice fed the custom diets, male mice fed the high BCAA diet had significantly higher body and heart masses than those on the low BCAA diet. The low BCAA diet preserved stroke volume and cardiac output after MI, whereas the high BCAA diet promoted progressive decreases in cardiac function. Although BCAAs were required for myofibroblast differentiation in vitro, cardiac fibrosis, scar collagen topography, and cardiomyocyte cross-sectional area were not different between the dietary groups; however, male mice fed the high BCAA diet had longer cardiomyocytes and higher capillary density compared with the low BCAA group.

CONCLUSIONS

A low BCAA diet mitigates eccentric cardiomyocyte remodeling and loss of cardiac function after MI in mice, with dietary effects more prominent in males.

Serum Periostin as a Novel Biomarker for Predicting 30-Day Major Adverse Cardiac Events After Off-Pump Coronary Artery Bypass Grafting

Background

The identification of predictors for major adverse cardiovascular events (MACEs) is essential for reducing mortality associated with off-pump coronary artery bypass grafting (OPCAB). The objective of this study is to assess serum periostin levels as a novel predictor of MACEs in patients undergoing OPCAB.

Methods

This prospective study included 79 patients diagnosed with coronary artery disease (CAD) who underwent OPCAB between May 2022 and May 2023. The changes in periostin levels (ΔPOSTN) were calculated using the formula: postoperative POSTN levels minus preoperative POSTN levels. Based on the optimal cut-off value determined from the receiver operating characteristic (ROC) curve, patients were categorized into Low POSTN Change (LPC) and High POSTN Change (HPC) groups for subgroup analysis. The primary outcomes assessed were MACEs, including cardiac death, myocardial infarction (MI), heart failure, and stroke.

Results

Follow up for the patients was conducted for 30 days, with 71 patients ultimately being included in the final analysis. During this period, 13 MACEs were recorded, representing an incidence rate of 18.3%. The events included 2 cases of cardiac death (2.8%), 5 cases of MI (7.0%), 5 cases of heart failure (7.0%), and 1 case of stroke (1.4%). The risk of MACEs increased by 4% for each unit increase in the ΔPOSTN (Odds Ratio [OR]: 1.04, 95% Confidence Interval [CI]: 1.01-1.06; p = 0.005). The area under the ROC curve was 0.869 (95% CI: 0.768-0.938; p < 0.001). Based on the Youden index (J = 0.683), the optimal threshold for ΔPOSTN was determined to be 16.6 µg/L, with a sensitivity of 76.9% and a specificity of 91.4%.

Conclusion

Changes in serum periostin levels during the perioperative period may serve as an independent predictor of 30-day MACEs in patients undergoing OPCAB.

Trial Registration

Link of the registry: https://www.chictr.org.cn. Date of registration: 2022/05/22. Trial registration number: ChiCTR2200060220.

Injectable pH Responsive Conductive Hydrogel for Intelligent Delivery of Metformin and Exosomes to Enhance Cardiac Repair after Myocardial Ischemia-Reperfusion Injury

Myocardial ischemia-reperfusion injury (MIRI) is a leading cause of complications and high mortality associated with acute myocardial infarction. Injectable hydrogel emerges as a promising biomaterial for myocardial repair due to their ability to mimic the mechanical and electrophysiological properties of heart tissue. In this study, an injectable conductive hydrogel is developed that responds to the weakly acidic microenvironment of ischemic injury, enabling the intelligent release of metformin and exosomes to enhance cardiac repair following MIRI. This multifunctional hydrogel demonstrates self-healing properties, shear-thinning injectability, electrical conductivity, and an elastic modulus comparable to natural myocardium, alongside excellent biocompatibility. At the cellular level, the hydrogel system exhibits significant antioxidant, anti-apoptotic, improvement of electrophysiological characteristics, mitochondrial protection and angiogenic effects, with transcriptome sequencing revealing the effective activation of the PI3K/AKT, VEGF, and AMPK signaling pathways. In vivo studies further confirm that the hydrogel treatment reduces infarct size, cardiac fibrosis and incidence of arrhythmia, while improving ventricular ejection fraction and facilitating the restoration of cardiac function after MIRI. In conclusion, an injectable pH-responsive conductive hydrogel is presented that enables the intelligent delivery of metformin and exosomes, offering a promising and novel therapeutic approach for enhancing cardiac repair and treating MIRI.

Hybrid coronary revascularization versus traditional coronary artery bypass grafting for left main coronary artery disease

BACKGROUND

The current recommended intervention for significant left main (LM) stenosis, especially in patients with complex and high SYNTAX score disease, is coronary artery bypass grafting (CABG). Hybrid coronary revascularization (HCR) combines robotic coronary artery bypass and percutaneous coronary intervention, offering a less invasive approach for patients with LM disease.

OBJECTIVES

We compare clinical outcomes between HCR and CABG in patients with LM disease.

METHODS

We retrospectively screened all patients treated for LM disease between 2019 and 2023 at a single institution. Propensity matching was used for baseline characteristics. The primary outcome was major adverse cardiovascular events (MACE) at 30 days, 6 months and 1 year. Secondary outcomes included death, myocardial infarction, repeat revascularization and stroke.

RESULTS

Out of a total of 761 patients treated for LM disease, 59 HCR patients were propensity matched to 59 CABG patients and were included in the final analysis. SYNTAX score was >33 for 49.1 % of HCR patients and 67.3 % of CABG patients (p = 0.15). Hospital length of stay was significantly shorter for HCR patients compared to CABG (4.07 days vs. 7.58 days, p < 0.001). MACE were significantly lower in the HCR group at 30 days (0 % vs 10.2 %; p = 0.01), 6 months (0 % vs 17 %; p = 0.002) and 1 year (2.4 % vs 20.5 %; p = 0.01) compared to CABG group. Additionally, there was a lower rate of repeat revascularization at 6 months in the HCR group (0 % vs 10.9 %; p = 0.02).

CONCLUSIONS

This retrospective study demonstrates that HCR is a safe and viable alternative to CABG in patients with LM disease. Randomized clinical trials comparing the two treatment modalities are needed to confirm these findings.

Practices of low value or unnecessary practices in vascular prevention

BACKGROUND

Low-value practices are avoidable interventions that provide no health benefits. The objective of this study was to conduct a narrative review of the recommendations for practices of low value-care in vascular prevention.

METHODS

A narrative review of all low value-care recommendations for vascular prevention published in the main European and North American scientific societies for clinical practice guidelines between 2014 and 2024 was carried out.

RESULTS

A total of 38 clinical practice guidelines and consensus documents from international organizations in the United States, Canada, the United Kingdom, and Europe were reviewed, 28 of which included between 1 and 20 recommendations on practices of low value-care in vascular prevention. The total number of recommendations was 141. The American Heart Association is the society that offers the largest number of recommendations of low value-care, with 39 recommendations (27.7%) in 5 clinical practice guidelines (13.2% of the total guidelines with recommendations). The guideline for the management of arterial hypertension of the European Society of Hypertension is the guideline that concentrates the largest number of recommendations of low value-care in a single guideline, with 20 recommendations (14.2% of the total guidelines with recommendations).

CONCLUSIONS

There are more and more guidelines that explicitly describe diagnostic or pharmacological activities of low value-care or Do Not Do Class III or recommendation D. Some guidelines agree, but others show clear discrepancies, which can illustrate the uncertainty of the scientific evidence and the differences in its interpretation.

Stroke-bleeding risk score pairings within individuals in the outcomes registry for better informed treatment of atrial fibrillation (ORBIT-AF) registry

BACKGROUND

Decisions about stroke prevention strategies in atrial fibrillation (AF) typically balance thromboembolism reduction against increased bleeding from oral anticoagulation therapy (OAC). When determining eligibility for OAC, guidelines recommend calculation of thromboembolic event rates using a validated score such as CHA2DS2-VASc. In contrast, routine calculation of bleeding scores is not recommended, in part because many patient factors associated with an increased risk of bleeding are associated with an even larger increased risk of ischemic stroke. We set out to characterize patients by paired stroke and bleeding risk scores to understand the level of concordance.

METHODS

Between 2010 and 2016, we identified 20,451 AF patients in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) I and II Registries. We grouped patients by stroke and bleeding risk pairings: low and high stroke risk (CHA2DS2-VASc < and ≥2), low and high bleeding risk (ORBIT < and ≥ 4) and described treatment rates with OAC and antiplatelet (AP) therapy.

RESULTS

Most patients (68.6 %) were at high stroke and low bleeding risk. Patients at high bleeding risk (19.4 %) had high stroke risk (98.5 %). Treatment rates differed with combined OAC + AP therapy highest for patients at high stroke and bleeding risks. Ischemic and bleeding events were also highest in this group.

CONCLUSIONS

Nearly all AF patients in this cohort with high bleeding risk (ORBIT score ≥ 4) had high stroke risk (CHA2DS2-VASc ≥ 2), supporting that bleeding risk should not obviate the need for stroke prevention. In contrast, most at high stroke risk were at low bleeding risk (ORBIT <4), supporting OAC for the majority. Bleeding scores, in combination with factors that specifically indicate a higher risk of bleeding, may identify patients who might be candidates for alternative stroke prevention such as left atrial appendage occlusion devices or bleeding mitigation strategies such as de-escalation of antiplatelet therapy.

Change in exercise capacity, physical activity and motivation for physical activity at 12 months after a cardiac rehabilitation program in coronary heart disease patients: a prospective, monocentric and observational study

Background

Exercise capacity (EC) and physical activity (PA) are relevant predictors of mortality in patients with coronary heart disease (CHD) but the CHD-specific long-term trajectories of these outcomes after a cardiac rehabilitation (CR) program are not well known. The main objective of this study was to determine the mean change in EC (6-min walking test (6MWT) distance) in CHD patients at 12 months after a CR program compared to the end of the program. We also performed a series of exploratory analyses: (i) estimating the decile shifts and the typical (median) individual change for EC, PA (International Physical Activity Questionnaire-Short Form Metabolic Equivalent of Task (IPAQ-SF MET)-min/week), and motivation for PA (Echelle de Motivation envers l'Activité Physique en contexte de Santé (EMAPS) scores) over the 12-month follow-up period; (ii) characterizing the PA motivational profiles at the end of the program and 12 months after the program; (iii) characterizing the barriers to PA perceived at 12 months; and (iv) estimating the categories of changes in EC and PA over time and their potential predictors.

Methods

Eighty-three patients were recruited at the end of a CR program.

Results

For an average patient, EC was trivially increased at 12 months. However, the decile shifts analysis did not confirm that the positive shift of the distribution of the performances over time was uniform. In contrast, we observed a significant decrease in PA between the end of the program and 12 months post-program but not between 6 and 12 months post-program when considering both the group of patients as a whole and the typical individual change. The results regarding motivation for PA were mixed, with significant and non-uniform shifts of the deciles towards scores depicting degrees of autonomous and controlled motivations as well as amotivation that would be more in favor of PA, but with no significant typical individual changes except for introjected regulation. Two motivational profiles were identified both at the end of the program and 12 months after the program: one with a very high level of autonomous motivation and a high level of introjected regulation; and another one with a high level of autonomous motivation and a moderate level of introjected regulation. Unfavorable weather, lack of time, fatigue, and fear of injury were the main barriers to PA at 12 months post-program. The change in EC and PA could be categorized into different classes without the possibility to determine any potential predictor of the assignment to a given class. Overall, these results suggest that clinicians managing a CR program with CHD patients as the one implemented in the present study may expect slightly positive or at least steady trajectories in EC, PA (after 6 months), and motivation for PA during the year after the program when considering the bulks of the distributions of patient scores. However, these global trajectories are actually the results of heterogeneous individual changes with some profiles of patients who could need a particular attention.

Saving Shared Decision-Making

The Agency for Healthcare Research and Quality encouraged a re-examination of the concept, process, and measurement of shared decision-making (SDM) in 2016. Progress, however, has been slow. One illustrative example is SDM's relationship with the concept of equipoise: there remains little consensus on what equipoise means in the context of SDM, creating confusion about when SDM is and is not indicated. In this paper, we describe the ways in which this focus on equipoise in SDM is counter-productive and argue that equipoise is neither a necessary nor sufficient criterion in determining the need for SDM. Moreover, we suggest that what is needed to move the field of SDM forward is a shift away from focusing on when SDM is needed to instead focusing on how best to accomplish SDM across a variety of contexts by advancing the science of SDM implementation.

A Case of Extended Duration Triple Antithrombotic Therapy in a Patient With an Intracranial Stent and Atrial Fibrillation

Our case report presents the clinical management of a 77-year-old female with recurrent acute ischemic stroke (AIS) due to severe intracranial large artery atherosclerosis (LAA), requiring intracranial stenting complicated by new-onset atrial fibrillation (AF). This clinical scenario necessitated the use of triple antithrombotic therapy (TAT) with aspirin, ticagrelor, and apixaban. While guidelines recommend minimizing the duration of TAT or favoring alternative regimens due to bleeding risks, this case highlights the safe application of an extended duration TAT course in a high-risk patient. The patient initially presented with recurrent AIS despite dual antiplatelet therapy (DAPT). Subsequent intracranial stenting and AF diagnosis posed challenges in balancing ischemic and bleeding risks. Multidisciplinary, shared decision-making guided the initiation of TAT. Despite a history of early recurrent strokes and high-risk stenting, no major, life-threatening, or minor bleeding complications were observed during the extended duration of TAT. This case underscores the need for tailored antithrombotic regimens in neurovascular patients with AF and high ischemic risk.

Outcomes and risk factors associated with in-hospital mortality in patients undergoing coronary artery bypass grafting with low ejection fraction

Objective

To investigate the short-term prognosis and risk factors associated with in-hospital mortality in patients undergoing coronary artery bypass grafting (CABG) with low ejection fraction.

Methods

Clinical data were collected from 765 patients who underwent CABG with an ejection fraction of less than 40% between 2019 and 2023 at Anhui Chest Hospital and Beijing Anzhen Hospital, Capital Medical University. The patients were categorized into a in-hospital mortality group (n = 38) and a in-hospital survival group (n = 727), based on whether they died within 30 days post-operation. Univariate and multivariate logistic regression analyses were employed to identify risk factors for in-hospital mortality. The relationship between these risk factors and the likelihood of in-hospital mortality was assessed using restricted cubic splines (RCS). Additionally, predictive values were evaluated by plotting receiver operating characteristic curves (ROC).

Results

In-hospital mortality occurred in 38 out of the 765 patients, resulting in an incidence rate of 4.97%. Compared to the survival group, those in the mortality group exhibited significantly higher rates of exploratory thoracotomy, intra-aortic balloon pump usage, extracorporeal membrane oxygenation application, gastrointestinal bleeding incidents, and acute renal failure occurrences. Independent risk factors for in-hospital mortality included preoperative age, left ventricular ejection fraction (LVEF), fasting glucose levels (Glu), and glomerular filtration rate (eGFR). Conversely, standardized preoperative administration of oral nitrates and aspirin as well as intraoperative utilization of internal mammary arteries emerged as protective factors against in-hospital mortality. ROC analysis revealed predictive efficiencies for age at 68.5%, LVEF at 76.6%, Glu at 60.5%, while eGFR demonstrated a predictive efficiency of 78.1%.

Conclusion

The incidence of in-hospital mortality in patients undergoing coronary artery bypass grafting with low ejection fraction is correlated with several factors, including advanced age, LVEF, Glu, eGFR, and the standardized preoperative administration of oral nitrates and aspirin. These findings serve as a guide for enhancing the in-hospital prognosis for this patient population in clinical practice.

Efficacy and safety of Shexiang Baoxin Pill (MUSKARDIA) in patients with stable coronary artery disease across different weight subgroups

ETHNOPHARMACOLOGICAL RELEVANCE

Shexiang Baoxin Pill (MUSKARDIA), a traditional Chinese patent medicine, plays a crucial role in both preventing and treating diverse cardiovascular diseases, including coronary heart disease, myocardial infarction (MI), and heart failure. Preclinical research has demonstrated that the cardioprotective effects of MUSKARDIA are achieved through multiple pathways, such as enhancing coronary artery dilation, fostering new blood vessel growth, reducing inflammation and oxidative stress, improving lipid metabolism, and protecting vascular endothelium.

AIM OF THE STUDY

This subgroup analysis aimed to evaluate the efficacy and safety of Shexiang Baoxin Pill (MUSKARDIA) plus optimal medical therapy (OMT) across different weight categories in treating stable coronary artery disease (CAD).

METHODS

This investigation was a subgroup analysis of a multicenter, randomized, double-blind, placebo-controlled phase IV clinical study. Patients receiving OMT were randomly assigned to either MUSKARDIA or placebo group for a 24-month period. This analysis focused on body weight as a distinguishing factor, using 65 kg as the cutoff. The primary efficacy endpoint was the composite of major adverse cardiovascular events (MACEs), including cardiovascular death, non-fatal myocardial infarction (MI), and non-fatal stroke. Secondary efficacy endpoint comprised a composite of all-cause mortality, non-fatal MI, non-fatal stroke, hospitalizations for unstable angina or heart failure, and coronary revascularization procedures.

RESULTS

A total of 2646 patients were included in the analysis, with 916 patients weighing less than 65 kg and 1730 patients weighing 65 kg or more. The median ages were 68 (range: 35-90) years and 62 (range: 29-90) in these two subgroups, respectively. For patients weighing less than 65 kg, the MUSKARDIA group exhibited a significantly lower incidence of the primary efficacy endpoint (0.65%) compared to the placebo group (2.64%) (P = 0.018), with a reduced risk of MACEs (HR = 0.241, 95%CI: 0.068-0.856; P = 0.0168). Conversely, in patients weighing 65 kg or more, no significant differences were observed in the incidence rates or risks of primary or secondary efficacy endpoints between the MUSKARDIA and placebo groups (All P > 0.05). Adverse events were similar between two groups across both weight subgroups.

CONCLUSIONS

MUSKARDIA plus OMT demonstrated promising efficacy and acceptable safety in CAD patients weighing less than 65 kg, potentially reducing the risk of MACEs. For patients weighing 65 kg or more, further investigation is needed to optimize dosing strategies.

Causal Effects of Sleep Traits on Angina Pectoris: Mediation by Cardiovascular Risk Factors

Purpose

Angina pectoris (AP) is a major factor in heightened risk of cardiac arrest and has been previously linked to sleep patterns. It remains unclear if sleep traits play a role in the onset of AP. Our study aims to declare the causality of sleep traits on AP by Mendelian randomization (MR) analyses.

Methods

Genome-wide association study (GWAS) data of sleep traits (sleep duration, insomnia, nap during day, chronotype, getting up in morning, narcolepsy, snoring) were obtained from the UK Biobank. The AP datasets came from an analysis containing samples from the UK biobank, FinnGen, and BioBank Japan. The GWAS data of cardiovascular risk factors (hypertension, smoking, hyperlipidemia, type 2 diabetes mellitus (T2DM)) came from the FinnGen. Two-sample MR analyses were carried out to gain a general map of sleep traits, risk factors and AP, then a multivariable MR was performed and the effect of each factor was calculated.

Results

We discovered a positive association between nap, narcolepsy, insomnia and stable angina pectoris (SAP), while getting up in morning associated with SAP negatively. Adequate sleep duration related to a reduced risk of SAP and unstable angina pectoris (UAP). Hypertension and T2DM acted as complete mediators in the relationship of nap and SAP, with an effect value of 1.267 (95% CI = 1.178-1.363, P < 0.01) and 1.059 (95% CI = 1.000-1.120, P < 0.05), and the mediating proportion was 27.7% (P < 0.05) and 7.70% (P = 0.102).

Conclusion

Our study found that nap, narcolepsy, and insomnia increased the risk of SAP, with hypertension and T2DM mediating the causal relationship between nap and SAP. Getting up in the morning reduced the risk of SAP, while longer sleep duration lowered the risk of SAP and UAP. More evidences are required to clarify the roles of sleep traits and risk factors in AP.

Derivation and Validation of the PRECISE-HBR Score to Predict Bleeding After Percutaneous Coronary Intervention

BACKGROUND

Accurate bleeding risk stratification after percutaneous coronary intervention is important for treatment individualization. However, there is still an unmet need for a more precise and standardized identification of patients at high bleeding risk. We derived and validated a novel bleeding risk score by augmenting the Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy (PRECISE-DAPT) score with the Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria.

METHODS

The derivation cohort comprised 29 188 patients undergoing percutaneous coronary intervention, of whom 1136 (3.9%) had Bleeding Academic Research Consortium (BARC) 3 or 5 bleeding at 1 year, from 4 contemporary real-world registries and the XIENCE V USA trial. The PRECISE-DAPT score was refitted with a Fine-Gray model in the derivation cohort and extended with the ARC-HBR criteria. The primary outcome was BARC 3 or 5 bleeding within 1 year. Independent predictors of BARC 3 or 5 bleeding were selected at multivariable analysis (P<0.01). The discrimination of the score was internally assessed with apparent validation and cross-validation. The score was externally validated in 4578 patients from the MASTER DAPT trial (Management of High Bleeding Risk Patients Post Bioresorbable Polymer Coated Stent Implantation With an Abbreviated Versus Prolonged DAPT Regimen) and 5970 patients from the STOPDAPT-2 (Short and Optimal Duration of Dual Antiplatelet Therapy-2) total cohort.

RESULTS

The PRECISE-HBR score (age, estimated glomerular filtration rate, hemoglobin, white blood cell count, previous bleeding, oral anticoagulation, and ARC-HBR criteria) showed an area under the curve (AUC) for 1-year BARC 3 or 5 bleeding of 0.73 (95% CI, 0.71-0.74) at apparent validation, 0.72 (95% CI, 0.70-0.73) at cross-validation, 0.74 (95% CI, 0.68-0.80) in MASTER DAPT, and 0.73 (95% CI, 0.66-0.79) in STOPDAPT-2, with superior discrimination compared with PRECISE-DAPT (cross-validation: ΔAUC, 0.01; P=0.02; MASTER DAPT: ΔAUC, 0.05; P=0.004; STOPDAPT-2: ΔAUC, 0.02; P=0.20) and other risk scores. In the derivation cohort, a cutoff of 23 points identified 11 414 patients (39.1%) with a 1-year BARC 3 or 5 bleeding risk ≥4%. An alternative version of the score, including acute myocardial infarction on admission instead of white blood cell count, showed similar predictive ability.

CONCLUSIONS

The PRECISE-HBR score is a contemporary, simple 7-item risk score to predict bleeding after percutaneous coronary intervention, offering a moderate improvement in discrimination over multiple existing scores. Further evaluation is required to assess its impact on clinical practice.

Phase 1 study of novel anti-platelet agent to overcome pharmacogenomic limitations of clopidogrel

AIMS

Clopidogrel is the most commonly prescribed thienopyridine as part of dual anti-platelet therapy for the treatment of cardiovascular diseases. However, clopidogrel responsiveness shows variability based on CYP2C19 polymorphism. Therefore, we planned a study with an objective of evaluating safety, tolerability, pharmacodynamics and pharmacokinetics of a novel thienopyridine antiplatelet agent AT-10 in healthy Indian subjects compared with standard dosage regimen of clopidogrel based on their CYP2C19 genotyping.

METHODS

Two CYP2C19 genotype-based groups were identified, that is, poor metabolisers and extensive metabolisers, with 20 subjects in each group (n=40) for participating in a randomised, two-period, crossover study. Each study period lasted 6 days including administration of loading and maintenance doses of AT-10 (40 mg/10 mg) or clopidogrel (300 mg/75 mg). The pharmacokinetics and pharmacodynamics were assessed on day 1 and day 6 at several time intervals.

RESULTS

Overall result of pharmacodynamic parameters showed that mean %inhibition of platelet aggregation between AT-10 and clopidogrel in all subjects at 6 hours postdose (loading dose) (AT-10: clopidogrel; 73.30% vs 18.53%) and 6 hours postdose on day 6 (maintenance dose) (AT-10: clopidogrel; 83.41% vs 51.19 %) obtained from the AT-10 group was significantly higher than the clopidogrel group. Further, %inhibition of platelet aggregation from AT-10 treatment in poor metaboliser group was significantly higher than the clopidogrel treatments in extensive metaboliser group.Overall pharmacokinetic comparison in all subjects indicates that AT-10 gives greater exposure to active Metabolite H4 than clopidogrel.

CONCLUSION

AT-10 showed better inhibition of platelet aggregation in poor metabolizers as compared to Clopidogrel. AT-10 may emerge as a potential alternative to Clopidogrel as an anti-platelet drug. It can be further developed in clinical studies for the unmet medical needs in management of CVDs and overcome the pharmacogenomic limitations of Clopidogrel.

TRIAL REGISTRATION NUMBER

Clinical Trial Registry-India URL: http://ctri.nic.in.

REGISTRATION NUMBER

CTRI/2021/03/032206.

An aspirin-free strategy for percutaneous coronary intervention in patients with diabetes: a pre-specified subgroup analysis of the STOPDAPT-3 trial

AIMS

Safety of aspirin-free strategy immediately after percutaneous coronary intervention (PCI) for cardiovascular events in patients with diabetes was unknown.

METHODS AND RESULTS

We conducted the prespecified subgroup analysis on diabetes in the STOPDAPT-3 trial, which randomly compared prasugrel (3.75 mg/day) monotherapy (2984 patients) to dual antiplatelet therapy (DAPT) with prasugrel and aspirin (2982 patients) in patients with acute coronary syndrome or high bleeding risk. The co-primary endpoints were major bleeding events (Bleeding Academic Research Consortium 3 or 5) and cardiovascular events (a composite of cardiovascular death, myocardial infarction, definite stent thrombosis, or stroke) at 1 month. Of 5966 study patients, there were 2715 patients (45.5%) with diabetes. Patients with diabetes more often had chronic coronary syndrome, heart failure or cardiogenic shock, and comorbidities than those without. Patients with diabetes compared to those without had higher incidences of major bleeding and cardiovascular events. Regardless of diabetes, the effect of no-aspirin relative to DAPT was not different for the co-primary bleeding (diabetes: 5.05% vs. 5.47%; HR, 0.92; 95%CI, 0.66-1.28 and non-diabetes: 3.99% vs. 4.07%; HR, 0.98; 95%CI, 0.69-1.38; P for interaction = 0.81) and cardiovascular (diabetes: 5.54% vs. 5.15%; HR, 1.08; 95%CI, 0.78-1.49 and non-diabetes: 2.95% vs. 2.47%; HR, 1.20; 95%CI, 0.79-1.82; P for interaction = 0.70) endpoints. The incidences of subacute definite or probable stent thrombosis and any coronary revascularization were higher in the no-aspirin group than in the DAPT group regardless of diabetes.

CONCLUSIONS

The effects of an aspirin-free prasugrel monotherapy (3.75 mg/day) relative to DAPT for major bleeding and cardiovascular events were not different regardless of diabetes.

Identification of potential biomarkers for coronary slow flow using untargeted metabolomics

BACKGROUND

Coronary slow flow (CSF) is associated with poor cardiovascular prognosis. However, its pathogenesis is unclear. This study aimed to identify potential characteristic biomarkers in patients with CSF using untargeted metabolomics.

METHODS

We prospectively enrolled 30 patients with CSF, 30 with coronary artery disease (CAD), and 30 with normal coronary arteries (NCA), all of whom were age-matched, according to the results of coronary angiography. Serum metabolomics were analyzed using ultra-performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS). Differentially expressed metabolites were identified through orthogonal partial least squares-discriminant analysis (OPLS-DA) combined with univariate fold-change and VIP value analysis. Pathway enrichment of these metabolites was performed using the KEGG database, and ROC curves were plotted to assess the diagnostic value of the metabolites in CSF patients.

RESULTS

Compared to the CAD and NCA groups, 256 metabolites showed specific expression in CSF, with 18 meeting stringent screening criteria (VIP > 1, FC ≥ 2, or FC ≤ 0.5, and P < 0.05). Seven metabolites demonstrated high diagnostic value for CSF: inositol 1,3,4-trisphosphate (AUC: 1.0), Cer (d24:1/18:0 (2OH)) (AUC: 0.984), Creosol (AUC: 0.976), Chaps (AUC: 0.904), Arg-Thr-Lys-Arg (AUC: 0.929), Ser-Tyr-Arg (AUC: 0.912), and Methyl Indole-3-Acetate (AUC: 0.909). Pathway analysis highlighted the HIF-1 signaling pathway as the most significant metabolic pathway.

CONCLUSIONS

We identified seven metabolites that may serve as serum biomarkers for predicting and diagnosing CSF through untargeted metabolomics. The HIF-1 signaling pathway appears to be crucial in the development of CSF.

Vegetarian Dietary Patterns for Adults: A Position Paper of the Academy of Nutrition and Dietetics

It is the position of the Academy of Nutrition and Dietetics that, in adults, appropriately planned vegetarian and vegan dietary patterns can be nutritionally adequate and can offer long-term health benefits such as improving several health outcomes associated with cardiometabolic diseases. Vegetarian dietary patterns exclude meat, poultry, and seafood, and vegan dietary patterns exclude all foods of animal origin. Registered dietitian nutritionists (RDNs) and nutrition and dietetics technicians, registered (NDTRs) play a pivotal role in providing meal-planning strategies and evidence-based nutrition information to clients currently following vegetarian or vegan dietary patterns or who may benefit from and express interest in following vegetarian or vegan dietary patterns. RDNs and NDTRs can work with their clients to create tailored, lifestyle-oriented, nutritionally balanced, and culturally suitable vegetarian and vegan dietary patterns that optimize health benefits while reducing concerns about nutrient inadequacies. Adults follow vegetarian and vegan dietary patterns for various reasons. The aim of this Position Paper is to inform health care practitioners, including RDNs and NDTRs, about the evidence-based benefits and potential concerns of following vegetarian and vegan dietary patterns for different populations of nonpregnant, nonlactating adults. This Position Paper is supported by current evidence, including several systematic reviews. As leaders in evidence-based nutrition care, RDNs and NDTRs should aim to support the development and facilitation of vegetarian and vegan dietary patterns and access to nutrient-dense plant-based meals. Promoting a nutrient-balanced vegetarian dietary pattern on both individual and community scales may be an effective tool for preventing and managing many diet-related conditions. This Position was approved in January 2025 and will remain in effect until December 31, 2032.

Atherosclerosis: A Comprehensive Review of Molecular Factors and Mechanisms

Atherosclerosis, a condition characterized by the accumulation of lipids and a culprit behind cardiovascular events, has long been studied. However, in recent years, there has been an increase in interest in its initiation, with researchers shifting focus from traditional pathways involving the vascular infiltration of oxidized lipids and towards the novel presence of chronic inflammatory pathways. The accumulation of pro-inflammatory cytokines, in combination with the activation of transcription factors, creates a positive feedback loop that drives the creation and progression of atherosclerosis. From the upregulation of the nod-like receptor protein 3 (NLRP3) inflammasome and the Notch and Wnt pathways to the increased expression of VEGF-A and the downregulation of connexins Cx32, Cx37, and Cx40, these processes contribute further to endothelial dysfunction and plaque formation. Herein, we aim to provide insight into the molecular pathways and mechanisms implicated in the initiation and progression of atherosclerotic plaques, and to review the risk factors associated with their development.

Engineered extracellular vesicles as nanosponges for lysosomal degradation of PCSK9

Proprotein convertase subtilisin/kexin type 9 (PCSK9) plays a crucial role in the degradation of the low-density lipoprotein receptor (LDLR), and PCSK9 inhibition emerges as an attractive strategy for atherosclerosis management. In this study, extracellular vesicles (EVs) were engineered to nanosponges, which could efficiently adsorb and deliver PCSK9 into lysosomes for degradation. Briefly, nanosponges were engineered by modifying EVs with EGF-A/PTGFRN fusion protein (PCSK9 binding domain EGF-A from the mutant LDLR with higher affinity was fused to the C terminus of prostaglandin F2 receptor negative regulator). The modification endowed the EVs with hundreds of EGF-As displayed on the surface, and thus the capacity to adsorb PCSK9 efficiently. The adsorbed PCSK9 would thus be delivered into lysosomes for degradation when the nanosponges were endocytosed by liver cells, thus releasing endogenous LDLR from degradation. In the ApoE-/- mouse model, tail vein-injected nanosponges were able to degrade PCSK9, increase LDLR expression, lower the LDL-C level, and thus alleviate atherosclerosis. In summary, here we not only develop a novel strategy for PCSK9 inhibition but we also propose a universal method for adsorption and degradation of circulating proteins for disease management.

Clinical and angiographic profile of left main coronary artery disease in patients with chronic coronary syndrome: a retrospective study

BACKGROUND

Obstructive left main disease (LMD) is a challenging entity of coronary artery disease with variable patterns among different studies. We aimed to evaluate the prevalence, demographic, clinical, and angiographic profiles of LMD. We conducted a single-center retrospective study over a period of 10 years to screen all patients who underwent elective cardiac catheterization for chronic coronary syndrome. Of the 19,336 screened cases, 944 obstructive LMD patients were included as the patients' group. Age and sex-matched control groups included patients with normal coronary angiography and non-LMD.

RESULTS

Obstructive LMD had a prevalence of 4.9%, a mean age of around 60 years, and a male to female ratio of approximately 3:1. About 9.8% of LMD patients were < 50 years. Compared to males, females with LMD had significantly older age and increasing prevalence with age from 9.7% in patients < 50 years to 27.4% in patients > 70 years. LMD versus non-LMD patients had a significantly higher prevalence of diabetes mellitus, dyslipidemia, and number of stenotic coronary segments and arteries, and nonsignificant differences regarding smoking, hypertension, previous myocardial infarction, and ejection fraction. Ostial LMD had a prevalence of 2%, a mean age of around 58 years and 21% were females. In LMD patients, the most affected sites were the ostial/proximal left anterior descending artery and distal left main bifurcation. Bypass grafting surgery was the standard angiographic decision in LMD in 75.8% of cases, which was significantly higher than non-LMD. LMD patients revascularized surgically versus percutaneous treatment had significantly lower ejection fraction, significantly higher multivessel disease, and no significant differences regarding age, sex, hypertension, and diabetes mellitus.

CONCLUSION

Obstructive LMD is a relatively common angiographic finding, with a higher prevalence among males around 60 years. In LMD, bypass grafting was the main revascularization strategy. We recommend integrating clinical characteristics, and noninvasive investigations as a predictive model of LMD.

Association of American Heart Association's Life's Essential 8 and mortality among US adults with and without cardiovascular disease

BACKGROUND

Differences in the American Heart Association's Life's Essential 8 (LE8) score and its association with mortality based on the presence of clinically prevalent cardiovascular disease (CVD) has not been assessed previously.

METHODS

Data from the National Health and Nutrition Examination Survey 2009-2018 were utilized to calculate LE8 scores among adult patients, stratified by the presence of existing CVD. Health metrics were further divided into health behaviors and health factors. Scores were also evaluated based on sex, age, race/ethnicity, and socioeconomic status. Cox proportional hazard models were used to evaluate the association between the levels of cardiovascular health (CVH), estimated using LE8 score, and risk of all-cause and cardiovascular mortality.

RESULTS

25,359 patients were included in the analysis, of which 10.2 % had CVD. Individuals with known CVD had lower overall CVH (55.9 vs. 65.8, p < 0.001), health behaviors (60.6 vs. 67.9, p < 0.001), and health factors (51.3 vs. 63.8, p < 0.001) scores. The lower CVH scores in those with prior CVD persisted after stratification by sex, age, race/ethnicity, and socioeconomic status. When assessing the association of CVH metrics with mortality, for every 10-point increase in LE8 score, there was a significant reduction (17 %-27 %) in all-cause and CV mortality in those with and without CVD.

CONCLUSIONS

Individuals with known CVD have lower CVH metric scores. Overall, the LE8 score is able to predict future CV outcomes in both individuals with and without CVD and highlights the importance of effective implementation strategies that target health factors and behaviors in primary and secondary prevention populations.

Polysaccharides: The Sweet and Bitter Impacts on Cardiovascular Risk

Cardiovascular risk is a clinical factor that represents the probability of developing cardiovascular diseases (CVDs). This risk is shaped by non-modifiable and modifiable factors, including dietary patterns, which are the main lifestyle factor influencing CVD. Dietary polysaccharides, integral to nutrition, have varying effects on cardiovascular health depending on their type and source. They include starches, non-starch polysaccharides, and prebiotic fibers, categorized further into soluble and insoluble fibers. Soluble fibers, found in oats, legumes, and fruits, dissolve in water, forming gels that help lower serum cholesterol and modulate blood glucose levels. Insoluble fibers, present in whole grains and vegetables, aid in bowel regularity. The cardiovascular benefits of polysaccharides are linked to their ability to bind bile acids, reducing cholesterol levels, and the production of short-chain fatty acids by gut microbiota, which have anti-inflammatory properties. However, not all polysaccharides are beneficial; refined starches can lead to adverse metabolic effects, and chitosan to mixed effects on gut microbiota. This review examines the dualistic nature of polysaccharides, highlighting their beneficial roles in reducing cardiovascular risk factors and the potential adverse effects of specific types.

Self-care behaviours of first-generation Chinese immigrants living with cardiovascular disease: A qualitative study

AIM

To identify and describe self-care behaviours performed by Chinese immigrants living with cardiovascular disease in Australia, and factors perceived as barriers and facilitators to evidence-based cardiac self-care.

DESIGN

A qualitative descriptive design.

METHODS

Individual semi-structured phone interviews were conducted among participants meeting the following criteria: (1) first-generation Chinese immigrants to Australia, born in Mainland China, Hong Kong, Macao or Taiwan; (2) Australian permanent residents or citizens; (3) self-reported or medically diagnosed with coronary heart disease, stroke or heart failure; (4) able to speak English or Mandarin; (5) able to provide informed consent, excluding those with history or evidence of impaired cognition such as dementia. Participants were recruited via social media, Chinese community associations and medical centres from September 2021 to June 2022. Data were analysed using inductive and deductive thematic analysis, guided by the Middle-Range Theory of Self-Care of Chronic Illness. The study was reported in line with the COREQ checklist.

RESULTS

Twenty participants were interviewed, 60% female, mean age 69.9 years. Most migrated to Australia at older age following their retirement in China; most had limited English proficiency. Many practiced adequate self-care for their CVD in self-care maintenance and monitoring. Variously, they adopted heart-healthy diets, developed exercise routines, attended medical services and closely monitored their body signs and symptoms. However, self-adjusting medications, taking Traditional Chinese Medicine and self-administering health supplements were prevalent practices and first-response management of acute cardiac symptoms was suboptimal. Linguistic and cultural barriers to obtaining mainstream heart health information meant most participants resorted to informal, anecdotal and mainland Chinese sources.

CONCLUSION

Diverse factors were held responsible for sub-optimal self-care behaviours but lack of access to linguistically and culturally appropriate heart health information was widely blamed. Linguistically and culturally appropriate community-based heart health education programmes are urgently needed, targeting healthy lifestyle modification, medication literacy and cardiac symptom management.

IMPACT

Study findings can be used to improve cardiac nurses' cultural sensitivity and practices targeting Chinese immigrants. Partnering with Chinese community associations offers health service providers and policymakers an innovative route to co-design and deliver targeted heart health education interventions and support for this population.

PUBLIC CONTRIBUTION

Chinese community centre managers contributed to data collection by supporting participant recruitment.

The Society of Thoracic Surgeons Preoperative Beta Blocker Working Group Interim Report

BACKGROUND

Atrial fibrillation (AF) occurs commonly after cardiac surgery and is associated with multiple adverse outcomes. Older randomized trials suggested that perioperative β- blockade reduced postoperative AF, and The Society of Thoracic Surgeons (STS) coronary artery bypass grafting (CABG) composite measure includes β-blocker administration preoperatively within 24 hours of surgery and at discharge. However, some more recent studies suggest preoperative β-blockade has limited value and question its continuation as an STS quality measure.

METHODS

In 2022, an STS Preoperative Beta Blocker Working Group was formed with representatives from the STS and the Society of Cardiovascular Anesthesiologists. Published randomized trials, observational studies, societal guidelines, and the current state of available data from the STS Adult Cardiac Surgery Database (ACSD) were reviewed.

RESULTS

Review of existing studies reveals substantial heterogeneity or insufficient detail regarding specific β-blockers used, timing of initiation, management of patients on chronic β-blockade, and whether other proarrhythmic or antiarrhythmic drugs were used concurrently. Further, β-blocker data currently collected in the STS ACSD lack sufficient granularity.

CONCLUSIONS

Because a new randomized trial seems unlikely, the Working Group believes that more granular data on real-world practice would facilitate assessment of the value of preoperative β-blockade in the current era, development of best practice recommendations, and evaluation of their continued appropriateness as an STS quality metric. STS ACSD participants have been invited to participate in a voluntary survey whose additional data, when linked to STS ACSD records, will better delineate contemporary β-blocker practice and outcomes.

Cardiovascular disease in the Americas: optimizing primary and secondary prevention of cardiovascular disease series: cardiovascular disease in the Americas

While, many interventions can prevent cardiovascular disease (CVD), and its resulting morbidity or mortality, these are used sub-optimally in most countries. Therefore, health systems need to develop new approaches to ensure that proven CVD therapies are delivered widely. In this review, we describe five impactful implementation strategies which include: (1) Task shifting, (2) Use of mobile-Health (mHealth) support and virtual access to care, (3) simplified diagnostic and management algorithms for the prevention of CVD, (4) improving the use of combinations of medicines (i.e., polypill), and (5) patient engagement and role of patient-nominated peer support (i.e., treatment supporters). Adapting and tailoring these strategies to the local context in different settings in various countries in the Americas and the Caribbean can reduce the morbidity and mortality of CVD substantially.

Assessment of bystander coronary artery disease in transcatheter aortic valve replacement (TAVR) patients using noncoronary-dedicated planning computed tomography angiography (CTA): diagnostic accuracy in a retrospective real-world cohort

AIM

To assess the diagnostic potential of a noncoronary-dedicated pre-TAVR CT angiography (CTA) conducted as a prospective ECG-gated scan without premedication and standard cardiac reconstructions in evaluating bystander coronary artery disease (CAD) against invasive coronary angiography (ICA) as the gold standard.

MATERIALS AND METHODS

This retrospective study included 232 patients who underwent both CTA and ICA as part of their pre-TAVR evaluation. Exclusion criteria included prior stent, pacemaker, coronary artery bypass, or valve surgery. Coronary arteries were analysed solely through thin-slice axial reconstructions, with observers blinded to ICA results. Stenosis was categorised as mild (< 50%), moderate (50%-69%), or severe (≥70%). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were calculated for 50% and 70% diameter stenosis (DS) thresholds.

RESULTS

At the 50% DS threshold, CTA demonstrated 71% sensitivity, 74% specificity, 92% NPV, and 38% PPV. At the 70% DS threshold, results included 46% sensitivity, 91% specificity, 93% NPV, and 41% PPV. The highest vessel-specific NPV at 50% DS was for the left main (98%) and left anterior descending (LAD) (91%); at 70% DS, left main (LM) (98%) and left circumflex (LCX) (94%) showed the highest NPV. Image quality impacted NPV, with excellent or very good image quality linked to higher diagnostic performance.

CONCLUSION

Noncoronary-dedicated pre-TAVR CTA shows promise for ruling out significant CAD effectively and may act as a gatekeeper for ICA, aligning with typical coronary CT angiography (CCTA) outcomes.

Cardiac Complications of Radiation Therapy

Radiation therapy is a critical component in managing many malignancies by improving local control and survival. The benefits of radiation may come at the expense of unintended radiation injury to the surrounding normal tissues, with the heart being one of the most affected organs in thoracic radiation treatments. As cancer survivors live longer, radiation-induced cardiotoxicity (RICT) is now increasingly recognized. In this review, we highlight the spectrum and pathophysiology of RICT. We summarize contemporary recommendations for risk stratification, screening, prevention, and management of RICT. We briefly highlight novel applications for radiation to treat some cardiac conditions such as resistant arrhythmias.

Beta-Blockers After PCI for Stable Coronary Artery Disease and Preserved Left Ventricular Ejection Fraction

BACKGROUND

Limited data exist on the long-term impact of beta-blocker therapy after percutaneous coronary intervention (PCI) in patients with stable coronary artery disease (CAD) and preserved left ventricular ejection fraction (LVEF).

OBJECTIVES

The aim of the study was to evaluate the effects of early beta-blocker initiation vs no initiation following PCI in patients with stable CAD and preserved LVEF.

METHODS

This retrospective cohort study employed target trial emulation and incident user design, utilizing the TriNetx database (2009-2024). Early beta-blocker initiation (within days 1 and 7) was compared with no initiation using 1:1 greedy propensity score matching. The outcomes included all-cause mortality, hospitalization for myocardial infarction, heart failure, atrial fibrillation/flutter, stroke, and safety endpoints. Hospitalization for bone fracture and acute appendicitis served as falsification endpoints. In the intention-to-treat analysis, outcomes were analyzed over 5 years using Cox-proportional hazards.

RESULTS

Out of 11,681 matched patients per group, beta-blocker therapy was associated with increased all-cause mortality (HR: 1.11 [95% CI: 1.09-1.18]). No significant differences were found in hospitalization for myocardial infarction (HR: 1.03 [95% CI: 0.97-1.09]), stroke (HR: 0.98 [95% CI: 0.91-1.05]), heart failure (HR: 0.99 [95% CI: 0.95-1.03]), and atrial fibrillation/flutter (HR: 0.97 [95% CI: 0.93-1.01]). Hospitalization for hypotension was higher with beta-blockers (HR: 1.10 [95% CI: 1.06-1.14]). Hospitalization for bone fracture (HR: 1.02 [95% CI: 0.85-1.22]) and acute appendicitis (HR: 1.17 [95% CI: 0.95-1.45]) showed no significant associations. Several sensitivity analyses showed consistent results.

CONCLUSIONS

Early beta-blocker initiation after PCI for stable CAD with preserved LVEF was associated with higher mortality, with no impact on cardiovascular events.

Main Coronary Flow Calculation With the Assistance of Physiological Side Branch Flow

OBJECTIVE

Fractional flow reserve (FFR) derived from coronary angiography, referred to as ICA-FFR, is a less-invasive alternative for invasive FFR measurement based on computational fluid dynamics. Blood flow into side branches influences the accuracy of ICA-FFR. However, properly compensating for side branch flow in ICA-FFR analysis is challenging. In this study, we proposed a physiological side branch flow model to comprehensively compensate side branch flow for ICA-FFR analysis with no need for reconstructing side branch geometry.

METHODOLOGY

the physiological side branch flow model employed a reduced-order model to calculate the pressure distribution in vessel segments. The main coronary artery (without side branches) was delineated and divided based on bifurcation nodes. The model compensates for flow to invisible side branches within each segment and flow to visible side branches at each bifurcation node. Lastly, ICA-FFR based on physiological side branch flow model (ICA-FFR) was calculated from a single angiographic view. Functional stenosis is defined by FFR 0.80.

RESULT

Our study involved 223 vessels from 172 patients. Using invasive FFR as a reference, the Pearson correlation coefficient of ICA-FFR was 0.93. ICA-FFR showed a high AUC (AUC = 0.96) and accuracy (91.9) in predicting functional stenosis.

CONCLUSION

The proposed model accurately compensates for flow to side branches without their geometry in ICA-FFR analysis. ICA-FFR analysis exhibits high feasibility and diagnostic performance in identifying functional stenosis.

Effect of Nuts on Anthropometric and Glycemic Indexes and Blood Pressure in Secondary Cardiovascular Prevention: A Systematic Review and Meta-analysis of Randomized Controlled Trials

CONTEXT

Nut-enriched diets have a positive impact on cardiovascular risk factors, such as body mass, blood pressure, and fasting blood glucose. However, studies in individuals undergoing secondary cardiovascular prevention show controversial results.

OBJECTIVE

This systematic review with meta-analysis assessed the effect of nut supplementation on anthropometric, glycemic, and blood pressure indices in patients with atherosclerotic cardiovascular disease, as well as the frequency of adverse events.

DATA SOURCES

Six databases were used for the search-PubMed, Cochrane Library, EMBASE, BVS (Biblioteca Virtual da Saude), Web of Science, and ClinicalTrials.gov-until February 2023, with no language restrictions.

DATA EXTRACTION

The Cochrane Handbook for Systematic Reviews of Interventions methodology and the PICOS (Population, Intervention, Comparison, Outcome, Setting/design) strategy were used. Seven independent reviewers were involved in data extraction and resolution of disagreements. Certainty of the evidence was evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.

DATA ANALYSIS

From 5187 records identified, 6 publications containing data referring to 5 randomized clinical trials (n = 436) were included in the final analyses. The nuts evaluated were almonds, pecans, Brazil nuts, and mixed nuts, with portions that varied between 5 g and 85 g (median: 30 g/day). The intervention period varied between 6 and 12 weeks. The nuts had no effect on fasting glucose and anthropometric indices, although the certainty of the evidence for most of these outcomes was low or very low. They also had no effect on systolic (mean difference [MD]: -1.16 mmHg [95% CI, -5.68 to 3.35], I2 = 0%-moderate certainty of evidence) or diastolic (MD: 0.10 mmHg [95% CI, -2.30 to 2.51], I2 = 0%-high certainty of evidence) blood pressure. It was not possible to aggregate data on adverse events.

CONCLUSION

Nut supplementation had no effect on blood pressure, fasting glucose, or anthropometric profile in the context of atherosclerotic cardiovascular disease.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42020163456.

Head-to-Head Comparison of Learning Curves Between QFR and FFRangio Software Users

BACKGROUND

Quantitative flow ratio (QFR) and FFRangio are angiography-based technologies used to perform functional assessment of coronary lesions from angiographic images, validated across multiple clinical studies. There is limited information on the learning curves associated with each technology.

AIMS

This study aims to compare the learning curves of QFR and FFRangio in evaluating coronary stenoses, focusing on changes in analysis speed and accuracy compared to invasive measurements.

METHODS

A team of five blinded investigators, including two nurses, one medical student, and one physician in training, underwent identical standardized training on both technologies. The time taken for each analysis and the computed FFR values were documented and compared against the invasive gold standard.

RESULTS

A total of 270 lesions (54 coronary lesions in 44 patients) were retrospectively analyzed. The median invasive FFR value was 0.88 [IQR 0.5, 0.9]. The median time for analysis with QFR and FFRangio was 245 [IQR 62, 319] and 252 [IQR 82, 315] s, respectively (p = 0.171). Both QFR and FFRangio demonstrated a significant reduction in the time required for analysis as experience increased (p < 0.01). Regarding accuracy, the median difference with invasive FFR for QFR and FFRangio was 0.06 [IQR: 0, 0.12] and 0.06 [IQR: 0, 0.12], respectively (p = 0.620). Both technologies reached a performance plateau early on, exhibiting comparable results throughout the study.

CONCLUSION

Initial training in QFR and FFRangio enables quick attainment of maximal performance, but further practice primarily enhances analysis speed while maintaining accuracy, for both software.