2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

Myocardial flow reserve and resting contractility modulate the impact of contractile reserve in patients undergoing rubidum-82 positron emission tomography

Although ejection fraction reserve (EFR) harbors prognostic value in patients undergoing positron emission tomography (PET) myocardial perfusion imaging (MPI), whether resting EF and myocardial flow reserve (MFR) modulate its prognostic value has not been studied. Consecutive patients undergoing stress/rest MPI using Rb-82 PET between 2019 and 2024 were included. The primary outcome was a composite of death and heart failure (HF) hospitalizations. Multivariable Andersen-Gill Cox models were used to assess the association of EFR with the primary outcome across the spectrum of resting EF and MFR. Restricted cubic splines were used to allow non-linearity. The 50th percentile of EFR served as the reference, with the 25th and 75th percentiles representing low and high EFR. The analysis included 7,737 consecutive patients among whom 463 deaths and 821 HF hospitalizations occurred over a median follow-up of 554 days. A low EFR was associated with a 25% greater risk of the primary outcome (HR: 1.25; 95% CI: 1.16 to 1.35). The association was stronger at higher values of resting EF (HR at EFs of 40% and 70%: 0.99 and 1.21 respectively) and MFR (HR at MFRs of 1 and 3: 1.06 and 1.27 respectively). Similarly, a high EFR carried a protective association that was more pronounced at a higher resting EF and MFR. The prognostic implications of contractile reserve, as measured by EFR, are most pronounced in patients with a higher resting EF and MFR.

High-Throughput Echocardiography-Guided Induction of Myocardial Ischemia/Reperfusion in Mice

BACKGROUND

Mouse models of myocardial ischemia with subsequent heart failure are common approaches to examine heart failure pathology and possible treatment strategies. We sought to establish a high-throughput approach for echocardiography-guided induction of myocardial ischemia/reperfusion (IR) in mice.

METHODS

After visualization of the left coronary artery with high-resolution ultrasound imaging and echocardiographic definition of the level of coronary occlusion, the left anterior descending artery was temporarily occluded with 2 micromanipulator-controlled needles. Functional and molecular changes were assessed and compared with commonly performed surgical techniques.

RESULTS

Echocardiography-guided induction of myocardial IR enabled standardized induction of myocardial IR injury with subsequent left ventricular remodeling. Incorporation of various quality control measures throughout the procedure ensured a high success rate and the absence of relevant postinterventional mortality in experienced hands. Compared with surgical approaches, echocardiography-guided induction of myocardial IR showed a quicker recovery time and induced a less pronounced inflammatory response characterized by decreased local and systemic neutrophil counts. Notably, infarct size and subsequent post-myocardial infarction cardiac dysfunction were comparable between methods. The novel procedure was successfully implemented at different academic institutions with imaging expertise and demonstrated high interinstitutional reproducibility.

CONCLUSIONS

Echocardiography-guided induction of myocardial IR enables high-throughput induction of myocardial IR injury with precise echocardiographic definition of the occlusion level and immediate evaluation of cardiac function during ischemia. The method provides a more clinically relevant assessment of IR sequelae and offers notable animal welfare advantages by eliminating the need for ventilation and thoracotomy, thereby mitigating potential surgery-related confounders.

The Association of Elevated Depression Levels and Life's Essential 8 on Cardiovascular Health With Predicted Machine Learning Models and Interpretations: Evidence From NHANES 2007-2018

Background and Objective: The association between depression severity and cardiovascular health (CVH) represented by Life's Essential 8 (LE8) was analyzed, with a novel focus on ranked levels and different ages. Machine learning (ML) algorithms were also selected aimed at providing predictions to suggest practical recommendations for public awareness and clinical treatment. Methods: We included 21,279 eligible participants from the National Health and Nutrition Examination Survey (NHANES) 2007-2018. Weighted ordinal logistic regression (LR) was utilized with further sensitivity and dose-response analysis, and ML algorithms were analyzed with SHapley Additive exPlanations (SHAP) applied to make interpretable results and visualization. Results: Our studies demonstrated an inverse relationship between LE8 and elevated depressive levels, with robustness confirmed through subgroup and interaction analysis. Age-specific findings revealed middle-aged and older adults (aged 40-60 and over 60) which showed higher depresion severity, highlighting the need for greater awareness and targeted interventions. Eight ML algorithms were selected to provide predictive results, and further SHAP would become ideal supplement to increase model interpretability. Conclusions: Our studies demonstrated a negative association between LE8 and elevated depressive levels and provided a suite of ML predictive models, which would generate recommendations toward clinical implications and subjective interventions.

Neuroinflammation and energy metabolism: a dual perspective on ischemic stroke

Ischemic stroke is a prevalent form of cerebrovascular accident, with its pathogenesis involving the intricate interplay between neuroinflammation and energy metabolism. Cerebral ischemia disrupts oxygen and energy supply, triggering metabolic dysregulation and activating neuroinflammatory responses, ultimately resulting in cellular damage. This review provides an exhaustive analysis of the complex mechanisms of ischemic stroke, with a particular focus on the interaction between neuroinflammation and energy metabolism. The interruption of oxygen and energy supply due to cerebral ischemia initiates metabolic dysregulation and activates neuroinflammatory responses, including the release of inflammatory cytokines and the activation of immune cells, contributing to cellular damage and further metabolic disturbances. Studies indicate that dysregulation of energy metabolism significantly impairs neural cell function and interacts with neuroinflammation, exacerbating ischemic brain injury. Therapeutic strategies primarily concentrate on modulating energy metabolism and suppressing neuroinflammatory responses, emphasizing the importance of in-depth research into their interaction to provide a theoretical foundation for new treatment strategies for ischemic stroke. Future research should focus on how to balance anti-inflammatory treatment with energy regulation to minimize neural damage and promote recovery.

Cardiac rhythm devices in heart failure with reduced ejection fraction - role, timing, and optimal use in contemporary practice. European Journal of Heart Failure expert consensus document

Guidelines for management of heart failure with reduced ejection fraction (HFrEF) emphasize personalized care, patient engagement, and shared decision-making. Medications and cardiac rhythm management (CRM) devices are recommended with a high level of evidence. However, there are significant disparities: patients who could benefit from devices are frequently referred too late or not at all. Misconceptions about device therapy and the notion that the needs of patients (especially the prevention of sudden cardiac death) can now be met by expanding drug therapies may play a role in these disparities. This state-of-the-art review is produced by members of the DIRECT HF initiative, a patient-centred, expert-led educational programme that aims to advance guideline-directed use of CRM devices in patients with HFrEF. This review discusses the latest evidence on the role of CRM devices in reducing HFrEF mortality and morbidity, and provides practical guidance on patient referral, device selection, implant timing and patient-centred follow-up.

Early Mortality and Medical Complexity Among Medicolegal Cardiovascular Disease Deaths: Comparing Housed and Unhoused Decedents

BACKGROUND

There are extreme psychosocial, environmental, and behavioral risks to the health and well-being of persons experiencing homelessness. Within this complex and hazardous environment, there is an opportunity to gain clearer perspective into the role of accelerating cardiovascular disease (CVD) progression alongside the aging cohort effect in this population.

METHOD

Utilizing 2021 and 2022 data from the Harris County Medical Examiner, investigators analyzed CVD-associated deaths for excess mortality and impact of age-related factors specific to persons experiencing homelessness. All medicolegal deaths involving CVD were examined to determine relative frequencies of secondary causes of death and the influence of age between housed individuals and individuals experiencing homelessness.

RESULTS

The examination of the CVD mortality cases among persons experiencing homelessness in 2021 (n = 52) and 2022 (n = 71) revealed important trends. The mean age for CVD deaths for persons experiencing homelessness was 58.6 and 60.6 years in 2021 and 2022, respectively. Despite this slight, recent increase, the average age for CVD death among persons experiencing homelessness is dramatically lower than the housed, medicolegal CVD deaths, and the general population. Top-associated conditions were hypertension and atherosclerosis, regardless of housing status. However, chronic obstructive pulmonary disease and congestive heart failure were more common in CVD deaths of people experiencing homelessness.

DISCUSSION

These findings reemphasize the uniqueness and complexity of the risks for premature mortality in people experiencing homelessness. This underscores the call for social services and healthcare systems to be more responsive to the challenges faced by persons experiencing homelessness, with more integrated and targeted health and aging care interventions to address the specific needs of these marginalized individuals.

Principles for the Future of Biomedical Research in the United States and Optimizing the National Institutes of Health: A Presidential Advisory From the American Heart Association

Groundbreaking achievements in science and medicine have contributed to reductions in cardiovascular disease and stroke mortality over the past 7 decades. Many of these advances were supported through investments by the National Institutes of Health, the global leader in funding biomedical research. This public investment has produced important economic returns, including supporting >400 000 jobs and roughly $93 billion in economic activity in the United States. Unfortunately, public funding has not kept pace with the burden of disease or rates of inflation. As the nation's oldest and largest volunteer organization dedicated to fighting heart disease and stroke, research is critical to the American Heart Association's mission. Given the American Heart Association's unique position in representation of patients, clinicians, and scientists and as a research funder, we offer the following principles to optimize the future of the US biomedical research enterprise in general and the National Institutes of Health in particular. Specifically, the United States should continue to prioritize innovative and impactful research; to improve efficiency and transparency in its peer review process; to lead in translating evidence into practice; to support the current and future biomedical workforce; and to ensure robust and reliable public investment for the future. The American Heart Association reiterates our strong support for the National Institutes of Health and federal agencies that fund and implement biomedical and population-based research initiatives, which yield important economic returns. These agencies are vital to support today's current and future health challenges, to drive foundational science, to improve patient health, to reduce the global disease burden, to address upstream and preventive strategies, and to improve the value of our public health and health care investments.

Physical activity and diet pattern do not mitigate C-reactive protein increases associated with oral contraceptive use

The purpose of this study was to examine the influence of body mass index (BMI), physical activity (PA) level, dietary inflammatory index (DII), and oral contractive (OC) use on C-reactive protein (CRP) levels, and to determine if elevated CRP values reflect systemic inflammation in OC users. Data were obtained from four cycles (1999-2006) of the U.S. National Health and Nutrition Examination Survey (NHANES) study, yielding a sample of 496 current OC users and a comparator group of 1,583 regularly menstruating women. A general linear model was used to test for interaction effects among BMI, PA level, and OC use, after adjusting for age and smoking status, with log-transformed CRP (lnCRP) identified as the outcome variable. Sequential general linear models with no interaction terms were then constructed to examine the impact of BMI, PA level, and OC use on circulating lnCRP after adjusting for age and smoking status. Follow-up analyses used general linear models to assess the relationship between lnCRP and other indices of systemic inflammation among OC users and nonusers, and to examine the predictors of lnCRP within each subgroup. The omnibus model including smoking status, age, PA level, OC use, and BMI did not identify any statistically significant two-way or three-way interaction effects (all p ≥ .259). The adjusted r2 value of the model modestly increased from 0.3789 to 0.3801 when all interaction terms were removed. After adjusting for smoking status and age, a sequentially built model indicated that PA level was inversely related to lnCRP values (p = .0019). When OC use was added to the model, it was positively associated with lnCRP values (p < .0001), with statistically and clinically significant lnCRP differences between OC users and nonusers. BMI was the last variable entered into the model, which was positively associated with lnCRP (p < .0001). Among OC nonusers, PA level (p = .0008) and BMI (p < .0001) were significantly predictive of lnCRP levels after adjusting for smoking status and age. In contrast, PA level was not significantly predictive of lnCRP values (p = .718) among OC users. All alternative indices of inflammation were positively correlated with lnCRP values (all p < .0001), but correlations were significantly stronger among OC users than nonusers (all p < .05). In a subset of OC nonusers with complete nutrition data, PA level (p = .021), BMI (p < .0001), and DII (p = .007) were significantly predictive of lnCRP after adjusting for smoking status and age. In contrast, PA level (p = .709) and DII (p = .690) were not significantly predictive of lnCRP values among OC users. In conclusion, OC-induced elevations in CRP appear to be reflective of a chronic, systemic inflammatory response. PA and low DII are associated with lower CRP among OC nonusers, but do not mitigate CRP elevations among OC users.

Bridging Prevention and Imaging: The Influence of Statins on CAC and CCTA Findings

To evaluate the impact of statins on CHD prevention, role of CAC scoring and CCTA in guiding statin therapy for both primary and secondary prevention in ASCVD. Coronary artery calcium (CAC) scoring and coronary computed tomography angiography (CCTA) have emerged as vital non-invasive imaging tools for refining cardiovascular risk assessment and guiding statin therapy in patients with atherosclerotic cardiovascular disease (ASCVD). CAC scoring helps stratify patients based on subclinical atherosclerosis burden, while CCTA provides detailed insights into plaque composition and distribution. Multiple studies, including the Multi-Ethnic Study of Atherosclerosis (MESA) and the CONFIRM registry, have demonstrated the utility of CAC scoring in identifying individuals at risk of major adverse cardiovascular events (MACE) and guiding personalized statin therapy. CAC scores, categorized into risk-based thresholds, enable clinicians to determine when statins should be initiated or deferred. CCTA complements CAC scoring by assessing plaque characteristics, including non-calcified plaque (NCP), calcified plaque, and high-risk features such as low-attenuation plaques, spotty calcifications, and positive remodeling. Serial CCTA imaging has further highlighted the effect of high-intensity statin therapy on plaque progression, demonstrating reductions in NCP and stabilization through increased calcification. CAC scoring effectively identifies patients with subclinical atherosclerosis who would benefit from statin therapy, particularly those with CAC scores > 100 or in the ≥ 75th percentile for age and sex. Statin therapy has been shown to promote plaque stabilization by increasing calcified plaque volume while reducing the progression of non-calcified plaques, thereby mitigating the risk of plaque rupture. CCTA provides additional value by identifying vulnerable plaque features and monitoring the impact of statin therapy over time. Studies have demonstrated significant reductions in total plaque volume and low-attenuation plaques in patients undergoing intensive lipid-lowering therapy, reinforcing the role of CCTA in guiding statin decisions for patients with established ASCVD. CAC scoring serves as a powerful tool to refine risk stratification and guide statin therapy initiation, particularly in asymptomatic individuals. CCTA enhances this approach by providing comprehensive plaque assessment and monitoring the response to statin therapy. Integrating CAC scoring and CCTA into clinical practice allows for a personalized approach to ASCVD management, improving patient outcomes through optimized statin therapy and targeted risk reduction.

Blood-brain barrier repair: potential and challenges of stem cells and exosomes in stroke treatment

Stroke is characterized with high morbidity, mortality and disability all over the world, and one of its core pathologies is blood-brain barrier (BBB) dysfunction. BBB plays a crucial physiological role in protecting brain tissues and maintaining homeostasis in central nervous system (CNS). BBB dysfunction serves as a key factor in the development of cerebral edema, inflammation, and further neurological damage in stroke patients. Currently, stem cells and their derived exosomes have shown remarkable potential in repairing the damaged BBB and improving neurological function after stroke. Stem cells repair the integrity of BBB through anti-inflammatory, antioxidant, angiogenesis and regulation of intercellular signaling mechanisms, while stem cell-derived exosomes, as natural nanocarriers, further enhance the therapeutic effect by carrying active substances such as proteins, RNAs and miRNAs. This review will present the latest research advances in stem cells and their exosomes in stroke treatment, as well as the challenges of cell source, transplantation timing, dosage, and route of administration in clinical application, aiming to discuss their mechanisms of repairing BBB integrity and potential for clinical application, and proposes future research directions. Stem cells and exosomes are expected to provide new strategies for early diagnosis and precise treatment of stroke, and promote breakthroughs in the field of stroke.

Robust EEG Characteristics for Predicting Neurological Recovery from Coma After Cardiac Arrest

OBJECTIVE

Clinically, patients in a coma after cardiac arrest are given the prognosis of "neurological recovery" to minimize discrepancies in opinions and reduce judgment errors. This study aimed to analyze the background patterns of electroencephalogram (EEG) signals from such patients to identify the key indicators for assessing the prognosis after coma.

APPROACH

Standard machine learning models were applied sequentially as feature selectors and filters. CatBoost demonstrated superior performance as a classification method compared to other approaches. In addition, Shapley additive explanation (SHAP) values were utilized to rank and analyze the importance of the features.

RESULTS

Our results indicated that the three different EEG features helped achieve a fivefold cross-validation receiver-operating characteristic (ROC) of 0.87. Our evaluation revealed that functional connectivity features contribute the most to classification at 70%. Among these, low-frequency long-distance functional connectivity (45%) was associated with a poor prognosis, whereas high-frequency short-distance functional connectivity (25%) was linked with a good prognosis. Burst suppression ratio is 20%, concentrated in the left frontal-temporal and right occipital-temporal regions at high thresholds (10/15 mV), demonstrating its strong discriminative power.

SIGNIFICANCE

Our research identifies key electroencephalographic (EEG) biomarkers, including low-frequency connectivity and burst suppression thresholds, to improve early and objective prognosis assessments. By integrating machine learning (ML) algorithms, such as Gradient Boosting Models and Support Vector Machines, with SHAP-based feature visualization, robust screening methods were applied to ensure the reliability of predictions. These findings provide a clinically actionable framework for advancing neurological prognosis and optimizing patient care.

Outpatient worsening heart failure: innovative decongestion strategies and health equity implications

Worsening heart failure (WHF) is a major clinical and economic challenge, contributing to high rates of hospitalization and significant healthcare costs. While WHF has traditionally been managed through hospitalization, recent approaches are shifting toward outpatient care to maximize patient time spent at home and optimize allocation of hospital resources. Emerging treatments like subcutaneous furosemide and intranasal bumetanide offer promising alternatives for safe, well-tolerated, and effective diuresis outside the hospital. However, these novel strategies face several challenges, including the need for clinician/staff training, patient education, logistical difficulties, and a lack of evidence in diverse populations. To ensure equitable management, it is also essential to address healthcare disparities, particularly in socioeconomically disadvantaged and rural populations. While these new treatments have the potential to improve care delivery, additional research is necessary to assess their comparative effectiveness and overcome current limitations fully.

Incidence, Prevalence, and Trends in Mortality and Stroke among Medicare Beneficiaries With Atrial Fibrillation: 2013 to 2019

BACKGROUND

Atrial fibrillation (AF) is known to be associated with increased risks of stroke and death, but contemporary studies of this association are lacking. We evaluated trends in stroke and death among Medicare beneficiaries with AF between 2013 and 2019.

METHODS

Medicare fee-for-service beneficiaries >65 years old (2011-2019) were included. AF incidence and prevalence were calculated overall and by age group, sex, race, and rurality. Within incident cohorts, the 1-year stroke rate was assessed. Age- and sex-adjusted mortality at 30 days, 1 year, and 3 years was calculated in each incident cohort.

RESULTS

The mean number of Medicare beneficiaries with incident AF per year was 572 630 from 2013 to 2019 (30.44 per 1000 patient-years). The study cohort on average was 79±7.7 years old, 52% female, 88% white, and 83% urban dwelling. Incidence and prevalence of AF increased with age and was highest among White beneficiaries; the incidence was greater in male compared with female beneficiaries. Differences by rurality were not seen. Overall AF prevalence per 1000 beneficiaries increased minimally but steadily from 2013 to 2019 reflecting an increase among male (104-109 per 1000) but not female beneficiaries (82.5 per 1000). The 1-year rate of stroke after incident AF peaked in the 2015 cohort (50.5 per 1000); the rate was at its lowest among the 2018 cohort (41.89 per 1000). Incident AF was associated with mortality that was 3.2× greater than expected at 1 year, but overall mortality and the magnitude of the AF-related mortality risk decreased steadily over time from 22% to 20%.

CONCLUSIONS

From 2013 to 2019, AF incidence and prevalence among Medicare beneficiaries were relatively stable but have varied by important demographic subgroups with age and sex remaining powerful risk factors. In contrast, mortality and stroke after incident AF have decreased significantly throughout this era.

Statin-Associated muscle symptoms and vitamin D supplementation

PURPOSE OF REVIEW

Statin medications play a pivotal role in the primary and secondary prevention and management of cardiovascular disease due to their potent lipid-lowering and anti-inflammatory effects. Nevertheless, the clinical application of statins is often hampered by statin-associated muscle symptoms (SAMS), which deter patient adherence and treatment efficacy considerably. SAMS currently affects 10-20% of statin users, thus understanding potential mitigation strategies is crucial. This review focuses on the role of vitamin D in mitigating SAMS, given the growing interest in vitamin D deficiency as a potentially modifiable risk factor.

RECENT FINDINGS

Despite observational suggestions linking vitamin D deficiency to heightened SAMS risk, recent studies have yielded conflicting results on the role of vitamin D supplementation in preventing SAMS. Some studies report an improvement in statin tolerance following vitamin D repletion. However, recent large-scale clinical trials, particularly the Vitamin D and Omega-3 trial (VITAL) report no significant benefit of vitamin D supplementation in preventing SAMS or reducing statin discontinuation rates, regardless of baseline vitamin D levels.

SUMMARY

Observational data provides evidence for the use of vitamin D supplementation in SAMS management, however conflicting evidence in recent clinical trials do not support its routine use for preventing or treating SAMS. To explore alternative strategies in improving statin tolerance and adherence, this discourse aims to elucidate the current understanding the complex mechanisms underlying SAMS, the influence of serum vitamin D levels, and the implications for clinical management.

CXCL12 drives natural variation in coronary artery anatomy across diverse populations

Coronary arteries have a specific branching pattern crucial for oxygenating heart muscle. Among humans, there is natural variation in coronary anatomy with respect to perfusion of the inferior/posterior left heart, which can branch from either the right arterial tree, the left, or both-a phenotype known as coronary dominance. Using angiographic data for >60,000 US veterans of diverse ancestry, we conducted a genome-wide association study of coronary dominance, revealing moderate heritability and identifying ten significant loci. The strongest association occurred near CXCL12 in both European- and African-ancestry cohorts, with downstream analyses implicating effects on CXCL12 expression. We show that CXCL12 is expressed in human fetal hearts at the time dominance is established. Reducing Cxcl12 in mice altered coronary dominance and caused septal arteries to develop away from Cxcl12 expression domains. These findings indicate that CXCL12 patterns human coronary arteries, paving the way for "medical revascularization" through targeting developmental pathways.

Patterns of Adherence to Home Blood Pressure Monitoring Among Men and Women in the Electronic Framingham Heart Study

Background

Worldwide, there are differences in hypertension control by sex. The use of home blood pressure monitoring (HBPM) is associated with lower average blood pressures and higher medication adherence. However, little is known about adherence trajectories and sex differences in HBPM. This study characterizes adherence to HBPM among those with and without hypertension.

Methods

Electronic Framingham Heart Study participants were instructed to perform HBPM weekly for 1 year. Adherence was defined as having ≥1 measurement per week averaged over 4-week segments. Primary exposures of hypertension status and sex were self-reported. Group-based trajectory modeling was used to identify adherence trajectories. Logistic regression was applied to investigate factors associated with membership in each trajectory group in the sex-stratified and whole cohorts.

Results

Among 990 participants (58% women, age 53±9 years, 26% hypertension), three groups with distinct HBPM adherence patterns were identified: "early discontinuation", "gradual decrease", and "high adherence". Participants with hypertension were more likely to maintain "high adherence" compared to those without (OR 1.55; 95% CI 1.08-2.23), with similar findings seen among women with hypertension (OR 2.24; 95% CI 1.35-3.72) but not men. In women, these findings remained significant when adjusting for anxiety, depression, and blood pressure, but were attenuated by adjusting for age and income.

Conclusions

This study highlights HBPM adherence trajectories and shows that women with hypertension were more likely to be in the high adherence group, though these associations were attenuated after adjusting for demographic factors and co-morbidities. Future studies should explore strategies to enhance adherence in populations at risk of early discontinuation.

Assessment of the association between constipation and atherosclerosis in cardiovascular and cerebrovascular diseases: a systematic review and meta-analysis

INTRODUCTION

Cardiovascular and cerebrovascular diseases remain leading causes of morbidity and mortality worldwide, with atherosclerosis as a key underlying mechanism.

METHODS

A systematic review was conducted of studies published between 2000 and August 2024, sourced from PubMed, Web of Science, Cochrane, and EMBASE databases. Twelve studies, involving 5,772,682 adults across six countries, met predefined inclusion criteria. Study quality was assessed using the Newcastle-Ottawa Scale (NOS) and the Agency for Healthcare Research and Quality (AHRQ) scale. A meta-analysis was performed to quantify the association.

RESULTS

The meta-analysis revealed a statistically significant association between constipation and atherosclerosis-related cardiovascular and cerebrovascular diseases, with a pooled odds ratio of 1.18 (95 % CI: 1.08-1.30). This finding indicates that individuals with constipation may face an elevated risk of these conditions.

CONCLUSIONS

These findings suggest that constipation could serve as a potential risk factor or marker warranting further investigation in clinical and mechanistic studies.

Sex Differences in Embolic Stroke of Undetermined Source: Echocardiographic Features and Clinical Outcomes

BACKGROUND

Sex differences in stroke are well-documented, but in embolic stroke of undetermined source (ESUS) remains underexplored. This study aims to investigate sex-related differences in clinical and cardiac features and stroke outcomes in ESUS.

METHODS

Retrospective observational single-center study including consecutive ESUS patients. Multivariate regression analyses evaluated the association between sex, echocardiographic features, and 90-day outcomes. Cox regression assessed the independent effect of sex on ischemic stroke recurrence, all-cause death, and atrial fibrillation detection after stroke (AFDAS).

RESULTS

Among 556 patients, 248 (44.6%) were women, who were older and had more severe strokes. Women exhibited larger left atria (LA) as evidenced by a higher LA volume index (adjusted β-coefficient = 2.59, 95% CI 0.53-4.65, p = 0.014) and more valve abnormalities, such as mitral annulus calcification (aOR 2.72; 95% CI 1.43-5.20, p = 0.002). Men showed more markers of left ventricular (LV) disease, including reduced ejection fraction < 50% (aOR 0.44; 95% CI 0.20-0.93, p = 0.033) and LV wall motion abnormalities (aOR 0.37; 95% CI 0.19-0.74, p = 0.005). In multivariate analyses, the female sex was independently associated with reduced all-cause death (aHR 0.59; 95% CI 0.38-0.91, p = 0.019) and showed a trend toward higher AFDAS risk (aHR 1.57; 95% CI 0.99-2.49, p = 0.053). No association was found with 90-day outcomes or stroke recurrence.

CONCLUSION

ESUS patients exhibit significant sex-based differences in echocardiographic features, with women showing larger LA and more valve abnormalities, while men present greater LV dysfunction. Female sex is independently associated with a lower risk of long-term mortality and a potentially higher risk of AFDAS. These findings underscore the need for individualized, sex-specific ESUS management strategies.

Age-Dependent Associations Between Pulse Pressure and Long-Term Outcomes After Myocardial Infarction

Pulse pressure (PP) is a recognized marker of cardiovascular risk in the general population. However, its role as an independent predictor of recurrent cardiovascular events following myocardial infarction (MI) and whether there are age-dependent differences in this relationship remains uncertain. We analyzed data from 4091 participants with a history of MI were enrolled in the Kailuan Study. Univariate and multivariable Cox models were used to analyze the associations between PP and primary outcome (composite cardiovascular events, a composite of all-cause death, nonfatal recurrent MI, nonfatal hospitalization for heart failure or nonfatal stroke) and secondary outcomes (each individual components of composite endpoint) after MI. Over a median follow-up of 7.8 years, 1610 composite cardiovascular events occurred. The mean baseline PP was 54.2 ± 16.1 mmHg. Compared with individuals in the first PP quartile, those in the fourth quartile had significantly greater risks of composite cardiovascular events (adjusted HR: 1.20; 95% CI: 1.03-1.41; p = 0.02) and recurrent MI (adjusted HR: 1.56; 95% CI: 1.03-2.36; p = 0.04). A linear, dose-response relationship was observed between PP and the risk of adverse cardiovascular outcomes (all p ≤ 0.02), except for stroke (p = 0.36). Subgroup analyses indicated that the association between PP and adverse outcomes was stronger among participants aged <60 years compared with older individuals. Elevated PP is an independent predictor of recurrent cardiovascular outcomes in post-MI patients, with particularly stronger associations observed in younger and middle-aged adults. Trial Registration: ChiCTR-TNRC-11001489.

Hybrid Electro-optical Stimulation Improves Ischemic Brain Damage by Augmenting the Glymphatic System

Ischemic brain injury not only results in significant neurological, motor, and cognitive impairment but also contributes to the accumulation of toxic solutes and proinflammatory cytokines in the infarction region, exacerbating ischemic brain damage. The glymphatic system, which is crucial for brain waste clearance and homeostasis, is impaired by ischemic injury, highlighting the importance of developing therapeutic strategies for poststroke complications. Herein, a novel hybrid electro-optical stimulation device is proposed that integrates near-infrared micro-light-emitting diode with transparent microneedles, enabling efficient noninvasive stimulation of the cortical area for ischemic stroke treatment. This study investigates whether this hybrid electro-optical stimulation enhances the glymphatic system function and ameliorates ischemic brain injury in the middle cerebral artery occlusion and reperfusion (MCAO/R) mice model. The results demonstrate that hybrid stimulation improves the neurological, motor, and cognitive functions and reduces brain atrophy following MCAO/R. Moreover, hybrid stimulation restores impaired glymphatic system function by modulation of aquaporin-4 (AQP4) polarization and alleviates the accumulation of proinflammatory cytokines such as IL-1β. Notably, AQP4 inhibition partly reverses the improved functional outcomes of hybrid stimulation. The findings suggest that targeting glymphatic drainage using hybrid electro-optical stimulation is a promising therapeutic approach for treating ischemic brain injury.

An Emergency Medical Services to Emergency Department Checklist for Handoff of Cardiac Arrest: A Modified Delphi Approach

Objectives

Effective communication during handoffs between emergency medical services (EMS) and emergency department (ED) personnel is a critical step in out-of-hospital cardiac arrest (OHCA) care. No handoff tool has been specifically designed for OHCA, in which timely and accurate transfer of information can substantially affect patient care. This study aimed to develop a standardized checklist for OHCA handoffs based on expert consensus using a modified Delphi approach.

Methods

A panel of experts from EMS and the ED were recruited to rate the importance of 17 preidentified communication items derived from video reviews of OHCA handoffs. Experts completed 2 rounds of identical surveys, followed by participation in a focus group. Participants were asked to rate the importance of each item from 1 to 10 and the timing of when items should be communicated (ie, first, second, or third part of the handoff). The focus group further refined the checklist, finalizing the key elements to be included during a 90-minute virtual session via unanimous consensus.

Results

Eleven experts were approached, 10 completed surveys, and 7 participated in the focus group. The expert panel developed a 13-item checklist (patient age, location/cause of arrest, witnessed arrest, estimated downtime, bystander cardiopulmonary resuscitation, initial rhythm, most recent rhythm, episodes of return of spontaneous circulation, defibrillation attempts, airway type, vascular access, medications administered, and code status). Witnessed arrest, bystander cardiopulmonary resuscitation, and estimated downtime were prioritized for the first part of handoff communication.

Conclusion

This study developed a concise, expert-driven checklist for OHCA handoffs to improve communication between EMS and ED.

Suboptimal medication possession ratio is associated with recurrent ischemic stroke in a veteran population

OBJECTIVES

Recurrent stroke results in higher disability and mortality but might be mitigated through interventions that improve medication adherence. The medication possession ratio (MPR) is an objective proxy for adherence that may provide an individualized risk assessment for recurrent stroke.

METHODS

This is a retrospective, longitudinal cohort study of patients with recent ischemic stroke or TIA referred to a Veterans Affairs vascular neurology outpatient clinic between 2010 and 2016. We calculated average MPR quartile for four medication classes used for secondary stroke prevention by reviewing pharmacy and medical records following an incident cerebral ischemic event. Traditional stroke risk factors were quantified using the Framingham Stroke Risk Profile (FSRP) score. We hypothesized that lower average MPR would relate to higher recurrent stroke risk more than FSRP or stroke etiological classification.

RESULTS

For 255 patients with stroke or TIA, 57 (22.4 %) patients had recurrent stroke during a median follow-up period of 5.0 years (IQR 2.0). Compared to optimal average MPR, each quartile lower average MPR was associated with higher cumulative incidence of recurrent stroke (subhazard ratio 1.63, 95 %CI: 1.24 to 2.14, p<0.001) while accounting for the competing risk of death and covarying for FSRP. Neither FSRP nor stroke etiology were associated with recurrent stroke. However, higher baseline systolic blood pressure starting at 132 mm Hg was independently associated with stroke recurrence.

CONCLUSIONS

MPR is an effective proxy measurement to assess risk of recurrent stroke. Systems-based and individualized interventions to improve medication adherence are needed to reduce recurrent stroke rates in VA populations.

Association Between Use of WATCHMAN Device and 1-Year Mortality Using High-Dimensional Propensity Scores to Reduce Confounding

BACKGROUND

Previous observational studies showed left atrial appendage occlusions with the WATCHMAN device reduced 1-year mortality, which conflicted with evidence generated from randomized controlled trials. We proposed to use the high-dimensional propensity score (hdPS) to assist in nonactive comparator selection (prevalent user of medication) and compared 1-year mortality between patients with atrial fibrillation who received the WATCHMAN device (percutaneous left atrial appendage occlusion device [pLAAO]) and direct oral anticoagulants in 2 matched cohorts based on (1) traditional propensity score (PS) and (2) integrating traditional PS with information learned from hdPS.

METHODS

Patients entered the cohort once diagnosed with atrial fibrillation in the 15% of Medicare fee-for-service claims database from 2011 to 2018. Patients could enter the study cohort upon receiving WATCHMAN or at an outpatient visit with an atrial fibrillation diagnosis, respectively. We used PS matching with a 1:3 ratio for patients in pLAAO and direct oral anticoagulant groups. In cohort 2, we implemented a multistep approach with information learned from hdPS. The Cox proportional hazards model was used to estimate hazard ratios of outcomes with 95% CIs.

RESULTS

In cohort 1, we identified 1159 and 3477 patients in the pLAAO and direct oral anticoagulant groups with a mean age of 78.1 versus 77.5 years, 44.9% versus 40.8% of women, and a 1-year mortality rate of 8.02 versus 8.97/100 person-years (hazard ratio, 0.87 [95% CI, 0.69-1.09]). With the support of hdPS, in cohort 2, we excluded patients with malignant cancer and added frailty score in the PS model. We identified 953 and 2859 patients in the pLAAO and direct oral anticoagulant groups with a mean age of 78.1 versus 77.9 years, 47.2% versus 46.1% of women, and a 1-year mortality rate of 7.45 and 7.69/100 person-years (hazard ratio, 0.95 [95% CI, 0.73-1.24]).

CONCLUSIONS

No association was found between pLAAO and 1-year mortality, which is consistent with existing evidence from randomized controlled trials. The hdPS approach provides an opportunity to improve nonactive comparator selection in traditional PS analysis.

Chronic Administration with FAD012 (3,5-Dimethyl-4-hydroxycinnamic Acid) Maintains Cerebral Blood Flow and Ameliorates Swallowing Dysfunction After Chronic Cerebral Hypoperfusion in Rats

Dysphagia is a serious complication of stroke, yet effective pharmacological treatments remain limited. This study investigated the effects of FAD012 (3,5-dimethyl-4-hydroxy cinnamic acid), a synthetic derivative of ferulic acid (FA), on cerebral damage and swallowing dysfunction in a rat model of bilateral common carotid artery occlusion (2VO). Sprague-Dawley rats were orally administered FAD012 (3 or 10 mg/kg), FA (10 mg/kg), or 0.5% carboxymethyl cellulose (CMC, suspension vehicle) starting one week before 2VO. Two weeks after 2VO surgery, which was performed under isoflurane anesthesia, reflex swallowing was assessed by electromyographic recordings of the mylohyoid muscle under urethane anesthesia. Two weeks after 2VO, cerebral blood flow (CBF) declined to approximately 40% of baseline, and the number of reflex swallowing responses was significantly reduced in the CMC group. Additionally, 2VO induced O2- production, apoptotic cell death in the striatum, and a reduction in tyrosine hydroxylase expression. Substance P (SP) levels in the laryngopharyngeal mucosa, positively regulated by dopaminergic signaling in the basal ganglia, also decreased. FAD012 (10 mg/kg) effectively prevented the 2VO-induced reduction in CBF, enhanced the reflex swallowing, and preserved the dopamine-SP system. Notably, FAD012 exerted significantly stronger effects than FA at the same dose. These findings suggest that FAD012 maintains CBF under cerebral hypoperfusion and enhances the swallowing reflex by maintaining neuronal function in the striatal and laryngopharyngeal regions of 2VO rats.

Evolution of Medical and Surgical Management of Carotid Disease from Carotid Endarterectomy to Transfemoral Carotid Stenting to TCAR

Patients with carotid stenosis can be broadly classified into 2 categories: symptomatic and asymptomatic. While there is little disagreement about surgical management of symptomatic carotid stenosis, the optimal management strategy for the patients with asymptomatic carotid disease has undergone significant evolution over past 5 decades. With increasing focus on role of plaque morphology on the etiology of symptoms, there has been an increased focus on optimizing the medical management targeted at plaque stabilization, especially for the patients with asymptomatic carotid disease, while reserving the most aggressive surgical treatment options for the patients with symptomatic carotid stenosis. This review summarizes the scientific evidence based on multiple large clinical studies showing how the modern-day management of carotid stenosis has evolved. Multiple, large randomized clinical trials have established carotid endarterectomy (CEA) as the treatment of choice for symptomatic patients with symptomatic, >50% stenosis of carotid artery or those who have asymptomatic high-grade carotid stenosis. With the advancements in endovascular techniques, the technique of transfemoral carotid artery stenting (TF-CAS) was popularized, but after multiple, large randomized controlled trials demonstrated superiority of CEA, the indications for TF-CAS as the initial operation of choice for carotid disease for all patients have been reduced. In the past 5 years, the introduction of the newer technique of trans carotid artery revascularization (TCAR) has shown promising results with significant reduction in the incidence of perioperative complications as compared to CEA and TF-CAS; however, there have been no randomized controlled trials comparing TCAR to either CEA or TF-CAS. Moreover, with the developments in the medical field with introduction of several new medications which have been demonstrated to successfully change the plaque morphology, there has been a renewed interest in exploring if the indications for surgical management for the asymptomatic carotid disease should be revisited.

What Is 'Food Is Medicine,' Really? Policy Considerations On The Road To Health Care Coverage

Food Is Medicine interventions are increasingly gaining attention from policy makers, payers, and health care professionals as a promising approach to addressing diet-related chronic health conditions in the health care setting, given the increasing burden and cost of these conditions. The American Heart Association defines Food Is Medicine as the provision of healthy food such as medically tailored meals, medically tailored groceries, and produce prescriptions to treat or manage specific clinical conditions in a way that is integrated with and paid for by the health care sector. Importantly, Food Is Medicine is distinct from, yet complementary to, food and nutrition assistance programs and population-level healthy food policies and programs. In this article, we discuss the importance of this distinction and the prerequisites for successfully integrating Food Is Medicine interventions within the health care system: a standard definition of Food Is Medicine focused on medically tailored meals, medically tailored groceries, and produce prescriptions; a research base showing clinical effectiveness and cost-effectiveness; and implementation that ensures fidelity and quality.

Pregnancy Metal Mixtures and Blood Pressure and Hypertension in Mid-Life: A Prospective U.S. Cohort Study

BACKGROUND

The long-term associations between metal mixtures in pregnancy and women's mid-life blood pressure (BP) and hypertension remain unclear.

METHODS

In Project Viva (enrolled 1999-2002), we measured nonessential (arsenic, barium, cadmium, cesium, mercury, lead) and essential metals (copper, magnesium, manganese, selenium, zinc) in red blood cells, along with folate and vitamin B12 in plasma, collected during pregnancy. We measured mid-life BP from 2017 to 2021 (median age, 51.2 years). We examined associations of individual metals with BP using linear regression and with hypertension (≥130/80 mm Hg or use of antihypertensive medication) using modified Poisson regression. We used Bayesian kernel machine regression to examine the mixture effects of metals and micronutrients.

RESULTS

The median follow-up time of the 493 women was 18.1 years (interquartile range, 17.8-18.6 years). After adjustment, a doubling of copper and manganese was associated with 0.75 (95% CI, 0.57-0.99) and 0.80 (95% CI, 0.71-0.91) times the risk of hypertension, respectively. Although higher cesium and selenium levels were associated with a slightly increased risk of hypertension, the 95% CIs were wide and crossed the null. A doubling of vitamin B12 was associated with a 3.64 (95% CI, 1.23-6.04) mm Hg lower systolic BP and a 2.52 (95% CI, 0.72-4.32) mm Hg lower diastolic BP. Bayesian kernel machine regression showed linear associations with no metal-metal or metal-micronutrient interactions. The essential metal mixture was monotonically associated with lower BP, while its association with hypertension showed threshold effects.

CONCLUSIONS

Optimizing essential metal levels during pregnancy, particularly copper and manganese, along with vitamin B12, may protect against higher BP and hypertension in mid-life women.

End-Of-Life Symptoms and Symptom Management in Older Adults With Stroke Versus Cancer

Background: Little is known about the end-of-life (EOL) experience in older adults with stroke or how similar the EOL experience is in older adults with stroke when compared to those with cancer. Purpose: We utilized data from the National Health and Aging Trends Study (NHATS) to compare symptoms, symptom management, and overall rating of care in the last month of life between older adults diagnosed with stroke and those diagnosed with cancer. Methods: Logistic regression was used to examine the associations between diagnosis and symptom prevalence, symptom management, and overall care quality, adjusting for care intensity, place of death, and demographic covariates. Results: A total of 747 NHATS participants diagnosed with stroke or cancer were identified. Diagnosis of stroke was associated with whether the symptoms of pain (OR .46, 95% CI .26-.83), dyspnea (OR .32, 95% CI .17-.64), and emotional distress were documented (OR .57, 95% CI .33-.98). Diagnosis was not associated with pain management (OR .85, 95% CI .48-1.48), dyspnea management (OR .97, 95% CI .47-2.03), or emotional distress management (OR 1.02, 95% CI .53-1.97). Correlates of overall care quality included place of death and diagnosis, with patients with stroke more likely to report poorer care quality (OR 1.77, 95% CI 1.03-3.04) as well as those who died in the hospital (OR 2.18, 95% CI 1.26-3.77). Conclusions: Older adults with stroke are at risk for inadequate symptom assessment and documentation, as well as poorer symptom management and poorer overall care quality.

Innovative approaches to boost mesenchymal stem cells efficacy in myocardial infarction therapy

Stem cell-based therapy has emerged as a promising approach for heart repair, potentially regenerating damaged heart tissue and improving outcomes for patients with heart disease. However, the efficacy of stem cell-based therapies remains limited by several challenges, including poor cell survival, low retention rates, poor integration, and limited functional outcomes. This article reviews current enhancement strategies to optimize mesenchymal stem cell therapy for cardiac repair. Key approaches include optimizing cell delivery methods, enhancing cell engraftment, promoting cell functions through genetic and molecular modifications, enhancing the paracrine effects of stem cells, and leveraging biomaterials and tissue engineering techniques. By focusing on these enhancement techniques, the paper highlights innovative approaches that can potentially transform stem cell therapy into a more viable and effective treatment option for cardiac repair. The ongoing research and technological advancements continue to push the boundaries, hoping to make stem cell therapy a mainstream treatment for heart disease.

Clinical practice patterns among older multimorbid adults presenting with suspected ischemic symptoms: A multi-center survey

Background

When patients with suspected or known coronary artery disease (CAD) present with new or worsening ischemic symptoms, initial referral to imaging or optimization of guideline directed medical therapy (GDMT) with deferral of testing are both acceptable management approaches.

Methods

In this 12-center study, a 19-item survey exploring preferred management strategy for symptomatic older adults (≥75 years) with or without known CAD, and major patient and clinical factors driving this decision making was administered to clinicians.

Results

There were 96 respondents (70.8 % cardiologists, 20.9 % primary care physicians/geriatricians). Among patients without known CAD, 59 (61.4 %) respondents favored early referral to testing, 6 (6.3 %) opted for initial GDMT and 23 (24.0 %) preferred both. For patients with known CAD, 27 (28.1 %) prioritized initial GDMT optimization, 37 (38.6 %) would refer for early testing and 19.8 % both. Key factors influencing initial preference for GDMT optimization were unoptimized anti-anginal medications, patient preference, increased complication risk, frailty, cognitive impairment and comorbidities. Key factors influencing preference for initial imaging were increasing symptom severity, already optimized GDMT, and electrocardiogram changes. When imaging revealed ischemia, clinicians reported weighing symptom severity, ischemic burden, current medications, comorbidities, frailty, and procedural risks before referring for invasive cardiac angiography.

Conclusion

Both initial GDMT optimization and referral for imaging are frequently used approaches for the symptomatic older patient with suspected or known CAD. The survey highlighted the importance of patient characteristics such as frailty, cognitive impairment, multimorbidity and the gap in clinical guidance on how to optimally manage symptomatic older adults with CAD.

Blood Pressure Monitoring and Knowledge in the First Year after a Hypertensive Disorder of Pregnancy

Introduction: In the first year postpartum, hypertension is a leading cause of morbidity and mortality, particularly for those with hypertensive disorders of pregnancy (HDPs). Given that timely recognition of hypertension is key to reducing short- and long-term cardiovascular risk, we assessed knowledge of when to seek medical attention for blood pressure (BP) elevations and rates of BP measurement in the first year postpartum. Methods: This was a secondary analysis of a cohort of 405 primiparas who enrolled in a randomized trial during pregnancy. We calculated the proportion who stated they would contact a clinician for a systolic BP above 140 and a diastolic BP above 90 at 3 months postpartum, and the frequency and location of BP checks reported from 2 to 12 months postpartum by HDP status. Results: HDPs were reported by 16% of participants. Mean age was 32 ± 5 years; 40% identified as non-White, and 25% had public insurance. At 3 months postpartum, 44.6% with HDPs and 23.5% without identified a systolic BP of 140 as the threshold above which to contact a clinician (p < 0.01); 52.4% with HDPs and 28.5% without identified a diastolic BP threshold of 90 (p < 0.01). From 3 to 12 months postpartum, people with HDPs were more likely to report a BP check (83.1% versus 59.4%, p < 0.01) and home BP monitoring (41.6% versus9.7%, p < 0.01). Home monitoring was not associated with awareness of when to seek help for hypertension among those with HDPs. Conclusions: Efforts are needed to improve awareness of when to seek medical attention for postpartum hypertension.

Development of hypertension in individuals with high normal blood pressure is related with sympathetic drive, arterial stiffness, and exercise blood pressure

BACKGROUND

High normal blood pressure (HNBP) is common in adults worldwide and is associated with a greater likelihood of developing hypertension. Thus, identifying those at risk is crucial, in order to intervene early and reduce future cardiovascular risk. This study aims to examine the role of sympathetic nervous system (SNS), aortic stiffness, and blood pressure (BP) response to exercise as predictors for development of hypertension in individuals with HNBP.

METHODS

One hundred individuals with HNBP were included in the study. Baseline anthropometric characteristics, BP levels, an electrocardiogram, and an echocardiogram were obtained. In order to evaluate the effect of SNS, aortic stiffness, and exercise response in the transition from the prehypertensive to hypertensive phenotype, we measured the levels of muscle sympathetic nerve activity (MSNA), pulse wave velocity (PWV), and exaggerated BP response (EBPR) to cardiopulmonary exercise, respectively.

RESULTS

At 3 years follow up, 40 patients (40%) developed hypertension. Baseline characteristics were similar between the two groups. Those who developed hypertension had sympathetic overactivation, as indicated by the higher mean values of MSNA (35 ± 4.4 vs 28 ± 3.8 bursts per minute; P = 0.003), increased aortic stiffness, and PWV (8.2 ± 0.7 vs 7.2 ± 0.5 m/s; P < 0.001), as well as an EBPR to exercise (P < 0.001).

CONCLUSION

Increased values of MSNA, PWV, and EBPR were found to be statistically related with hypertension development in HNBP phenotypes. These markers could be of great clinical use in identifying prehypertensives at high risk for developing hypertension.

2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" incorporates new evidence since the "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction" and the corresponding "2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes" and the "2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction." The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" and the "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization" retire and replace, respectively, the "2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease."

METHODS

A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Rates of Acute Kidney Injury Utilizing Area Under the Concentration-Time Curve Versus Trough-Based Vancomycin Dosing Strategies in Patients With Obesity

Background

Vancomycin is commonly utilized for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections. Dosing recommendations for vancomycin have shifted in recent years to favor area under the concentration-time curve (AUC) instead of trough-based dosing strategies to decrease vancomycin exposure and rates of acute kidney injury (AKI). However, little data exist on the safety and efficacy of AUC-based dosing in patients with obesity.

Methods

This was a single-center retrospective cohort study conducted between 1 January 2014 and 31 December 2022. Adult patients aged ≥18 years were included if they were obese and received vancomycin for treatment of a severe MRSA infection for at least 72 hours. The primary outcome was incidence of AKI based on Kidney Disease: Improving Global Outcomes (KDIGO) criteria.

Results

After initial screening, 398 patients were included, with 230 in the trough group and 168 in the AUC group. Rates of AKI were lower in the AUC group compared to the trough group (11.3% vs 25.2%, P < .001). After adjusting for potential confounders, logistic regression maintained a reduction in AKI with AUC-based dosing for cumulative doses less than the median of 10 250 mg (odds ratio, 0.47 [95% confidence interval, .25-.88]) but not for doses above. Rates of initial target attainment were also higher with AUC-based dosing (50.0% vs 23.9%, P < .001).

Conclusions

Patients with obesity receiving vancomycin for treatment of severe MRSA infections experienced lower rates of AKI when utilizing an AUC- versus trough-based dosing strategy.

A Clinical Retrospective Study on the Combined Use of Monocyte-to-Lymphocyte Ratio and Triglyceride-Glucose Index to Predict the Severity of Coronary Artery Disease

Background

Coronary artery disease (CAD) remains a leading cause of morbidity and mortality. Traditional risk models based on factors like age, hypertension, and lipid levels are limited in individualized prediction, especially for high-risk populations. This study evaluates the independent and combined predictive value of the monocyte-to-lymphocyte ratio (MLR) and triglyceride-glucose (TyG) index for assessing CAD severity.

Methods

In this single-center, retrospective study, 678 patients who underwent coronary angiography (CAG) between January 2022 and June 2024 were included. Eligible patients were aged ≥ 40 years with suspected or confirmed CAD. Clinical data and laboratory values were extracted from electronic records. MLR was calculated as the monocyte-to-lymphocyte ratio, and TyG index was derived from fasting triglycerides and glucose. CAD severity was categorized by SYNTAX scores into no CAD, mild, moderate, and severe CAD. Statistical analyses included Spearman correlation, multivariate logistic regression, and receiver operating characteristic (ROC) curve analysis to assess the diagnostic accuracy of MLR and TyG index.

Results

Of the 678 patients, 67.1% had CAD. Both MLR and TyG index were significantly associated with CAD severity, with MLR showing a stronger correlation with SYNTAX scores. Multivariate analysis confirmed MLR (odds ratio (OR) = 2.15) and TyG index (OR = 1.75) as independent predictors of CAD. The combined MLR-TyG model achieved an area under the curve (AUC) of 0.804, surpassing the predictive value of each marker alone. Subgroup analysis indicated high predictive accuracy in diabetic and hypertensive patients.

Conclusions

MLR and TyG index independently and jointly predict CAD severity, with the combined model enhancing diagnostic accuracy. Reflecting both inflammatory and metabolic dysfunction, this dual-marker approach offers a practical tool for CAD risk stratification, particularly in high-risk populations. Further multicenter studies are needed to validate these findings and examine additional biomarker combinations to refine CAD risk models.

Combination of Biological Aging and Genetic Susceptibility Helps Identifying At-Risk Population of Venous Thromboembolism: A Prospective Cohort Study of 394 041 Participants

Phenotypic age acceleration (PhenoAgeAccel) is a novel clinical aging indicator. This study was carried out to investigate the relationship between PhenoAgeAccel and the incidence of VTE, as well as to integrate PhenoAgeAccel with genetic susceptibility to improve risk stratification of VTE. The study included 394 041 individuals from the UK Biobank. Phenotypic age was calculated based on actual age and clinical biomarkers. PhenoAgeAccel presents the residual obtained from a linear regression of phenotypic age against actual age, reflecting the rate of aging. Significant associations were observed between PhenoAgeAccel and higher risk of VTE (Hazard ratio [HR] 1.37, 95% CI: 1.32-1.42), deep vein thrombosis (DVT, HR 1.35, 95% CI: 1.29-1.42), and PE (pulmonary embolism, HR 1.41, 95% CI: 1.34-1.48) in the findings. PhenoAgeAccel exhibited a significant additive interaction with genetic susceptibility. Biologically older participants with high genetic risk have a 3.83 (95% CI: 3.51-4.18) folds risk of VTE, a 3.59 (95% CI: 3.21-4.03) folds risk of DVT, and 4.39 (95% CI: 3.88-4.98) folds risk of PE, in comparison to biologically younger participants with low genetic risk. Mediation analyses indicated that PhenoAgeAccel mediated approximately 6% of the association between cancer and VTE, and about 20% of the association between obesity and VTE. Our study indicated that PhenoAgeAccel is significantly associated with higher risk of VTE, and can be combined with genetic risk to improve VTE risk stratification. Additionally, PhenoAgeAccel holds promise as a clinical biomarker for guiding targeted prevention and treatment strategies for VTE.

Targeting cardiac fibrosis with Chimeric Antigen Receptor-Engineered Cells

Cardiac fibrosis poses a significant challenge in cardiovascular diseases due to its intricate pathogenesis, and there is currently no standardized and effective treatment approach. The fibrotic process entails the involvement of various cell types and molecular mechanisms, such as fibroblast activation and proliferation, increased collagen synthesis, and extracellular matrix rearrangement. Traditional therapies often fall short in efficacy or carry substantial side effects. However, recent studies have shown that Chimeric Antigen Receptor T (CAR-T) cells can selectively target and eliminate activated cardiac fibroblasts (CFs) in mice, leading to reduced cardiac fibrosis and improved myocardial tissue compliance. This breakthrough presents a new and promising avenue for treating cardiac fibrosis. Currently, CAR-T cell-based therapy for cardiac fibrosis is undergoing animal experimentation, indicating ample scope for enhancement. Future investigations could explore the application of CAR cell therapy in cardiac fibrosis treatment, including the potential of CAR-natural killer (CAR-NK) cells and CAR macrophages (CAR-M), offering novel insights and strategies for combating cardiac fibrosis.

Transcarotid Artery Revascularization Learning Curves Differ between Surgeon Experience Level

BACKGROUND

There has been ensuing interest in adopting transcarotid artery revascularization (TCAR), because of its low perioperative stroke and complication rates. In our study, we aimed to identify the case number at which there is improvement in TCAR technical proficiency. We also assessed how surgeon experience influenced outcomes.

METHODS

The primary outcome was technical proficiency, measured by skin-to-skin, fluoroscopy, and flow reversal times. Secondary outcomes included hospital length of stay and perioperative complication rate. Data was collected from a deidentified database, which included all patients that had a TCAR between 2017 and 2023 at 1 of 4 hospitals. Cases were grouped by the experience of the surgeon who performed the case (≤10 and > 10 years). Linear mixed models were used to analyze primary outcomes after being log-transformed, due to their skewed distributions. The estimated level of the outcome was compared at the first, fifth, 10th and 15th surgery between surgeon groups, and the significance level was adjusted using the Bonferroni correction.

RESULTS

There were 160 cases performed by 13 surgeons included in the study. Patients with hostile necks (23.9% vs. 9.7%, P = 0.015) and contralateral occlusions (7.5% vs. 0%, P = 0.007) were operated on more frequently by surgeons with ≤10 years of experience. There was no difference in secondary outcomes between groups. While primary outcomes between groups were not significant when comparing median values, linear mixed models demonstrated a significant improvement among the group of surgeons with less experience after the 15th case relative to their senior partners. At this point, they were operating with 30% less skin-to-skin time (P = 0.002, 95% confidence interval (CI) 13%-44%) and 51% less fluoroscopy time (P = 0.005, 95% CI 20%-70%) compared to surgeons with >10 years of experience. There was no significant difference between groups with respect to flow reversal times.

CONCLUSION

There was significant improvement experienced by the junior attendings relative to their senior partners after the 15th case. This was not influenced by patient characteristics nor the type of anesthesia used.

Factor XI/XIa inhibitors: a potential solution to anticoagulation dilemmas

INTRODUCTION

Antithrombotic therapy is the cornerstone of stroke prevention, but standard of care therapies are underutilized and use is limited by bleeding rates, drug interactions, and renal elimination. Factor XI/XIa (FXI/XIa) inhibitors are a novel anticoagulation class that purportedly target thrombosis more than hemostasis, thereby raising the hope of reducing bleeding consequences while maintaining efficacy.

AREAS COVERED

This review covers the mechanistic rationale for FXI/XIa inhibitors, describes the various molecule sub-classes, addresses barriers to current anticoagulation use, and reviews clinical trial data to date for this novel class of anticoagulants.

EXPERT OPINION

FXI/XIa inhibitors offer several advantages over DOACs in stroke prevention such as reduced bleeding, fewer drug interactions, and less renal elimination. However, clinical trials must demonstrate non-inferior efficacy and improved safety compared to DOACs. Additional barriers to use will include cost, inadequacy of antidotes, and overall anticoagulant underutilization. The potential for a small molecule or monoclonal antibody to reach the clinic is very high.

Primary aldosteronism: Screening, diagnosis, and management

ABSTRACT

Hypertension (HTN) is a common condition that physician associates (PAs) encounter in clinical practice. Of patients with HTN, about 10% have secondary HTN, of which primary aldosteronism is one of the most common causes. Primary aldosteronism is a condition in which the adrenal glands produce excess aldosterone, and it contributes to HTN development by inducing sodium and water retention. Primary aldosteronism is underdiagnosed, as it can be hard to identify due to its lack of specific signs and symptoms. Moreover, without proper treatment, patients are at higher risk of cardiovascular disease, chronic kidney disease, metabolic syndrome, osteoporosis, and lower quality of life. It is therefore critical for PAs to be aware of indicators for primary aldosteronism screening. This review discusses primary aldosteronism screening and treatment in primary care while highlighting appropriate specialist referral.

A Retrospective Case-Control Study Examining the Association of Thyroid-Stimulating Hormone Suppression and Vascular Wall Inflammation on [18F]FDG-PET/CT

Background: This retrospective case-control study aimed to investigate the effects of thyroid-stimulating hormone (TSH) suppression on vascular wall inflammation, assessed by [18F]-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT). Vascular [18F]FDG-uptake is highly correlated with arterial inflammation, which represents a major risk factor for atherosclerotic plaques. Methods: Forty patients with differentiated thyroid cancer underwent [18F]FDG-PET/CTs under TSH suppression therapy following surgical removal of the thyroid and subsequent radioiodine ablation. The [18F]FDG-uptake was measured in the carotid arteries, aortic arch, and the ascending, descending, and abdominal aorta. All measurements in the PET scans were normalized to body weight and corrected for blood pool activity in the superior vena cava, creating target-to-background ratios (TBRs). Twenty-five patients with euthyroid hormone status were used as a control group. In addition, to evaluate long-term changes, the follow-up PET/CTs of 24 thyroid carcinoma patients under continued TSH suppression therapy were analyzed. Results: In patients with TSH suppression, significantly higher arterial [18F]FDG-uptake (p < 0.001) was observed in the ascending aorta, aortic arch, abdominal aorta, carotid artery, and for all arterial vessels combined (mean TBRmax ± standard deviation [SD]: 1.8 ± 0.4, 1.8 ± 0.3, 1.9 ± 0.4, 1.4 ± 0.3, 1.7 ± 0.2, respectively) compared with the euthyroid control group (TBRmax ± SD: 1.4 ± 0.2, 1.4 ± 0.2, 1.4 ± 0.2, 1.1 ± 0.2, 1.3 ± 0.1, respectively). In the subgroup of patients who received an additional follow-up scan after a mean duration of 1.9 ± 1.1 years of continued TSH suppression therapy, no significant changes in arterial [18F]FDG-uptake were found in the five arterial sites when both scans were compared over time (p > 0.05). Conclusions: Our study suggests that patients under TSH suppression may experience a significant increase in vascular [18F]FDG-uptake, a marker of arterial inflammation, and, therefore, might be at higher risk for cardiovascular disease. Interestingly, the duration of TSH suppression was not significantly associated with vascular [18F]FDG-uptake in our study, indicating that the observed increase in arterial inflammation may not be influenced by the duration of TSH suppression.

Apparently healthy young black adults report lower total fluid intake and exhibit higher plasma copeptin than young White adults

Underhydration is associated with higher plasma copeptin concentration ([copeptin]), an arginine vasopressin surrogate associated with multiple chronic diseases. Middle-aged and older Black individuals are more likely to be underhydrated and exhibit higher [copeptin] than White individuals. However, limited data exists on racial differences in [copeptin] in young adults. Therefore, we tested the hypothesis that apparently healthy young Black adults would report lower fluid intake and exhibit higher plasma [copeptin] than young White adults. Participants (n = 86; sex: 40F/46M; race: White n = 48, Black n = 38; age: 21±2 years, BMI: 25±4 kg/m2) completed 3-day food and fluid diaries. We operationalized beverages into 8 categories (water, sugar-sweetened beverages, milk/non-dairy alternatives, juice, nonaloric beverages (eg, diet drinks), coffee or tea (noncaloric), coffee or tea (caloric), and alcohol) and measured plasma [copeptin]. We assessed racial differences in fluid intake and [copeptin] and also examined relations between race, fluid intake, and [copeptin] via regression and correlation analyses. Compared with White adults, Black adults consumed less total fluid (64.0[31.3] vs. 89.7[53.6] oz), water, alcohol, and coffee/tea (noncaloric and caloric) but more juice (ps < .05). Black participants exhibited higher plasma [copeptin] (6.38[4.83] vs. 4.45[2.92] pmol/L, P = .021). In the whole cohort, plasma [copeptin] was negatively correlated with water intake (ρ= -0.249, P = .021). However, racial differences in [copeptin] were attenuated by 27% when accounting for total fluid intake. Black young adults reported lower fluid intake and exhibited higher plasma [copeptin] than White young adults. Interventions are needed to address racial disparities in hydration practices, potentially attenuating racial differences in [copeptin] and related health disparities.

Heart Failure Symptoms Improve With More Intense Physical Activity

BACKGROUND

Little is known about how changes in physical activity (PA) over time may influence symptoms in people with heart failure (HF).

METHODS

A secondary analysis was conducted with data from an RCT of an exercise intervention in patients with ICDs (implantable cardioverter defibrillator) and a HF diagnosis (n = 96). Data were collected at baseline and 2 months of PA intervention. Physical activity (PA Steps = mean steps/day; PA Intensity = mean steps/min for most intense 30 minutes/day) were measured over 5 days at each timepoint. Physical symptoms were measured using the Patient Concerns Assessment, the SF-36 Vitality, and Bodily Pain subscales for fatigue and pain. Psychological symptoms were assessed using the Patient Health Questionnaire-9, and the State-Trait Anxiety Index. Associations between PA and physical and psychological symptoms were analyzed with multivariate regression.

RESULTS

Patients (n = 96) were predominately male (83%) and Caucasian (79%), aged 55.8 ± 12.3 years, BMI of 29.7 ± 5.1, with heart failure with reduced ejection fraction (HFrEF; 30.9 ± 9.9%). An increase in PA Steps was associated with improvement in anxiety (β = -1.178, p = .048). An increase in PA Intensity was associated with significant reductions in depression (β = -0.127, p = .021), anxiety (β = -0.234, p = .037), and fatigue (β = 0.528, p = .022). Decreases in PA Steps and PA Intensity were not associated with changes in any symptoms.

CONCLUSION

For HF patients with an ICD, more intense PA over 2 months was associated with improved psychological symptoms and reduced fatigue. Decreases in PA (total and intensity) were not associated with changes in symptoms. Interventions promoting increasing the intensity of PA over time may be an effective approach to reduce some HF symptoms.

Understanding Reasons for Oral Anticoagulation Nonprescription in Atrial Fibrillation Using Large Language Models

BACKGROUND

Rates of oral anticoagulation (OAC) nonprescription in atrial fibrillation approach 50%. Understanding reasons for OAC nonprescription may reduce gaps in guideline-recommended care. We aimed to identify reasons for OAC nonprescription from clinical notes using large language models.

METHODS

We identified all patients and associated clinical notes in our health care system with a clinician-billed visit for atrial fibrillation without another indication for OAC and stratified them on the basis of active OAC prescriptions. Three annotators labeled reasons for OAC nonprescription in clinical notes on 10% of all patients ("annotation set"). We engineered prompts for a generative large language model (Generative Pre-trained Transformer 4) and trained a discriminative large language model (ClinicalBERT) to identify reasons for OAC nonprescription and selected the best-performing model to predict reasons for the remaining 90% of patients ("inference set").

RESULTS

A total of 35 737 patients were identified, of which 7712 (21.6%) did not have active OAC prescriptions. A total of 910 notes across 771 patients were annotated. Generative Pre-trained Transformer 4 outperformed ClinicalBERT (macro-F1 score across all reasons of 0.79, compared with 0.69 for ClinicalBERT). Using Generative Pre-trained Transformer 4 on the inference set, 61.1% of notes had documented reasons for OAC nonprescription, most commonly the alternative use of an antiplatelet agent (23.3%), therapeutic inertia (21.0%), and low burden of atrial fibrillation (17.1%).

CONCLUSIONS

This is the first study using large language models to extract documented reasons for OAC nonprescription from clinical notes in patients with atrial fibrillation and reveals guideline-discordant practices and actionable insights for the development of health system interventions to reduce OAC nonprescription.