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

B Cells in Atherosclerosis: Mechanisms and Potential Clinical Applications

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B cells regulate atherosclerotic plaque formation through production of antibodies and cytokines, and effects are subset specific (B1 and B2).

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Putative human atheroprotective B1 cells function similarly to murine B1 in their spontaneous IgM antibody production. However, marker strategies in identifying human and murine B1 are different.

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IgM antibody to oxidation specific epitopes produced by B1 cells associate with human coronary artery disease.

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Neoantigen immunization may be a promising strategy for atherosclerosis vaccine development, but further study to determine relevant antigens still need to be done.

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B-cell–targeted therapies, used in treating autoimmune diseases as well as lymphoid cancers, might have potential applications in treating cardiovascular diseases. Short- and long-term cardiovascular effects of these agents need to be assessed.

Because atherosclerotic cardiovascular disease is a leading cause of death worldwide, understanding inflammatory processes underpinning its pathology is critical. B cells have been implicated as a key immune cell type in regulating atherosclerosis. B-cell effects, mediated by antibodies and cytokines, are subset specific. In this review, we focus on elaborating mechanisms underlying subtype-specific roles of B cells in atherosclerosis and discuss available human data implicating B cells in atherosclerosis. We further discuss potential B cell–linked therapeutic approaches, including immunization and B cell–targeted biologics. Given recent evidence strongly supporting a role for B cells in human atherosclerosis and the expansion of immunomodulatory agents that affect B-cell biology in clinical use and clinical trials for other disorders, it is important that the cardiovascular field be cognizant of potential beneficial or untoward effects of modulating B-cell activity on atherosclerosis.

Nutrition in Menopausal Women: A Narrative Review

Among the various aspects of health promotion and lifestyle adaptation to the postmenopausal period, nutritional habits are essential because they concern all women, can be modified, and impact both longevity and quality of life. In this narrative review, we discuss the current evidence on the association between dietary patterns and clinical endpoints in postmenopausal women, such as body composition, bone mass, and risk markers for cardiovascular disease. Current evidence suggests that low-fat, plant-based diets are associated with beneficial effects on body composition, but further studies are needed to confirm these results in postmenopausal women. The Mediterranean diet pattern along with other healthy habits may help the primary prevention of bone, metabolic, and cardiovascular diseases in the postmenopausal period. It consists on the use of healthy foods that have anti-inflammatory and antioxidant properties, and is associated with a small but significant decrease in blood pressure, reduction of fat mass, and improvement in cholesterol levels. These effects remain to be evaluated over a longer period of time, with the assessment of hard outcomes such as bone fractures, diabetes, and coronary ischemia.

Enzymatic Preparation of Bioactive Peptides Exhibiting ACE Inhibitory Activity from Soybean and Velvet Bean: A Systematic Review

The Angiotensin-I-converting enzyme (ACE) is a peptidase with a significant role in the regulation of blood pressure. Within this work, a systematic review on the enzymatic preparation of Angiotensin-I-Converting Enzyme inhibitory (ACEi) peptides is presented. The systematic review is conducted by following PRISMA guidelines. Soybeans and velvet beans are known to have high protein contents that make them suitable as sources of parent proteins for the production of ACEi peptides. Endopeptidase is commonly used in the preparation of soybean-based ACEi peptides, whereas for velvet bean, a combination of both endo- and exopeptidase is frequently used. Soybean glycinin is the preferred substrate for the preparation of ACEi peptides. It contains proline as one of its major amino acids, which exhibits a potent significance in inhibiting ACE. The best enzymatic treatments for producing ACEi peptides from soybean are as follows: proteolytic activity by Protease P (Amano-P from Aspergillus sp.), a temperature of 37 °C, a reaction time of 18 h, pH 8.2, and an E/S ratio of 2%. On the other hand, the best enzymatic conditions for producing peptide hydrolysates with high ACEi activity are through sequential hydrolytic activity by the combination of pepsin-pancreatic, an E/S ratio for each enzyme is 10%, the temperature and reaction time for each proteolysis are 37 °C and 0.74 h, respectively, pH for pepsin is 2.0, whereas for pancreatin it is 7.0. As an underutilized pulse, the studies on the enzymatic hydrolysis of velvet bean proteins in producing ACEi peptides are limited. Conclusively, the activity of soybean-based ACEi peptides is found to depend on their molecular sizes, the amino acid residues, and positions. Hydrophobic amino acids with nonpolar side chains, positively charged, branched, and cyclic or aromatic residues are generally preferred for ACEi peptides.

Compliance in Primary Prevention With Statins and Associations With Cardiovascular Risk and Death in a Low-Risk Population With Type 2 Diabetes Mellitus

Background

We examined whether primary prevention with statins and high adherence to statins reduce the associated risk of cardiovascular events or death in a low‐risk population with type 2 diabetes mellitus (T2D).

Methods and Results

Using Danish nationwide registers, we included patients with new‐onset T2D, aged 40 to 89 years, between 2005 and 2011, who were alive 18 months following the T2D diagnosis (index date). In patients who purchased statins within 6 months following T2D diagnosis, we calculated the proportion of days covered (PDC) within 1 year after the initial 6‐month period. We studied the combined end point of myocardial infarction, stroke, or all‐cause mortality, whichever came first, with Cox regression. Reported were standardized 5‐year risk differences for fixed comorbidity distribution according to statin treatment history, stratified by sex and age. Among 77 170 patients, 42 975 (56%) were treated with statins, of whom 31 061 (72%) had a PDC ≥80%. In men aged 70 to 79 years who were treated with statins, the standardized 5‐year risk was 22.9% (95% CI, 21.5%–24.3%), whereas the risk was 29.1% (95% CI, 27.4%–30.7%) in men not treated, resulting in a significant risk reduction of 6.2% (95% CI, 4.0%–8.4%), P<0.0001. The risk reduction associated with statins increased with advancing age group (women: age 40–49 years, 0.0% [95% CI, −1.0% to 1.0%]; age 80–89 years, 10.8% [95% CI, 7.2%–14.4%]). Standardizing to all patients treated with statins, PDC <80% was associated with increased risk difference (reference PDC ≥80%; PDC <20%, 4.2% [95% CI, 2.9%–5.6%]).

Conclusions

This study supports the use of statins as primary prevention against cardiovascular diseases or death in 18‐month surviving low‐risk patients with T2D, with the highest effect in the elderly and adherent patients.

[Effectiveness of different screening strategies for cardiovascular diseases prevention in a community-based Chinese population: A decision-analytic Markov model]

OBJECTIVE

To evaluate the potential effectiveness of different screening strategies for cardiovascular diseases prevention in a community-based Chinese population from economically developed area of China.

METHODS

Totally 202 179 adults aged 40 to 74 years without cardiovascular diseases at baseline (January 1, 2010) were enrolled from the Chinese electronic health records research in Yinzhou (CHERRY) study. Three scenarios were considered: the screening strategy based on risk charts recommended by the 2020 Chinese guideline on the primary prevention of cardiovascular diseases in Chinese adults aged 40-74 years (Strategy 1); the screening strategy based on the prediction for atherosclerotic cardiovascular disease risk in China (China-PAR) models recommended by the 2019 Guideline on the assessment and management of cardiovascular risk in China in Chinese adults aged 40-74 years (Strategy 2); and the screening strategy based on the China-PAR models in Chinese adults aged 50-74 years (Strategy 3). According to the guidelines, individuals who were classified into medium- or high-risk groups after cardiovascular risk assessment by the corresponding strategies would be introduced to lifestyle intervention, while high-risk population would take medication in addition. Markov model was used to simulate different screening scenarios for 10 years (cycles), using parameters mainly from the CHERRY study, as well as published data, Meta-analyses and systematic reviews for Chinese populations. The life year gained, quality-adjusted life year (QALY) gained, number of cardiovascular disease events/deaths could be prevented and number needed to be screened (NNS) were calculated to compare the effectiveness between the different strategies. One-way sensitivity analysis on uncertainty of cardiovascular disease incidence rate and probabilistic sensitivity analysis on uncertainty of distributions for the hazard ratios were conducted.

RESULTS

Compared with non-screening strategy, QALYs gained were 1 433 [95% uncertainty interval (UI): 969-1 831], 1 401 (95%UI: 936-1 807), and 716 (95%UI: 265-1 111) for the Strategies 1, 2, and 3; and the NNS per QALY in the above strategies were 141 (95%UI: 110-209), 144 (95%UI: 112-216), and 198 (95%UI: 127-529), respectively. The Strategies 1 and 2 based on different guidelines showed similar effectiveness, while more benefits were found for screening using China-PAR models in adults aged 40-74 years than those aged 50-74 years. The results were consistent in the sensitivity analyses.

CONCLUSION

Screening for cardiovascular diseases in Chinese adults aged above 40 years seems effective in coastal developed areas of China, and the different screening strategies based on risk charts by the 2020 Chinese guideline on the primary prevention of cardiovascular diseases or China-PAR models by the 2019 Guideline on the assessment and management of cardiovascular risk in China may have similar effectiveness.

[Effectiveness of different screening strategies for cardiovascular diseases prevention in a community-based Chinese population: A decision-analytic Markov model]

OBJECTIVE

To evaluate the potential effectiveness of different screening strategies for cardiovascular diseases prevention in a community-based Chinese population from economically developed area of China.

METHODS

Totally 202 179 adults aged 40 to 74 years without cardiovascular diseases at baseline (January 1, 2010) were enrolled from the Chinese electronic health records research in Yinzhou (CHERRY) study. Three scenarios were considered: the screening strategy based on risk charts recommended by the 2020 Chinese guideline on the primary prevention of cardiovascular diseases in Chinese adults aged 40-74 years (Strategy 1); the screening strategy based on the prediction for atherosclerotic cardiovascular disease risk in China (China-PAR) models recommended by the 2019 Guideline on the assessment and management of cardiovascular risk in China in Chinese adults aged 40-74 years (Strategy 2); and the screening strategy based on the China-PAR models in Chinese adults aged 50-74 years (Strategy 3). According to the guidelines, individuals who were classified into medium- or high-risk groups after cardiovascular risk assessment by the corresponding strategies would be introduced to lifestyle intervention, while high-risk population would take medication in addition. Markov model was used to simulate different screening scenarios for 10 years (cycles), using parameters mainly from the CHERRY study, as well as published data, Meta-analyses and systematic reviews for Chinese populations. The life year gained, quality-adjusted life year (QALY) gained, number of cardiovascular disease events/deaths could be prevented and number needed to be screened (NNS) were calculated to compare the effectiveness between the different strategies. One-way sensitivity analysis on uncertainty of cardiovascular disease incidence rate and probabilistic sensitivity analysis on uncertainty of distributions for the hazard ratios were conducted.

RESULTS

Compared with non-screening strategy, QALYs gained were 1 433 [95% uncertainty interval (UI): 969-1 831], 1 401 (95%UI: 936-1 807), and 716 (95%UI: 265-1 111) for the Strategies 1, 2, and 3; and the NNS per QALY in the above strategies were 141 (95%UI: 110-209), 144 (95%UI: 112-216), and 198 (95%UI: 127-529), respectively. The Strategies 1 and 2 based on different guidelines showed similar effectiveness, while more benefits were found for screening using China-PAR models in adults aged 40-74 years than those aged 50-74 years. The results were consistent in the sensitivity analyses.

CONCLUSION

Screening for cardiovascular diseases in Chinese adults aged above 40 years seems effective in coastal developed areas of China, and the different screening strategies based on risk charts by the 2020 Chinese guideline on the primary prevention of cardiovascular diseases or China-PAR models by the 2019 Guideline on the assessment and management of cardiovascular risk in China may have similar effectiveness.

Attenuating the Variability of Lipids Is Beneficial for the Hypertension Management to Reduce the Cardiovascular Morbidity and Mortality in Older Adults

Objective: To investigate the beneficial of attenuating the variability of lipids to the hypertension management in older adults.

Methods: Between April 2008 and November 2010, 1,244 hypertensive patients aged ≥60 years were recruited and randomized into placebo and rosuvastatin groups. Outcomes and inter-visit plasma lipids variability were assessed.

Results: Over an average follow-up of 83.5 months, the coefficients of variation (CVs) in total cholesterol (TCHO), triglycerides, high-density lipoprotein cholesterol (HDL-c), and low-density lipoprotein cholesterol (LDL-c) were significantly lower in the rosuvastatin group than the placebo group (p < 0.05). The risks of composite cardiovascular event, myocardial infarction, coronary revascularization, heart failure, total stroke, ischemic stroke, cardiovascular death, and all-cause death were significantly lower in the rosuvastatin group than the placebo group (all p < 0.05). The differences in the risks were significantly diminished after the CVs for TCHO, triglycerides, HDL-c, and LDL-c were separately included as confounders. One-SD of CVs for TCHO, triglycerides, HDL-c, and LDL-c increment were significantly associated with the risks of composite cardiovascular event, myocardial infarction, heart failure, total stroke, ischemic stroke, cardiovascular death, and all-cause death, respectively (all p < 0.05).

Conclusions: Rosuvastatin significantly attenuated the intra-visit variability in lipids and decreased the risk of cardiovascular mortality and morbidity. Controlling the variability of lipids is as important as antihypertensive treatment to reduce the cardiovascular morbidity and mortality in the management of older hypertensive patients.

Clinical Trial Registration:ChiCTR.org.cn, ChiCTR-IOR-17013557.

Modest Gains After an 8-Week Exercise Program Correlate With Reductions in Non-traditional Markers of Cardiovascular Risk

Background: Although engaging in physical exercise has been shown to reduce the incidence of cardiovascular events, the molecular mechanisms by which exercise mediates these benefits remain unclear. Based on epidemiological evidence, reductions in traditional risk factors only accounts for 50% of the protective effects of exercise, leaving the remaining mechanisms unexplained. The objective of this study was to determine whether engaging in a regular exercise program in a real world clinical setting mediates cardiovascular protection via modulation of non-traditional risk factors, such as those involved in coagulation, inflammation and metabolic regulation. Methods and Results: We performed a prospective, cohort study in 52 sedentary patients with cardiovascular disease or cardiovascular risk factors at two tertiary medical centers between January 1, 2016 and December 31, 2019. Prior to and at the completion of an 8-week exercise program, we collected information on traditional cardiovascular risk factors, exercise capacity, and physical activity and performed plasma analysis to measure levels of fibrinolytic, inflammatory and metabolic biomarkers to assess changes in non-traditional cardiovascular risk factors. The median weight change, improvement in physical fitness, and change in physical activity for the entire cohort were: -4.6 pounds (IQR: +2 pounds, -11.8 pounds), 0.37 METs (IQR: -0.076 METs, 1.06 METs), and 252.7 kcals/week (IQR: -119, 921.2 kcals/week). In addition to improvement in blood pressure and cholesterol, patients who lost at least 5 pounds, expended at least 1,000 additional kcals/week, and/or achieved ≥0.5 MET increase in fitness had a significant reduction in plasminogen activator inhibitor-1 [9.07 ng/mL (95% CI: 2.78-15.35 ng/mL); P = 0.026], platelet derived growth factor beta [376.077 pg/mL (95% CI: 44.69-707.46 pg/mL); P = 0.026); and angiopoietin-1 [(1104.11 pg/mL (95% CI: 2.92-2205.30 pg/mL); P = 0.049)]. Conclusion: Modest improvements in physical fitness, physical activity, and/or weight loss through a short-term exercise program was associated with decreased plasma levels of plasminogen activator inhibitor, platelet derived growth factor beta, and angiopoietin, which have been associated with impaired fibrinolysis and inflammation.

Physical Activity and Exercise Patterns After Spontaneous Coronary Artery Dissection: Insights From a Large Multinational Registry

Objective: The objective of the study was to assess the physical activity (PA) and exercise patterns among participants in a large multinational spontaneous coronary artery dissection (SCAD) registry. Patients and Methods: Participants with SCAD enrolled from March 2011 to November 2019 completed surveys including details regarding PA and exercise habits prior to SCAD, and PA counseling received from their provider after SCAD. Demographics and clinical characteristics were collected by electronic record review. Exercise prescribed to patients after SCAD was categorized according to exercise components: type, intensity, frequency, time/session, and extreme environmental conditions.

Results: We included 950 participants; mean ± age was 46.8 ± 9.5 years old at the time of first SCAD; most (96.3%) were women and (77.0%) attended ≥1 cardiac rehabilitation session. Hyperlipidemia (34.3%), hypertension (32.8%), and elevated body weight (overweight = 27.0%; obesity = 20.0%) were the most common comorbidities. Prior to SCAD, 48.5% performed aerobic exercise ≥3 times/week, and only 32.0% performed strength-building exercise regularly. PA counseling details after SCAD in 299/950 participants showed that most (93.3%) patients received some form of counseling including exercise prescription (EXP), non-specific recommendations, and discouraged from any exercise. Limits regarding exercise type and intensity were the most common advice among participants who received EXP.

Conclusion: Insights from our study suggest that only 48% of the patients performed some aerobic exercise three or more times per week, and 32.0% performed strength-building exercises, which suggest that most of them may not be as active as assumed. Furthermore, 70% of the SCAD patients have ≥1 cardiovascular risk factors. We suggest guiding patients based on individual assessment, taking into consideration baseline PA habits, treatment, and risk factors. SCAD-tailored PA guidelines are needed for optimal EXP without compromising patient safety.

[Lifestyle changes for stroke prevention]

Changes of lifestyle have a substantial effect on stroke prevention, especially in high-risk patients. Maintaining a healthier lifestyle can have greater effects than most pharmacological therapies of cardiovascular prevention. For example, increasing the amount of physical activity, adopting a healthy diet, limiting alcohol consumption and quitting smoking are associated with a 70 % decrease in stroke risk. Despite the abundance of observational data and meta-analyses assessing the association of different lifestyle changes and stroke risk, the literature frequently lacks evidence from randomized controlled clinical trial. This article will provide an overview of various forms of lifestyle changes and summarize their potential to modify the risk of stroke.

Impact of Mediterranean Diet on Chronic Non-Communicable Diseases and Longevity

The average life expectancy of the world population has increased remarkably in the past 150 years and it is still increasing. A long life is a dream of humans since the beginning of time but also a dream is to live it in good physical and mental condition. Nutrition research has focused on recent decades more on food combination patterns than on individual foods/nutrients due to the possible synergistic/antagonistic effects of the components in a dietary model. Various dietary patterns have been associated with health benefits, but the largest body of evidence in the literature is attributable to the traditional dietary habits and lifestyle followed by populations from the Mediterranean region. After the Seven Countries Study, many prospective observational studies and trials in diverse populations reinforced the beneficial effects associated with a higher adherence to the Mediterranean diet in reference to the prevention/management of age-associated non-communicable diseases, such as cardiovascular and metabolic diseases, neurodegenerative diseases, cancer, depression, respiratory diseases, and fragility fractures. In addition, the Mediterranean diet is ecologically sustainable. Therefore, this immaterial world heritage constitutes a healthy way of eating and living respecting the environment.

Impact of Mediterranean Diet on Chronic Non-Communicable Diseases and Longevity

The average life expectancy of the world population has increased remarkably in the past 150 years and it is still increasing. A long life is a dream of humans since the beginning of time but also a dream is to live it in good physical and mental condition. Nutrition research has focused on recent decades more on food combination patterns than on individual foods/nutrients due to the possible synergistic/antagonistic effects of the components in a dietary model. Various dietary patterns have been associated with health benefits, but the largest body of evidence in the literature is attributable to the traditional dietary habits and lifestyle followed by populations from the Mediterranean region. After the Seven Countries Study, many prospective observational studies and trials in diverse populations reinforced the beneficial effects associated with a higher adherence to the Mediterranean diet in reference to the prevention/management of age-associated non-communicable diseases, such as cardiovascular and metabolic diseases, neurodegenerative diseases, cancer, depression, respiratory diseases, and fragility fractures. In addition, the Mediterranean diet is ecologically sustainable. Therefore, this immaterial world heritage constitutes a healthy way of eating and living respecting the environment.

Cardiotoxicity of Radiation Therapy: Mechanisms, Management, and Mitigation

OPINION STATEMENT

Radiation therapy is a key component of modern-day cancer therapy and can reduce the rates of recurrence and death from cancer. However, it can increase risk of cardiovascular (CV) events, and our understanding of the timeline associated with that risk is shorter than previously thought. Risk mitigation strategies, such as different positioning techniques, and breath hold acquisitions as well as baseline cardiovascular risk stratification that can be undertaken at the time of radiotherapy planning should be implemented, particularly for patients receiving chest radiation therapy. Primary and secondary prevention of cardiovascular disease (CVD), as appropriate, should be used before, during, and after radiation treatment in order to minimize the risks. Opportunistic screening for subclinical coronary disease provides an attractive possibility for primary/secondary CVD prevention and thus mitigation of long-term CV risk. More data on long-term clinical usefulness of this strategy and development of appropriate management pathways would further strengthen the evidence for the implementation of such screening. Clear guidelines in initial cardiovascular screening and cardiac aftercare following radiotherapy need to be formulated in order to integrate these measures into everyday clinical practice and policy and subsequently improve post-treatment morbidity and mortality for these patients.

Evaluating the Impact of a Digital Nutrition Platform on Cholesterol Levels in Users With Dyslipidemia: Longitudinal Study

Background

A strong association exists between consuming a healthy diet and lowering cholesterol levels among individuals with high cholesterol. However, implementing and sustaining a healthy diet in the real world is a major challenge. Digital technologies are at the forefront of changing dietary behavior on a massive scale, as they can reach broad populations. There is a lack of evidence that has examined the benefit of a digital nutrition intervention, especially one that incorporates nutrition education, meal planning, and food ordering, on cholesterol levels among individuals with dyslipidemia.

Objective

The aim of this observational longitudinal study was to examine the characteristics of people with dyslipidemia, determine how their status changed over time, and evaluate the changes in total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), non-HDL-C, and triglycerides among individuals with elevated lipids who used Foodsmart, a digital nutrition platform that integrates education, meal planning, and food ordering.

Methods

We included 653 adults who used Foodsmart between January 2015 and February 2021, and reported a lipid marker twice. Participants self-reported age, gender, weight, and usual dietary intake in a 53-item food frequency questionnaire, and lipid values could be provided at any time. Dyslipidemia was defined as total cholesterol ≥200 mg/dL, HDL-C ≤40 mg/dL, LDL-C ≥130 mg/dL, or triglycerides ≥150 mg/dL. We retrospectively analyzed distributions of user characteristics and their associations with the likelihood of returning to normal lipid levels. We calculated the mean changes and percent changes in lipid markers among users with elevated lipids.

Results

In our total sample, 54.1% (353/653) of participants had dyslipidemia at baseline. Participants with dyslipidemia at baseline were more likely to be older, be male, and have a higher weight and BMI compared with participants who had normal lipid levels. We found that 36.3% (128/353) of participants who had dyslipidemia at baseline improved their lipid levels to normal by the end of follow-up. Using multivariate logistic regression, we found that baseline obesity (odds ratio [OR] 2.57, 95% CI 1.25-5.29; P=.01) and Nutriscore (OR 1.04, 95% CI 1.00-1.09; P=.04) were directly associated with achieving normal lipid levels. Participants with elevated lipid levels saw improvements as follows: HDL-C increased by 38.5%, total cholesterol decreased by 6.8%, cholesterol ratio decreased by 20.9%, LDL-C decreased by 12.9%, non-HDL-C decreased by 7.8%, and triglycerides decreased by 10.8%.

Conclusions

This study characterized users of the Foodsmart platform who had dyslipidemia and found that users with elevated lipid levels showed improvements in the levels over time.

Understanding providers' attitudes and key concerns toward incorporating CVD risk prediction into clinical practice: a qualitative study

Background

Although risk prediction has become an integral part of clinical practice guidelines for cardiovascular disease (CVD) prevention, multiple studies have shown that patients’ risk still plays almost no role in clinical decision-making. Because little is known about why this is so, we sought to understand providers’ views on the opportunities, barriers, and facilitators of incorporating risk prediction to guide their use of cardiovascular preventive medicines.

Methods

We conducted semi-structured interviews with primary care providers (n = 33) at VA facilities in the Midwest. Facilities were chosen using a maximum variation approach according to their geography, size, proportion of MD to non-MD providers, and percentage of full-time providers. Providers included MD/DO physicians, physician assistants, nurse practitioners, and clinical pharmacists. Providers were asked about their reaction to a hypothetical situation in which the VA would introduce a risk prediction-based approach to CVD treatment. We conducted matrix and content analysis to identify providers’ reactions to risk prediction, reasons for their reaction, and exemplar quotes.

Results

Most providers were classified as Enthusiastic (n = 14) or Cautious Adopters (n = 15), with only a few Non-Adopters (n = 4). Providers described four key concerns toward adopting risk prediction. Their primary concern was that risk prediction is not always compatible with a “whole patient” approach to patient care. Other concerns included questions about the validity of the proposed risk prediction model, potential workflow burdens, and whether risk prediction adds value to existing clinical practice. Enthusiastic, Cautious, and Non-Adopters all expressed both doubts about and support for risk prediction categorizable in the above four key areas of concern.

Conclusions

Providers were generally supportive of adopting risk prediction into CVD prevention, but many had misgivings, which included concerns about impact on workflow, validity of predictive models, the value of making this change, and possible negative effects on providers’ ability to address the whole patient. These concerns have likely contributed to the slow introduction of risk prediction into clinical practice. These concerns will need to be addressed for risk prediction, and other approaches relying on “big data” including machine learning and artificial intelligence, to have a meaningful role in clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06540-y.

Physical Activity and Inhibition of ACE Additively Modulate ACE/ACE-2 Balance in Heart Failure in Mice

Angiotensin-converting enzyme inhibition (ACE-I) and physical activity favorably modulate the ACE/ACE-2 balance. However, it is not clear whether physical activity and ACE-I could synergistically modulate ACE/ACE-2 balance in the course of heart failure (HF). Here, we studied the effects of combined spontaneous physical activity and ACE-I–based treatment on angiotensin (Ang) pattern and cardiac function in a mouse model of HF (Tgαq*44). Tgαq*44 mice with advanced HF (at the age of 12 months) were running spontaneously in a running wheel (exercise training group, ExT) and/or were treated with ACE inhibitor (ACE-I, perindopril, 10 mg/kg) for 2 months. Angiotensin profile was characterized by an LC-MS/MS-based method. The cardiac performance was assessed in vivo by MRI. Ang-(1–7)/Ang II ratio in both plasma and the aorta was significantly higher in the combined treatment group than the ACE-I group or ExT alone, suggesting the additive favorable effects on ACE-2/Ang-(1–7) and ACE/Ang II axes’ balance induced by a combination of ACE-I with ExT. The basal cardiac performance did not differ among the experimental groups of Tgαq*44 mice. We demonstrated additive changes in ACE/ACE-2 balance in both plasma and the aorta by spontaneous physical activity and ACE-I treatment in Tgαq*44 mice. However, these changes did not result in an improvement of failing heart function most likely because the disease was at the end-stage. Ang-(1–7)/Ang II balance represents a valuable biochemical end point for monitoring therapeutic intervention outcome in heart failure.

Prospective evaluation of lipid management following acute coronary syndrome in non-Western countries

Background

Half the global burden of cardiovascular disease (CVD) is concentrated in the Asia‐Pacific (APAC) region.

Hypothesis

Suboptimal control of low‐density lipoprotein cholesterol (LDL‐C) may play a large role in the burden of CVD in APAC and non‐Western countries.

Methods

The Acute Coronary Syndrome Management (ACOSYM) registry is a multinational, multicenter, prospective observational registry designed to evaluate LDL‐C control in patients within 6 months after hospitalization following an acute coronary syndrome (ACS) event across nine countries.

Results

Overall, 1581 patients were enrolled, of whom 1567 patients met the eligibility criteria; 80.3% of the eligible patients were men, 46.1% had ST‐elevation myocardial infarction, and 39.5% had non‐ST‐elevation myocardial infarction. Most (1245; 79.5%) patients were discharged on a high‐intensity statin. During the follow‐up, only 992 (63.3%) patients had at least one LDL‐C measurement; of these, 52.9% had persistently elevated LDL‐C (>70 mg/dl). The patients not discharged on a high‐dose statin were more likely (OR 3.2; 95% CI 2.1–4.8) to have an LDL‐C above the 70 mg/dl LDL‐C target compared with those who were discharged on a high‐dose statin.

Conclusion

Our real‐world registry found that a third or more of post‐ACS patients did not have a repeat LDL‐C follow‐up measurement. In those with an LDL‐C follow‐up measurement, more than half (52.9%) were not achieving a <70 mg/dl LDL‐C goal, despite a greater uptake of high‐intensity statin therapy than has been observed in recent evidence. This demonstrates the opportunity to improve post‐ACS lipid management in global community practice.

Effects of Palm Stearin versus Butter in the Context of Low-Carbohydrate/High-Fat and High-Carbohydrate/Low-Fat Diets on Circulating Lipids in a Controlled Feeding Study in Healthy Humans

Background. Foods rich in saturated fatty acids (SFAs) have been discouraged by virtue of their cholesterol-raising potential, but this effect is modulated by the food source and background level of carbohydrate. Objective. We aimed to compare the consumption of palm stearin (PS) versus butter on circulating cholesterol responses in the setting of both a low-carbohydrate/high-fat (LC/HF) and high-carbohydrate/low-fat (HC/LF) diet in healthy subjects. We also explored effects on plasma lipoprotein particle distribution and fatty acid composition. Methods. We performed a randomized, controlled-feeding, cross-over study that compared a PS- versus a Butter-based diet in a group of normocholesterolemic, non-obese adults. A controlled canola oil-based ‘Run-In’ diet preceded the experimental PS and Butter diets. All diets were eucaloric, provided for 3-weeks, and had the same macronutrient distribution but varied in primary fat source (40% of the total fat). The same Run-In and cross-over experiments were done in two separate groups who self-selected to either a LC/HF (n = 12) or a HC/LF (n = 12) diet track. The primary outcomes were low-density lipoprotein-cholesterol (LDL-C), high-density lipoprotein (HDL)-C, triglycerides, and LDL particle distribution. Results. Compared to PS, Butter resulted in higher LDL-C in both the LC/HF (13.4%, p = 0.003) and HC/LF (10.8%, p = 0.002) groups, which was primarily attributed to large LDL I and LDL IIa particles. There were no differences between PS and Butter in HDL-C, triglycerides, or small LDL particles. Oxidized LDL was lower after PS than Butter in LC/HF (p = 0.011), but not the HC/LF group. Conclusions. These results demonstrate that Butter raises LDL-C relative to PS in healthy normocholesterolemic adults regardless of background variations in carbohydrate and fat, an effect primarily attributed to larger cholesterol-rich LDL particles.

Association of Body Mass Index, Central Obesity, and Body Composition With Mortality Among Black Breast Cancer Survivors

IMPORTANCE

Obesity disproportionately affects Black women, who also have a higher risk of death after a breast cancer diagnosis compared with women of other racial/ethnic groups. However, few studies have evaluated the association of measures of adiposity with mortality among Black breast cancer survivors.

OBJECTIVE

To assess the association of measures of adiposity with survival after a breast cancer diagnosis among Black women.

DESIGN, SETTING, AND PARTICIPANTS

This prospective population-based cohort study comprised 1891 women with stage 0 to IV breast cancer who self-identified as African American or Black and were ages 20 to 75 years. The New Jersey State Cancer Registry was used to identify women living in 10 counties in New Jersey who were recruited from March 1, 2006, to February 29, 2020, and followed up until September 2, 2020.

EXPOSURES

Measures of adiposity, including body mass index, body fat distribution (waist circumference and waist-to-hip ratio), and body composition (percent body fat and fat mass index), were collected during in-person interviews at approximately 10 months after breast cancer diagnosis.

MAIN OUTCOMES AND MEASURES

All-cause and breast cancer-specific mortality.

RESULTS

Among 1891 women, the mean (SD) age at breast cancer diagnosis was 54.5 (10.8) years. During a median follow-up of 5.9 years (range, 0.5-14.8 years), 286 deaths were identified; of those, 175 deaths (61.2%) were associated with breast cancer. A total of 1060 women (56.1%) had obesity, and 1291 women (68.3%) had central obesity. Higher adiposity, particularly higher waist-to-hip ratio, was associated with worse survival. Women in the highest quartile of waist-to-hip ratio had a 61% increased risk of dying from any cause (hazard ratio [HR], 1.61; 95% CI, 1.12-2.33) and a 68% increased risk of breast cancer death (HR, 1.68; 95% CI, 1.04-2.71) compared with women in the lowest quartile. The risks of all-cause and breast cancer-specific death were similarly high among women in the highest quartile for waist circumference (HR, 1.74 [95% CI, 1.26-2.41] and 1.64 [95% CI, 1.08-2.48], respectively), percent body fat (HR, 1.53 [95% CI, 1.09-2.15] and 1.81 [95% CI, 1.17-2.80]), and fat mass index (HR, 1.57 [95% CI, 1.11-2.22] and 1.74 [95% CI, 1.10-2.75]); however, the risk was less substantial for body mass index (HR, 1.26 [95% CI, 0.89-1.79] and 1.33 [95% CI, 0.84-2.10]). In analyses stratified by estrogen receptor status, menopausal status, and age, a higher waist-to-hip ratio was associated with a higher risk of all-cause death among women who had estrogen receptor-negative tumors (HR, 2.24; 95% CI, 1.14-4.41), women who were postmenopausal (HR, 2.15; 95% CI, 1.28-3.61), and women who were 60 years or older at diagnosis (HR per 0.10-U increase, 1.76; 95% CI, 1.37-2.26).

CONCLUSIONS AND RELEVANCE

In this population-based cohort study, central obesity and higher adiposity were associated with higher all-cause and breast cancer-specific mortality among Black breast cancer survivors. Simple measures of body fat distribution and body composition were found to be useful tools for identifying Black women with a higher risk of death after a breast cancer diagnosis.

Sex-Specific Plaque Signature: Uniqueness of Atherosclerosis in Women

PURPOSE OF REVIEW

Cardiovascular disease is a leading cause of morbidity and mortality in both men and women, although there are notable differences in presentation between men and women. Atherosclerosis remains the predominant driver of coronary heart disease in both sexes; however, sex differences in atherosclerosis should be investigated further to understand clinical manifestations between men and women.

RECENT FINDINGS

There are sex differences in the prevalence, progression, and prognostic impact of atherosclerosis. Furthermore, developing evidence demonstrates unique differences in atherosclerotic plaque characteristics between men and women on both noninvasive and invasive imaging modalities. Coronary microvascular dysfunction may be present even if no obstructive lesions are found. Most importantly, non-obstructive coronary artery disease is associated with a heightened risk of future adverse cardiovascular events and should not be ignored. The distinct plaque signature in women should be recognized, and optimal preventive strategies should be performed for both sexes.

Effect of the Million Hearts Cardiovascular Disease Risk Reduction Model on Initiating and Intensifying Medications: A Prespecified Secondary Analysis of a Randomized Clinical Trial

Importance

The Million Hearts Cardiovascular Disease (CVD) Risk Reduction Model pays provider organizations for measuring and reducing Medicare patients' cardiovascular risk.

Objective

To assess whether the model increases the initiation or intensification of antihypertensive medications or statins among patients with blood pressure or low-density lipoprotein (LDL) cholesterol levels above guideline thresholds for treatment intensification.

Design, Setting, and Participants

This prespecified secondary analysis of a cluster-randomized, pragmatic trial included primary care and cardiology practices, health care centers, and hospital-based outpatient departments across the US. Participants included Medicare patients who were enrolled into the model in 2017 by participating organizations and who were at high risk and at medium risk of a myocardial infarction or stroke in 10 years. Patient outcomes were analyzed for 1 year postenrollment (through December 2018) using an intent-to-treat design. Analysis began November 2019.

Interventions

US Centers for Medicare & Medicaid Services paid organizations for risk stratifying Medicare patients and reducing CVD risk among high-risk patients through discussing risk scores, developing individualized risk reduction plans, and following up with patients twice yearly.

Main Outcomes and Measures

Initiating or intensifying statin or antihypertensive therapy within 1 year of enrollment, measured in Medicare Part D claims, and LDL cholesterol and systolic blood pressure levels approximately 1 year after enrollment, measured in usual care and reported to Centers for Medicare & Medicaid Services via a data registry (data complete for 51% of high-risk enrollees). The study's primary outcome (incidence of first-time myocardial infarction and stroke) is not reported because the trial is ongoing.

Results

A total of 330 primary care and cardiology practices, health care centers, and hospital-based outpatient departments and 125 436 Medicare patients were included in this analysis. High-risk patients in the intervention group had a mean (SD) age of 74 (4.1), 15 213 (63%) were male, 21 657 (90%) were receiving antihypertensive medication at baseline, and 16 558 (69%) were receiving statins. Almost all (21 791 [91%]) high-risk intervention group patients had above-threshold systolic blood pressure level (>130 mm Hg), LDL cholesterol level (>70 mg/dL), or both. Patients in the intervention group with these risk factors were more likely than control patients (8127 [37.3%] vs 4753 [32.4%]; adjusted difference in percentage points, 4.8; 95% CI, 2.9-6.7; P < .001) to initiate or intensify statins or antihypertensive medication. Centers for Medicare & Medicaid Services did not pay for CVD risk reduction for medium-risk enrollees, but initiation or intensification rates for these enrollees were also higher in the intervention vs control groups (12 668 [27.9%] vs 7544 [24.8%]; adjusted difference in percentage points, 3.1; 95% CI, 1.9-4.3; P < .001). Among high-risk enrollees with clinical data approximately 1 year after enrollment, LDL cholesterol level was slightly lower in the intervention vs control groups (mean [SD], 89 [31.8] vs 91 [32.1] mg/dL; adjusted difference in percentage points, -1.8; 95% CI, -2.9 to -0.6; P = .002), as was systolic blood pressure (mean [SD], 133 [15.7] vs 135 [16.4] mm Hg; adjusted difference in percentage points, -1.7; 95% CI, -2.8 to -0.6; P = .003).

Conclusions and Relevance

In this study, a pay-for-performance model led to modest increases in the use of CVD medications in a range of organizations, despite high medication use at baseline.

Physical Activity as a Critical Component of First-Line Treatment for Elevated Blood Pressure or Cholesterol: Who, What, and How?: A Scientific Statement From the American Heart Association

Current guidelines published by the American Heart Association and the American College of Cardiology broadly recommend lifestyle approaches to prevent and treat elevated blood pressure and cholesterol. For patients with mildly or moderately elevated blood pressure and blood cholesterol, lifestyle-only approaches are the first line of therapy. The purpose of this scientific statement is to: (1) highlight the mild-moderate-risk patient groups indicated for lifestyle-only treatment for elevated blood pressure or cholesterol; (2) describe recommendations, average effects, and additional considerations when prescribing lifestyle treatment with physical activity; and (3) provide guidance and resources for clinicians to assess, prescribe, counsel, and refer to support increased physical activity in their patients. An estimated 21% and 28% to 37% of US adults, respectively, have mild-moderate-risk blood pressure and cholesterol and should receive lifestyle-only as first-line treatment. Of the recommended lifestyle changes, increasing physical activity has extensive benefits, including improving both blood pressure and blood cholesterol, that are comparable, superior, or complementary to other healthy lifestyle changes. Physical activity assessment and prescription are an excellent lifestyle behavior treatment option for all patients, including for the large population of mild-moderate-risk patients with elevated blood pressure and blood cholesterol.

The Johns Hopkins Ciccarone Center's expanded 'ABC's approach to highlight 2020 updates in cardiovascular disease prevention

In recent years, improvement in outcomes related to cardiovascular disease is in part due to the prioritization and progress of primary and secondary prevention efforts. The Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease expanded 'ABC's approach is used to highlight key findings in Preventive Cardiology from 2020 and further emphasize the importance of cardiovascular prevention. This simplified approach helps clinicians focus on the most relevant and up to date recommendations for optimizing cardiovascular disease risk through accurate risk assessment and appropriate implementation of lifestyle, behavioral and pharmacologic interventions. While 2020 not only provided practice changing updates by way of clinical guidelines and randomized controlled trials on topics related to antithrombotic and lipid lowering therapy, diabetes management and risk assessment, it also provided promising data on how to improve dietary and exercise adherence and manage genetic risk. By providing clinicians with a systematic approach to cardiovascular prevention and key highlights from the prior year, the goal of significantly reducing the burden of cardiovascular disease worldwide can be achieved.

Coronary Artery Disease Evaluation and Management Considerations for High Risk Occupations: Commercial Vehicle Drivers and Pilots

Optimal treatment of stable ischemic heart disease for those in the transportation industry is considered in the context of the individual's health, as well as with the perspective that sudden impairment could have catastrophic consequences for others. This article focuses on two high risk occupations that one may encounter in practice: commercial motor vehicle drivers and commercial pilots. This article discusses coronary heart disease in patients in high risk occupations and covers current guideline recommendations for screening, treatment, and secondary prevention. The importance of the complimentary perspectives of the regulatory agency, medical examiners, physicians, and pilot or driver are considered in this narrative review, as are considerations for future guideline updates.

A Primary Care Agenda for Brain Health: A Scientific Statement From the American Heart Association

A healthy brain is critical for living a longer and fuller life. The projected aging of the population, however, raises new challenges in maintaining quality of life. As we age, there is increasing compromise of neuronal activity that affects functions such as cognition, also making the brain vulnerable to disease. Once pathology-induced decline begins, few therapeutic options are available. Prevention is therefore paramount, and primary care can play a critical role. The purpose of this American Heart Association scientific statement is to provide an up-to-date summary for primary care providers in the assessment and modification of risk factors at the individual level that maintain brain health and prevent cognitive impairment. Building on the 2017 American Heart Association/American Stroke Association presidential advisory on defining brain health that included "Life's Simple 7," we describe here modifiable risk factors for cognitive decline, including depression, hypertension, physical inactivity, diabetes, obesity, hyperlipidemia, poor diet, smoking, social isolation, excessive alcohol use, sleep disorders, and hearing loss. These risk factors include behaviors, conditions, and lifestyles that can emerge before adulthood and can be routinely identified and managed by primary care clinicians.

Results of a prospective cardiovascular disease prevention program

The Cardiovascular Health Program (CHP) Registry is a 12-month, prospective study of therapeutic lifestyle change (TLC). Adult participants received comprehensive assessment of health behaviors and cardiovascular disease (CVD) risk factors. Personalized TLC action plans addressed modifiable health behaviors for diet, exercise, stress management, and sleep. Participants attended a half-day interactive workshop and met face-to-face with certified health coaches four times over 6 months. Monthly telephonic coaching for 6 more months completed the intervention. Measured outcomes included adherence to behavioral prescriptions, anthropometrics, CVD-relevant laboratory tests, and for a subset of participants, carotid intima-media thickness (CIMT). Of 965 participants, 648 (67%) completed the program and were included in the analysis. Participants were of mean age 55.4 ± 12.5 years, 57% women, and racially diverse. Adherence to prescribed TLC was substantial: dietary behaviors at goal rose from 53% to 86%, exercise 44% to 66%, perceived stress 65% to 79%, and sleep quality 28% to 49%. For participants with abnormal anthropometrics at baseline, there were improvements in body mass index in 63%, waist circumference (men 71%, women 74%), systolic BP 69%, and diastolic BP 71%. For participants with abnormal laboratory values at baseline, there were improvements in total cholesterol in 74%, LDL-cholesterol 65%, triglycerides 86%, fasting glucose 72%, and insulin resistance 71%. Improvements were not driven by prescribed medications. CIMT improved or showed no change in 70% of those measured, associated with significant improvements in sleep quality and longer total sleep time. Longer trials incorporating controls and major adverse CVD events are warranted.

Smoking Cessation and Coronary Artery Calcification in CKD

BACKGROUND AND OBJECTIVES

Smoking is associated with vascular calcification and a higher risk of cardiovascular disease. In this study, we investigated the association of smoking dose and cessation with coronary artery calcification (CAC) in patients with CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

From a nationwide, prospective cohort of Korean patients with CKD, 1914 participants were included. Prevalent CAC was defined as an Agatston score >0, using computed tomography. CAC progression was defined as ≥30%/yr increase in Agatston score at the 4-year follow-up examination in patients with baseline CAC.

RESULTS

Prevalent CAC was observed in 952 (50%) patients. Compared with never smokers, former smokers had a similar prevalence ratio for CAC, but current smokers had a 1.25-fold higher prevalence ratio (95% confidence interval [95% CI], 1.10 to 1.42). Among former smokers, a lower smoking load of <10 pack-years (prevalence ratio, 0.77; 95% CI, 0.65 to 0.90) and longer duration of smoking cessation (prevalence ratio for 10 to <20 years, 0.85; 95% CI, 0.73 to 0.98: prevalence ratio for ≥20 years, 0.83; 95% CI, 0.73 to 0.96) were associated with lower risk of prevalent CAC compared with current smoking. The prevalence ratios did not differ between never smoking and long-term cessation. However, short-term cessation with heavy smoking load was associated with a higher risk of prevalent CAC (prevalence ratio, 1.21; 95% CI, 1.03 to 1.40) compared with never smoking. CAC progression was observed in 111 (33%) patients with baseline CAC. Compared with never smokers, former smokers showed a similar risk of CAC progression, but current smokers had a higher risk (relative risk, 1.92; 95% CI, 1.30 to 2.86).

CONCLUSIONS

In CKD, former smoking with a lower smoking load and long-term cessation were associated with a lower risk of prevalent CAC than current smoking. CAC progression was more pronounced in current smokers.

Impact of a preventive cardiology clinic focusing on lifestyle and nutrition counseling: A pilot analysis

Standard cardiology practice often defers preventive strategies to primary care providers. We aimed to evaluate the effectiveness of a preventive cardiology clinic focused on lifestyle and nutrition counseling combined with guideline-directed medical therapy on reducing cardiovascular disease (CVD) risk. We queried the University of Florida-Health database for patients enrolled in the preventive cardiology clinic, and a general and interventional cardiology clinic from January 2016 to October 2019. Mean change in weight and blood cholesterol including LDL cholesterol (LDL-C), total cholesterol (TC) and triglycerides (TG) were compared in the three clinics in the initial cohort and stratified into primary and secondary prevention. A propensity score-matched analysis was done to adjust for CVD risk factors and statin use. Among a cohort of 239 patients, enrollment in the preventive clinic (n = 99) was associated with greater weight loss at 6 months compared to other clinics (n = 140) (mean -1.7 vs +0.1 kg, p 0.007). Preventive clinic was also associated with greater mean reduction in LDL-C (-24.8 vs -7.1 mg/dl, p 0.021), TC (-29.3 vs -2.0, p 0.003) and TG (-19.7 vs +13.3, p 0.002) at both initial and last follow-up (median time 6 and 16 months). The association with reduction in TG was observed in both primary and secondary prevention, but reduction in LDL-C and TC was only significant in secondary prevention. In a propensity-matched linear regression analysis, preventive clinic was independently associated with LDL-C reduction (b -14.7, r -0.3, p 0.038). A preventive cardiology clinic focused on patient education can be effective in reducing CVD risk.

Use of Preventive Aspirin Among Older US Adults With and Without Diabetes

IMPORTANCE

The net benefit of aspirin for prevention of cardiovascular disease (CVD), particularly primary prevention, remains debated in people with and without diabetes. Recent studies suggest that the benefits of preventive aspirin may be outweighed by the potential for harm in older adults; therefore, it is important to monitor current aspirin use in order to minimize risk for future harm in the oldest segment of the population.

OBJECTIVE

To determine the prevalence of preventive aspirin use in older US adults with and without diabetes for both primary and secondary prevention by age, sex, and CVD risk category.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional analysis used nationally representative data from the National Health and Nutrition Examination Survey from 2011 to 2018. A total of 7103 individuals 60 years or older with and without diabetes completed a questionnaire on preventive aspirin use. Statistical analyses were performed from July 1, 2019, to April 1, 2021.

MAIN OUTCOMES AND MEASURES

Preventive aspirin use was defined as participants' self-reported use of low-dose aspirin therapy based on their physician's advice or their own decision.

RESULTS

A total of 7103 individuals (mean [SD] age, 69.6 [0.1] years; 45.2% men; 75.8% White participants) were evaluated. Overall, 61.7% of older US adults with diabetes vs 42.2% without diabetes used aspirin. Among people with diabetes, in multivariable logistic models adjusting for race, sex, education, CVD risk category, and body mass index, the likelihood of aspirin use in older vs younger age categories (reference: 60-69 years) did not differ. Among people without diabetes, aspirin use was significantly greater in older age categories vs the reference (model 3, 70-79 years, odds ratio [OR], 1.50; 95% CI, 1.23-1.83; model 3, ≥80 years, OR, 1.59; 95% CI, 1.24-2.04). An estimated 9.9 million US adults 70 years or older with or without diabetes reported taking aspirin for primary prevention. The likelihood of aspirin use for primary prevention in those at high vs low risk for CVD did not differ among older adults with diabetes (model 3, OR, 1.69; 95% CI, 0.65-4.39) but was significantly higher in those without diabetes (model 3, OR, 2.46; 95% CI, 1.63-3.71). Women vs men with diabetes were less likely to be using aspirin for primary prevention (model 3, OR, 0.63; 95% CI, 0.48-0.83).

CONCLUSIONS AND RELEVANCE

This cross-sectional study found that preventive aspirin use was higher among older adults with diabetes than in those without diabetes. Results suggest that 9.9 million older US adults who previously took aspirin for primary prevention would not be recommended for its continued use, particularly among those with diabetes.

Cerebrovascular disease in patients with cognitive impairment: A white paper from the ESO dementia committee - A practical point of view with suggestions for the management of cerebrovascular diseases in memory clinics

PURPOSE

Practical suggestions on clinical decisions about vascular disease management in patients with cognitive impairment are proposed.

METHODS

The document was produced by the Dementia Committee of the European Stroke Organisation (ESO) based on the evidence from the literature where available and on the clinical experience of the Committee members. This paper was endorsed by the ESO.

FINDINGS

Vascular risk factors and cerebrovascular disease are frequent in patients with cognitive impairment. While acute stroke treatment has evolved substantially in last decades, evidence of management of cerebrovascular pathology beyond stroke in patients with cognitive impairment and dementia is quite limited. Additionally, trials to test some daily-life clinical decisions are likely to be complex, difficult to undertake and take many years to provide sufficient evidence to produce recommendations. This document was conceived to provide some suggestions until data from field trials are available. It was conceived for the use of clinicians from memory clinics or involved specifically in cognitive disorders, addressing practical aspects on diagnostic tools, vascular risk management and suggestions on some therapeutic options.

DISCUSSION AND CONCLUSIONS

The authors did not aim to do an exhaustive or systematic review or to cover all current evidence. The document approach in a very practical way frequent issues concerning cerebrovascular disease in patients with known cognitive impairment.

Metabolic Evaluation in Patients With Hepatitis C Treated With Direct Antiviral Agents

Epidemiological data clearly indicate a link between hepatitis C virus (HCV) and altered glucose homeostasis.

Objective: To evaluate the response of treatment with direct antiviral agents (DAAs) on metabolic variables of patients with hepatitis C.

Methods: Observational, cross-sectional study in a sample of patients with hepatitis C starting therapy with DAAs followed on the hepatology division of Federal University of Rio de Janeiro State. Data were collected in two stages: before the start of therapy and between 12 and 52 weeks after obtaining the sustained virological response.

Results: In the baseline assessment of the 97 patients selected, 19.3% were obese, 38.6% were overweight, 50% were hypertensive, 43.8% were pre-diabetic, 12.5% were diabetic, 31.2% were dyslipidemic, and 21.8% had metabolic syndrome. There was an increase in total cholesterol and LDL levels (p < 0.001), and a non-significant reduction in blood glucose, glycated hemoglobin, insulin, and HOMA-IR levels after treatment. In the post-treatment, there was a reduction in fibrosis (p = 0.016), with a reduction in the levels of GGT, AST, and ALT (all with p < 0.001), as well as in the FIB4 and APRI scores (both with p < 0.001) and in the degree of fibrosis evaluated by elastography represented in kPa (p = 0.006). The blood glucose level was higher in patients with steatosis (p = 0.039) after treatment. There was a positive pre-treatment correlation between the degree of fibrosis (kPa) and FIB4 (r = 0.319, p = 0.004), APRI (r = 0.287, p = 0.010), and the NAFLD score (r = 0.275, p = 0.016).

Conclusion: Patients with hepatitis C had a high prevalence of metabolic disturbance in the pre-treatment phase, but the therapy did not show beneficial effects, especially on glucose metabolism.

Association of Heart Failure With Outcomes Among Patients With Peripheral Artery Disease: Insights From EUCLID

Background Peripheral artery disease (PAD) and heart failure (HF) are each independently associated with poor outcomes. Risk factors associated with new-onset HF in patients with primary PAD are unknown. Furthermore, how the presence of HF is associated with outcomes in patients with PAD is unknown. Methods and Results This analysis examined risk relationships of HF on outcomes in patients with symptomatic PAD randomized to ticagrelor or clopidogrel as part of the EUCLID (Examining Use of Ticagrelor in Peripheral Arterial Disease) trial. Patients were stratified based on presence of HF at enrollment. Cox models were used to determine the association of HF with outcomes. A separate Cox model was used to identify risk factors associated with development of HF during follow-up. Patients with PAD and HF had over twice the rate of concomitant coronary artery disease as those without HF. Patients with PAD and HF had significantly increased risk of major adverse cardiovascular events (hazard ratio [HR], 1.31; 95% CI, 1.13-1.51) and all-cause mortality (HR, 1.39; 95% CI, 1.19-1.63). In patients with PAD, the presence of HF was associated with significantly less bleeding (HR, 0.65; 95% CI, 0.45-0.96). Characteristics associated with HF development included age ≥66 (HR, 1.29; 95% CI, 1.18-1.40 per 5 years), diabetes mellitus (HR, 1.85; 95% CI, 1.41-2.43), and weight (bidirectionally associated, ≥76 kg, HR, 0.77; 95% CI, 0.64-0.93; <76 kg, HR, 1.12; 95% CI, 1.07-1.16). Conclusions Patients with PAD and HF have a high rate of coronary artery disease with a high risk for major adverse cardiovascular events and death. These data support the possible need for aggressive treatment of (recurrent) atherosclerotic disease in PAD, especially patients with HF.

Effects of Anthocyanins on Vascular Health

Cardiovascular disorders are leading mortality causes worldwide, often with a latent evolution. Vascular health depends on endothelial function, arterial stiffness, and the presence of atherosclerotic plaques. Preventive medicine deserves special attention, focusing on modifiable cardiovascular risk factors, including diet. A diet rich in fruits and vegetables has well-known health benefits, especially due to its polyphenolic components. Anthocyanins, water-soluble flavonoid species, responsible for the red-blue color in plants and commonly found in berries, exert favorable effects on the endothelial function, oxidative stress, inhibit COX-1, and COX-2 enzymes, exert antiatherogenic, antihypertensive, antiglycation, antithrombotic, and anti-inflammatory activity, ameliorate dyslipidemia and arterial stiffness. The present review aims to give a current overview of the mechanisms involved in the vascular protective effect of anthocyanins from the human diet, considering epidemiological data, in vitro and in vivo preclinical research, clinical observational, retrospective, intervention and randomized studies, dietary and biomarker studies, and discussing preventive benefits of anthocyanins and future research directions.

Cardiovascular disease recurrence and long-term mortality in a tri-ethnic British cohort

OBJECTIVE

Ethnic differences in cardiovascular disease incidence, but not cardiovascular disease recurrence, are reported. We characterised long-term risk of major adverse cardiovascular event (MACE) and mortality following a non-fatal cardiovascular event in a British cohort of South Asians, African Caribbeans and Europeans.

METHODS

We identified index and recurrent cardiovascular events and mortality between 1988 and 2017 using hospital records and death registry. Using multivariable hazards models, we separately calculated the adjusted HR of MACE and death following index event, adjusting for demographics, vascular and lifestyle risk factors. Using interaction terms, we evaluated if decade of index event modified the association between ethnicity and outcomes.

RESULTS

South Asians were younger at the index event (median age 66 years, n=396) than Europeans (69 years, n=335) and African Caribbeans (70 years, n=70). During 4228 person-years, of the 801 patients, 537 developed MACE and 338 died, with the highest crude rate of MACE in South Asians. On adjustment of baseline factors, compared with the Europeans, the higher risk of MACE (HR 0.97, 95% CI 0.77 to 1.21) and the lower risk of mortality (HR 0.95, 95% CI 0.72 to 1.26) in South Asians was eliminated. African Caribbeans had similar outcomes to Europeans (HR MACE 1.04, 95% CI 0.74 to 1.47; and HR death 1.07, 95% CI 0.70 to 1.64). Long-term survival following an index event improved in South Asians (ptrend 0.02) and African Caribbeans (ptrend 0.07) compared with Europeans.

CONCLUSIONS

Baseline vascular risk factors explained the observed ethnic variation in cardiovascular disease recurrence and long-term mortality, with a relative improvement in survival of minority ethnic groups over time.

Role of R-spondin 2 in arterial lymphangiogenesis and atherosclerosis

AIMS

Impaired lymphatic drainage of the arterial wall results in intimal lipid accumulation and atherosclerosis. However, the mechanisms regulating lymphangiogenesis in atherosclerotic arteries are not well understood. Our studies identified elevated levels of matrix protein R-spondin 2 (RSPO2) in atherosclerotic arteries. In this study, we investigated the role of RSPO2 in lymphangiogenesis, arterial cholesterol efflux into lesion-draining lymph nodes (LNs) and development of atherosclerosis.

METHODS AND RESULTS

The effect of RSPO2 on lymphangiogenesis was investigated using human lymphatic endothelial cells (LEC) in vitro and implanted Matrigel plugs in vivo. Cellular and molecular approaches, pharmacological agents, and siRNA silencing of RSPO2 receptor LGR4 were used to investigate RSPO2-mediated signalling in LEC. In vivo low-density lipoprotein (LDL) tracking and perivascular blockade of RSPO2-LGR4 signalling using LGR4-extracellular domain (ECD) pluronic gel in hypercholesterolemic mice were utilized to investigate the role of RSPO2 in arterial reverse cholesterol transport and atherosclerosis. Immunoblotting and imaging experiments demonstrated increased RSPO2 expression in human and mouse atherosclerotic arteries compared to non-atherosclerotic controls. RSPO2 treatment inhibited lymphangiogenesis both in vitro and in vivo. LGR4 silencing and inhibition of RSPO2-LGR4 signalling abrogated RSPO2-induced inhibition of lymphangiogenesis. Mechanistically, we found that RSPO2 suppresses PI3K-AKT-endothelial nitric oxide synthase (eNOS) signalling via LGR4 and inhibits activation of the canonical Wnt-β-catenin pathway. ApoE-/- mice treated with LGR4-ECD developed significantly less atherosclerosis compared with control treatment. Finally, increased arterial lymphatic vessel density and improved lymphatic drainage of fluorescently labelled LDL to deep cervical LNs were observed in LGR4-ECD-treated mice.

CONCLUSION

These findings demonstrate that RSPO2 inhibits lymphangiogenesis via LGR4 and downstream impairment of AKT-eNOS-nitric oxide signalling. These results may also inform new therapeutic strategies to promote lymphangiogenesis and improve cholesterol efflux from atherosclerotic arteries.

Weather temperature and the incidence of hospitalization for cardiovascular diseases in an aging society

Weather temperatures affect the incidence of cardiovascular diseases (CVD), but there is limited information on whether CVD hospitalizations are affected by changes in weather temperatures in a super-aging society. We aimed to examine the association of diurnal weather temperature changes with CVD hospitalizations. We included 1,067,171 consecutive patients who were admitted to acute-care hospitals in Japan between April 1, 2012 and March 31, 2015. The primary outcome was the number of CVD hospitalizations per day. The diurnal weather temperature range (DTR) was defined as the minimum weather temperature subtracted from the maximum weather temperature on the day before hospitalization. Multilevel mixed-effects linear regression models were used to estimate the association of DTR with cardiovascular hospitalizations after adjusting for weather, hospital, and patient demographics. An increased DTR was associated with a higher number of CVD hospitalizations (coefficient, 4.540 [4.310–4.765]/°C change, p < 0.001), with greater effects in those aged 75–89 (p < 0.001) and ≥ 90 years (p = 0.006) than among those aged ≤ 64 years; however, there were no sex-related differences (p = 0.166). Greater intraday weather temperature changes are associated with an increased number of CVD hospitalizations in the super-aging society of Japan, with a greater effect in older individuals.

Do statins reduce mortality in older people? Findings from a longitudinal study using primary care records

Objective

Assess whether statins reduce mortality in the general population aged 60 years and above.

Design

Retrospective cohort study.

Setting

Primary care practices contributing to The Health Improvement Network database, England and Wales, 1990–2017.

Participants

Cohort who turned age 60 between 1990 and 2000 with no previous cardiovascular disease or statin prescription and followed up until 2017.

Results

Current statin prescription was associated with a significant reduction in all-cause mortality from age 65 years onward, with greater reductions seen at older ages. The adjusted HRs of mortality associated with statin prescription at ages 65, 70, 75, 80 and 85 years were 0.76 (95% CI 0.71 to 0.81), 0.71 (95% CI 0.68 to 0.75), 0.68 (95% CI 0.65 to 0.72), 0.63 (95% CI 0.53 to 0.73) and 0.54 (95% CI 0.33 to 0.92), respectively. The adjusted HRs did not vary by sex or cardiac risk.

Conclusions

Using regularly updated clinical information on sequential treatment decisions in older people, mortality predictions were updated every 6 months until age 85 years in a combined primary and secondary prevention population. The consistent mortality reduction of statins from age 65 years onward supports their use where clinically indicated at age 75 and older, where there has been particular uncertainty of the benefits.

Impact of Antecedent Aspirin Use on Infarct Size, Bleeding and Composite Endpoint in Patients with de Novo Acute Myocardial Infarction

BACKGROUND

The study aimed to evaluate the impact of antecedent aspirin use on infarct size, bleeding and composite endpoint in patients with de novo acute myocardial infarction.

PATIENTS AND METHODS

A total of 562 consecutive patients with de novo acute myocardial infarction were included in this prospective cohort study. Patients were assigned into two groups based on presence (n=212) and absence (n=350) of prior aspirin use. Primary endpoint was myocardial infarct size, as estimated by troponin I peak. In-hospital mortality, bleeding and composite clinical endpoint including cardiogenic shock, stroke, in-hospital mortality and major bleeding were also evaluated.

RESULTS

Although GRACE and CRUSADE scores were higher, troponin I peak was lower in prior aspirin users. This result was maintained after adjustment for baseline ischemic risk profile and other major confounders including MI type and location. Despite high CRUSADE score, there was no increase in major and minor bleeding. Minimal bleeding was higher in antecedent aspirin users. When it was adjusted for the CRUSADE score, a similar risk was reported.

CONCLUSION

Patients with de novo acute myocardial infarction using aspirin for primary prevention have an unexpectedly smaller infarct size and similar bleeding rates.

Cardio-ankle vascular index represents the best surrogate for 10-year ASCVD risk estimation in patients with primary hypertension

Background: Identification of target organ damage and/or risk-enhancing factors help treatment decisions in hypertensive and hyperlipidaemic patients who reside in borderline to an intermediate risk category based on 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimates.Aim: In the present study, we aimed to investigate the comparative efficacy of certain hypertension-mediated organ damage markers (HMOD) for the prediction of 10-year ASCVD risk ≥10%, in patients with primary hypertension without established CVD.Methods: One-hundred thirty-seven asymptomatic hypertensive patients ≥40 years of age were enrolled in the present study. Ten-year ASCVD risks were estimated by Pooled Cohort Equations. The following HMOD markers; pulse pressure (PP), left ventricular mass index (LVMI), carotid intima-media thickness (CIMT), ankle-brachial index (ABI), cardio-ankle vascular index (CAVI) and estimated glomerular filtration rate (eGFR) were evaluated with respect to efficacy for predicting ≥10% ASCVD risk with ROC analysis.Results: CAVI gave the greatest Area Under Curve (AUC = 0.736, p < .000), and followed by CIMT (AUC = 0.727, p < .000), LVMI (AUC = O.630, p = .01), and PP (AUC = 0.623, p = .02). ABI and eGFR were not found to be predictive. CAVI correlated best with estimated 10-year ASCVD risk (r = 0.460, p < .000). A CAVI value ≥8 was found 71% sensitive and 72% specific for predicting ≥10% risk in 10-year ASCVD risk scale. CAVI gave the best graded response to increments in 10-year ASCVD risk categories.Conclusion: We suggest that CAVI is the best surrogate for 10-year ASCVD risk, among several HMOD markers.

Systematic review of international clinical guidelines for the promotion of physical activity for the primary prevention of cardiovascular diseases

BACKGROUND

Cardiovascular diseases are the world's leading cause of morbidity and mortality. An active lifestyle is one of the cornerstones in the primary prevention of cardiovascular disease. An initial step in guiding primary prevention programs is to refer to clinical guidelines. We aimed to systematically review clinical practice guidelines on primary prevention of cardiovascular disease and their recommendations regarding physical activity.

METHODS

We systematically searched Trip Medical Database, PubMed and Guidelines International Network from January 2012 up to December 2020 using the following search strings: 'cardiovascular disease', 'prevention', combined with specific cardiovascular disease risk factors. The identified records were screened for relevance and content. We methodologically assessed the selected guidelines using the AGREE II tool. Recommendations were summarized using a consensus-developed extraction form.

RESULTS

After screening, 27 clinical practice guidelines were included, all of which were developed in Western countries and showed consistent rigor of development. Guidelines were consistent about the benefit of regular, moderate-intensity, aerobic physical activity. However, recommendations on strategies to achieve and sustain behavior change varied. Multicomponent interventions, comprising education, counseling and self-management support, are recommended to be delivered by various providers in primary health care or community settings. Guidelines advise to embed patient-centered care and behavioral change techniques in prevention programs.

CONCLUSIONS

Current clinical practice guidelines recommend similar PA lifestyle advice and propose various delivery models to be considered in the design of such interventions. Guidelines identify a gap in evidence on the implementation of these recommendations into practice.

Sex Differences in the Associations of Visceral Adipose Tissue and Cardiometabolic and Cardiovascular Disease Risk: The Framingham Heart Study

Background

Men and women are labeled as obese on the basis of a body mass index (BMI) using the same criterion despite known differences in their fat distributions. Subcutaneous adipose tissue and visceral adipose tissue (VAT), as measured by computed tomography, are advanced measures of obesity that closely correlate with cardiometabolic risk independent of BMI. However, it remains unknown whether prognostic significance of anthropometric measures of adiposity versus VAT varies in men versus women.

Methods and Results

In 3482 FHS (Framingham Heart Study) participants (48.1% women; mean age, 50.8±10.3 years), we tested the associations of computed tomography–based versus anthropometric measures of fat with cardiometabolic and cardiovascular disease (CVD) risk. Mean follow‐up was 12.7±2.1 years. In men, VAT, as compared with BMI, had a similar strength of association with incident cardiometabolic risk factors (eg, adjusted odds ratio [OR], 2.36 [95% CI, 1.84–3.04] versus 2.66 [95% CI, 2.04–3.47] for diabetes mellitus) and CVD events (eg, adjusted hazard ratio [HR], 1.32 [95% CI, 0.97–1.80] versus 1.74 [95% CI, 1.14–2.65] for CVD death). In women, however, VAT, when compared with BMI, conferred a markedly greater association with incident cardiometabolic risk factors (eg, adjusted OR, 4.51 [95% CI, 3.13–6.50] versus 2.33 [95% CI, 1.88–3.04] for diabetes mellitus) as well as CVD events (eg, adjusted HR, 1.85 [95% CI, 1.26–2.71] versus 1.19 [95% CI, 1.01–1.40] for CVD death).

Conclusions

Anthropometric measures of obesity, including waist circumference and BMI, adequately capture VAT‐associated cardiometabolic and cardiovascular risk in men but not in women. In women, abdominal computed tomography–based VAT measures permit more precise assessment of obesity‐associated cardiometabolic and cardiovascular risk.

Short-term e-cigarette vapour exposure causes vascular oxidative stress and dysfunction: evidence for a close connection to brain damage and a key role of the phagocytic NADPH oxidase (NOX-2)

AIMS

Electronic (e)-cigarettes have been marketed as a 'healthy' alternative to traditional combustible cigarettes and as an effective method of smoking cessation. There are, however, a paucity of data to support these claims. In fact, e-cigarettes are implicated in endothelial dysfunction and oxidative stress in the vasculature and the lungs. The mechanisms underlying these side effects remain unclear. Here, we investigated the effects of e-cigarette vapour on vascular function in smokers and experimental animals to determine the underlying mechanisms.

METHODS AND RESULTS

Acute e-cigarette smoking produced a marked impairment of endothelial function in chronic smokers determined by flow-mediated dilation. In mice, e-cigarette vapour without nicotine had more detrimental effects on endothelial function, markers of oxidative stress, inflammation, and lipid peroxidation than vapour containing nicotine. These effects of e-cigarette vapour were largely absent in mice lacking phagocytic NADPH oxidase (NOX-2) or upon treatment with the endothelin receptor blocker macitentan or the FOXO3 activator bepridil. We also established that the e-cigarette product acrolein, a reactive aldehyde, recapitulated many of the NOX-2-dependent effects of e-cigarette vapour using in vitro blood vessel incubation.

CONCLUSIONS

E-cigarette vapour exposure increases vascular, cerebral, and pulmonary oxidative stress via a NOX-2-dependent mechanism. Our study identifies the toxic aldehyde acrolein as a key mediator of the observed adverse vascular consequences. Thus, e-cigarettes have the potential to induce marked adverse cardiovascular, pulmonary, and cerebrovascular consequences. Since e-cigarette use is increasing, particularly amongst youth, our data suggest that aggressive steps are warranted to limit their health risks.

Physical Activity and Diet Quality Modify the Association between Comorbidity and Disability among Stroke Patients

Background: Comorbidity is common and causes poor stroke outcomes. We aimed to examine the modifying impacts of physical activity (PA) and diet quality on the association between comorbidity and disability in stroke patients. Methods: A cross-sectional study was conducted on 951 stable stroke patients in Vietnam from December 2019 to December 2020. The survey questionnaires were administered to assess patients’ characteristics, clinical parameters (e.g., Charlson Comorbidity Index items), health-related behaviors (e.g., PA using the International Physical Activity Questionnaire- short version), health literacy, diet quality (using the Dietary Approaches to Stop Hypertension Quality (DASH-Q) questionnaire), and disability (using the World Health Organization Disability Assessment Schedule II (WHODAS II)). Linear regression models were used to analyze the associations and interactions. Results: The proportion of comorbidity was 49.9% (475/951). The scores of DASH-Q and WHODAS II were 29.2 ± 11.8, 32.3 ± 13.5, respectively. Patients with comorbidity had a higher score of disability (regression coefficient, B, 8.24; 95% confidence interval, 95%CI, 6.66, 9.83; p < 0.001) as compared with those without comorbidity. Patients with comorbidity and higher tertiles of PA (B, −4.65 to −5.48; p < 0.05), and a higher DASH-Q score (B, −0.32; p < 0.001) had a lower disability score, as compared with those without comorbidity and the lowest tertile of PA, and the lowest score of DASH-Q, respectively. Conclusions: Physical activity and diet quality significantly modified the negative impact of comorbidity on disability in stroke patients. Strategic approaches are required to promote physical activity and healthy diet which further improve stroke rehabilitation outcomes.

Dietary patterns associated with renal impairment in the Northern Ireland Cohort for the Longitudinal Study of Ageing (NICOLA)

Background

Dietary-based primary prevention guidelines for chronic kidney disease (CKD) treatment are lacking due to limited evidence. Single nutrient intake studies do not account for complex dietary interactions. We assessed associations between dietary patterns and renal function in the Northern Ireland Cohort for the Longitudinal Study of Ageing (NICOLA).

Design

A cross-sectional observational study used NICOLA baseline dietary data collected between February 2014 and March 2016 via a food frequency questionnaire for 2590 participants aged ≥ 50 years. Principal component analysis identified a posteriori dietary patterns. Renal function was characterised by estimated glomerular filtration rate (eGFR) using serum creatinine and cystatin-C. Associations were assessed according to quintiles of dietary pattern adherence and multivariable regression analysis examined associations with eGFR.

Results

Variation in three dietary patterns was significantly associated with eGFR. After adjustment for potential confounders, participants with least adherence to the ‘healthy’ dietary pattern 1 had a mean eGFR 3.4 ml/min/1.73m² (95% confidence interval, [CI] − 5.0, − 1.7, p < 0.001) lower than the most adherent. Those with lowest adherence to the ‘unhealthy’ dietary pattern 2 had a mean eGFR 1.9 ml/min/1.73m² (CI 0.2, 3.5, p = 0.03) higher than those with highest adherence. Participants with lowest adherence to dietary pattern 3, characterised by a high consumption of alcohol and coffee, had a mean eGFR 1.8 ml/min/1.73m² (− 3.5, − 0.01, p = 0.05) lower than those with greatest adherence.

Conclusions

Our findings identify independent associations between dietary patterns and eGFR. These findings can inform the development of diet-related primary prevention advice for CKD.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00394-021-02579-z.

Aspirin, Statins, and Primary Prevention: Opportunities for Shared Decision Making in the Face of Uncertainty

PURPOSE OF REVIEW

The utility of aspirin and statins for primary prevention of atherosclerotic cardiovascular disease remains ambiguous in older adults. Current guidelines and recent data are vague and inconclusive. This review seeks to summarize the landscape of primary prevention of cardiovascular disease in older adults and explore the role of shared decision making.

RECENT FINDINGS

Observational data suggest potential benefit of statin therapy in older adults. Aspirin is presently not recommended for primary prevention based on evidence from recent clinical trials. The implementation of shared decision making and decision aids in routine clinical practice remains challenging but may rise in coming years. Clinical trial data on the horizon may aid in solidifying guideline therapy for statin use. However, in the face of uncertainty, shared decision making between provider and patient should be utilized to determine whether pharmacotherapy may benefit older adults. Decision aids are an effective tool to guide this process.

National Heart Foundation of Australia: position statement on coronary artery calcium scoring for the primary prevention of cardiovascular disease in Australia

Introduction

This position statement considers the evolving evidence on the use of coronary artery calcium scoring (CAC) for defining cardiovascular risk in the context of Australian practice and provides advice to health professionals regarding the use of CAC scoring in primary prevention of cardiovascular disease in Australia.

Main recommendations:

CAC scoring could be considered for selected people with moderate absolute cardiovascular risk, as assessed by the National Vascular Disease Prevention Alliance (NVDPA) absolute cardiovascular risk algorithm, and for whom the findings are likely to influence the intensity of risk management. (GRADE evidence certainty: Low. GRADE recommendation strength: Conditional.)

CAC scoring could be considered for selected people with low absolute cardiovascular risk, as assessed by the NVDPA absolute cardiovascular risk algorithm, and who have additional risk-enhancing factors that may result in the underestimation of risk. (GRADE evidence certainty: Low. GRADE recommendation strength: Conditional.)

If CAC scoring is undertaken, a CAC score of 0 AU could reclassify a person to a low absolute cardiovascular risk status, with subsequent management to be informed by patient–clinician discussion and follow contemporary recommendations for low absolute cardiovascular risk. (GRADE evidence certainty: Very low. GRADE recommendation strength: Conditional.)

If CAC scoring is undertaken, a CAC score > 99 AU or ≥ 75th percentile for age and sex could reclassify a person to a high absolute cardiovascular risk status, with subsequent management to be informed by patient–clinician discussion and follow contemporary recommendations for high absolute cardiovascular risk. (GRADE evidence certainty: Very low. GRADE recommendation strength: Conditional.)

Changes in management as a result of this statement

CAC scoring can have a role in reclassification of absolute cardiovascular risk for selected patients in Australia, in conjunction with traditional absolute risk assessment and as part of a shared decision‐making approach that considers the preferences and values of individual patients.

Dyslipidemia and prevention of atherosclerotic cardiovascular disease in the elderly

The atherosclerotic cardiovascular disease (ASCVD) represents the leading cause of death and disability in the elderly. The study of atherosclerosis and the strategies to control ASCVD are evolving. All strategies emphasize the need to lower LDL cholesterol (LDL-C) through an appropriate lifestyle and the use of lipid-lowering drugs, mainly statins. Available evidence coming from clinical trials is useful to inform clinical choices but the older people are poorly represented in those trials. Thus evidence supporting the benefit of statin therapy for primary and secondary prevention of fatal and nonfatal ASCVD events in adults aged 75 years and older are limited. The pharmacological therapy of dyslipidemia is recommended by guidelines provided by international expert panels in adults, while in the elderly it is still a matter of debate. Statins are generally well tolerated drugs but their use in the elderly, especially in fragile ones or with multi-pathology that take many other drugs, requires a careful evaluation of the risk-benefit ratio and a shared decision-making process between doctor and patient.