Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association

The effect of long-term administration of green tea catechins on aging-related cardiac diastolic dysfunction and decline of troponin I

Aging is an independent risk factor for cardiovascular diseases. Cardiac diastolic dysfunction (CDD), ultimately leading to heart failure with preserved ejection fraction (HFpEF), is prevalent among older individuals. Although therapeutics have made great progress, preventive strategies remain unmet medical needs. Green tea catechins have been shown to be effective in improving aging-related cardiovascular and cerebral disorders in animal models and patients. However, little attention has been paid to whether long-term administration of epigallocatechin gallate (EGCG), the major bioactive ingredient of green tea catechins, could prevent the onset and progression of CDD. In this study, 12-month-old female mice were orally administered 50, 100 and 200 mg EGCG mixed with drinking water for 6 months. Aged mice (18 months old) exhibited the major features of HFpEF, including CDD with pEF, cardiac fibrosis, increased cardiomyocyte apoptosis, and mitochondrial damages, as well as elevated A/B-type natriuretic peptide. Cardiac troponin I (cTnI) expression was also reduced. Long-term administration of 100 or 200 mg EGCG prevented aging-related CDD and exercise capacity decline, along with alleviating myocardial apoptosis and mitochondria damage. The transcription and protein expression of cTnI were increased, which might be achieved by inhibiting the expression and activity of histone deacetylase 1 (HDAC1), and reducing its binding level near cTnI's promoter, thereby elevating acetylated histone 3 (AcH3) and acetylated lysine 9 on histone H3 (AcH3K9) in the aged mice. We provide a novel insight that long-term administration of EGCG is a potentially effective strategy in preventing aging-related CDD and cTnI expression decline.

Ischemic stroke reduces bone perfusion and alters osteovascular structure

Stroke patients lose bone mass and experience fracture at an elevated rate. Although functional intraosseous vasculature is necessary for skeletal maintenance, the effect of stroke on osteovasculature is unknown. In this study we characterized changes to osteovascular perfusion, structure, and composition following mild-to-moderate stroke severity in mice, both with and without exercise therapy. Twelve-week-old male mice (n = 27) received either an ischemic stroke (middle cerebral artery occlusion) or sham procedure, followed by a four-week recovery with either moderate daily treadmill or sedentary activity. Intraosseous perfusion, measured weekly in the proximal tibial metaphysis with laser Doppler flowmetry, was reduced for two weeks in the stroke group relative to the sham group. After four weeks, osteovascular structure was assessed in the distal femoral metaphysis with contrast-enhanced computed tomography. Increased osteovascular volume and branching, decreased number of smaller vessels (6-22 μm), and increased number of larger vessels (>66 μm) were observed in the stroke groups compared to sham groups, which may be a compensatory response to early perfusion deficits. Although moderate exercise mitigated the impact of stroke on osteovascular perfusion and volume, it tended to reduce the amount of osteogenic type H vasculature quantified with immunofluorescence microscopy and, exacerbated by stroke effects, produced fewer vessels in close proximity to bone and thus may have detrimental effects on bone remodeling during early stroke recovery. Since results were similar in both limbs, the effects of ischemic stroke on osteovascular perfusion and structure were primarily systemic, rather than resulting from paresis or disuse, providing new insight for future studies on the pathogenesis and treatment of skeletal fragility in stroke patients.

Investigation of hemodynamic bulk flow patterns caused by aortic stenosis using a combined 4D Flow MRI-CFD framework

Aortic stenosis (AS) leads to alterations of supra-valvular flow patterns which can cause increased damage of red blood cell (RBC) membranes. We investigated these patient specific patterns of a severe AS patient and their reversal in healthy flow through a 4D Flow MRI-based CFD methodology. Computational models of subject-specific aortic geometries were created using in-vivo medical imaging data. Temporally and spatially resolved boundary conditions derived from 4D Flow MRI were implemented for an AS patient and a healthy subject. After validation of the in-silico results with in-vivo data, a healthy inflow profile was set for the AS patient in the CFD model. Pathological versus healthy flow fields were compared regarding their blood flow characteristics, i.e., shear stresses on RBCs and helicity. The accuracy of the 4D Flow MRI-based CFD model was proven with excellent agreement between in-vivo and in-silico velocity fields and R² = 0.9. A pathological high shear stress region in the bulk flow was present during late systole with an increase of 125% compared to both healthy flow. The physiological bihelical structure with predominantly right-handed helices vanished for the pathological state. Instead, a left-handed helix appeared, accompanied by an overall increase in turbulent kinetic energy in areas of accumulated left-handed helicity. The validated 4D Flow MRI-based CFD model identified marked differences between AS and healthy flow. It suggests that altered turbulent and helical structures in the bulk flow are the cause for increased, potentially damaging forces acting upon RBCs in AS.

Frontal Plane QRS - T Angle Is a Predictor of Ventricular Arrhythmia in Heart Failure With Preserved Ejection Fraction

INTRODUCTION

Various ventricular repolarization parameters are known to predict ventricular arrhythmias and mortality in various diseases. Although mortality in patients with heart failure with preserved ejection fraction (HFpEF) is similar to that in heart failure with reduced ejection fraction patients, studies on this subject are more limited. Therefore, it is important to evaluate the relationship between ventricular arrhythmias and mortality and ventricular repolarization parameters, especially the frontal plane QRS-T angle, in patients with HFpEF.

METHODS

Electrocardiographic, echocardiographic, and laboratory data of 811 patients were evaluated, and the fQRST angle was calculated on ECG. The occurrence of ventricular tachycardia, ventricular fibrillation, or sudden death within a mean of 48 ± 12 months was recorded. Statistical significance was determined as p < 0.05.

RESULTS

A total of 811 patients were evaluated, 180 patients in the cardiac event group and 631 patients in the no cardiac event group. NT-proBNP, La size, La volume index, Tp-e time, Tp-e/QTc ratio, and fQRS-T angle were statistically significantly higher in the cardiac event group. NT-proBNP level and fQRS-T angle were found to be independent predictors of mortality in multivariate cox analysis. According to ROC analysis, when QRS-T angle has a cut-off value of 58.63, its sensitivity is 81.2, and its specificity is 79.3. Kaplan-Meier analysis also found that when the fQRS-T angle was > 58.63, mortality was higher than at narrower angles.

CONCLUSIONS

According to our study, the fQRS-T angle, which can be easily and inexpensively calculated on ECG, predicts long-term ventricular arrhythmias in patients with HFpEF.

Redox imbalance driven epigenetic reprogramming and cardiovascular dysfunctions: phytocompounds for prospective epidrugs

BACKGROUND

Cardiovascular diseases (CVDs) are the major contributor to global mortality and are gaining incremental attention following the COVID-19 outbreak. Epigenetic events such as DNA methylation, histone modifications, and non-coding RNAs have a significant impact on the incidence and onset of CVDs. Altered redox status is one of the major causative factors that regulate epigenetic pathways linked to CVDs. Various bioactive phytocompounds used in alternative therapies including Traditional Chinese Medicines (TCM) regulate redox balance and epigenetic phenomena linked to CVDs. Phytocompound-based medications are in the limelight for the development of cost-effective drugs with the least side effects, which will have immense therapeutic applications.

PURPOSE

This review comprehends certain risk factors associated with CVDs and triggered by oxidative stress-driven epigenetic remodelling. Further, it critically evaluates the pharmacological efficacy of phytocompounds as inhibitors of HAT/HDAC and DNMTs as well as miRNAs regulator that lowers the incidence of CVDs, aiming for new candidates as prospective epidrugs.

METHODS

PRISMA flow approach has been adopted for systematic literature review. Different Journals, computational databases, search engines such as Google Scholar, PubMed, Science Direct, Scopus, and ResearchGate were used to collect online information for literature survey. Statistical information collected from the World Health Organization (WHO) site (https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds)) and the American Heart Association of Heart Disease and Stroke reported the international and national status of CVDs.

RESULTS

The meta-analysis of various studies is elucidated in the literature, shedding light on major risk factors such as socioeconomic parameters, which contribute highly to redox imbalance, epigenetic modulations, and CVDs. Going forward, redox imbalance driven epigenetic regulations include changes in DNA methylation status, histone modifications and non-coding RNAs expression pattern which further regulates global as well as promoter modification of various transcription factors leading to the onset of CVDs. Further, the role of various bioactive compounds used in herbal medicine, including TCM for redox regulation and epigenetic modifications are discussed. Pharmacological safety doses and different phases of clinical trials of these phytocompounds are elaborated on, which shed light on the acceptance of these phytocompounds as prospective drugs.

CONCLUSION

This review suggests a strong linkage between therapeutic and preventive measures against CVDs by targeting redox imbalance-driven epigenetic reprogramming using phytocompounds as prospective epidrugs. Future in-depth research is required to evaluate the possible molecular mechanisms behind the phytocompound-mediated epigenetic reprogramming and oxidative stress management during CVD progression.

Mitochondrial dysfunction and calcium homeostasis in heart failure: Exploring the interplay between oxidative stress and cardiac remodeling for future therapeutic innovations

Heart failure (HF) is a multifaceted clinical syndrome characterized by the heart's inability to pump sufficient blood to meet the body's metabolic demands. It arises from various etiologies, including myocardial injury, hypertension, and valvular heart disease. A critical aspect of HF pathophysiology involves mitochondrial dysfunction, particularly concerning calcium (Ca2+) homeostasis and oxidative stress. This review highlights the pivotal role of excess mitochondrial Ca2+ in exacerbating oxidative stress, contributing significantly to HF progression. Novel insights are provided regarding the mechanisms by which mitochondrial Ca2+ overload leads to increased production of reactive oxygen species (ROS) and impaired cellular function. Despite this understanding, key gaps in research remain, particularly in elucidating the complex interplay between mitochondrial dynamics and oxidative stress across different HF phenotypes. Furthermore, therapeutic strategies targeting mitochondrial dysfunction are still in their infancy, with limited applications in clinical practice. By summarizing recent findings and identifying these critical research gaps, this review aims to pave the way for innovative therapeutic approaches that improve the management of heart failure, ultimately enhancing patient outcomes through targeted interventions.

Hypertension increases sympathetic neuron activity by enhancing intraganglionic cholinergic collateral connections

Autonomic dysregulation, including sympathetic hyperactivity, is a common feature of hypertension (HT) and other cardiovascular diseases. The CNS plays a role in driving chronic sympathetic activation in disease, but several lines of evidence suggest that neuroplasticity in the periphery may also contribute. The potential contribution of postganglionic sympathetic neurons to sustained sympathetic hyperactivity is not well understood. We recently discovered that noradrenergic sympathetic neurons in the stellate ganglion (SG) have excitatory cholinergic collateral connections to other neurons within the ganglion. We hypothesize that remodelling of these neurons and increased cholinergic collateral transmission contributes to sustained sympathetic hyperactivity in cardiovascular diseases, including HT. To test that hypothesis, we examined the activity of sympathetic neurons in isolated SG under control conditions and after 1 week of HT induced by peripheral angiotensin II infusion, using whole-cell patch clamp recordings. Despite the absence of central inputs, we observed elevated spontaneous activity and synaptic transmission in sympathetic SG neurons from hypertensive mice that required generation of action potentials. Genetically disrupting cholinergic transmission in noradrenergic neurons decreased basal neuronal activity and prevented angiotensin II-mediated enhancement of activity. Similar changes in activity, driven by increased collateral transmission, were identified in cardiac projecting neurons and neurons projecting to brown adipose tissue. These changes were not driven by altered A-type K+ currents. This suggests that HT stimulates increased activity throughout the intraganglionic network of collateral connections, contributing to the sustained sympathetic hyperactivity characteristic in cardiovascular disease. KEY POINTS: Sympathetic neurons in ganglia isolated from angiotensin II-treated hypertensive mice are more active than neurons from control mice despite the absence of central activation. The enhanced activity is the result of a ganglionic network of cholinergic collaterals, rather than altered intrinsic excitability. Increased neuronal activity was observed in both cardiac neurons and brown adipose tissue-projecting neurons, which are not involved in cardiovascular homeostasis.

Unveiling the role of exercise in modulating plasma heat shock protein 27 levels: insights for exercise immunology and cardiovascular health

Cardiovascular disease is one of the leading causes of mortality worldwide, primarily driven by atherosclerosis, a chronic inflammatory condition contributing significantly to fatalities. Various biological determinants affecting cardiovascular health across different age and sex groups have been identified. In this context, recent attention has focused on the potential therapeutic and preventive role of increasing circulating levels of heat shock protein 27 (plasma HSP27) in combating atherosclerosis. Plasma HSP27 is recognized for its protective function in inflammatory atherogenesis, offering promising avenues for intervention and management strategies against this prevalent cardiovascular ailment. Exercise has emerged as a pivotal strategy in preventing and managing cardiovascular disease, with literature indicating an increase in plasma HSP27 levels post-exercise. However, there is limited understanding of the impact of exercise on the release of HSP27 into circulation. Clarifying these aspects is crucial for understanding the role of exercise in modulating plasma HSP27 levels and its potential implications for cardiovascular health across diverse populations. Therefore, this review aims to establish a more comprehensive understanding of the relationship between plasma HSP27 and exercise.

Evaluation of a deep learning-based software to automatically detect and quantify breast arterial calcifications on digital mammogram

PURPOSE

The purpose of this study was to evaluate an artificial intelligence (AI) software that automatically detects and quantifies breast arterial calcifications (BAC).

MATERIALS AND METHODS

Women who underwent both mammography and thoracic computed tomography (CT) from 2009 to 2018 were retrospectively included in this single-center study. Deep learning-based software was used to automatically detect and quantify BAC with a BAC AI score ranging from 0 to 10-points. Results were compared using Spearman correlation test with a previously described BAC manual score based on radiologists' visual quantification of BAC on the mammogram. Coronary artery calcification (CAC) score was manually scored using a 12-point scale on CT. The diagnostic performance of the marked BAC AI score (defined as BAC AI score ≥ 5) for the detection of marked CAC (CAC score ≥ 4) was analyzed in terms of sensitivity, specificity, accuracy and area under the receiver operating characteristic curve (AUC).

RESULTS

A total of 502 women with a median age of 62 years (age range: 42-96 years) were included. The BAC AI score showed a very strong correlation with the BAC manual score (r = 0.83). Marked BAC AI score had 32.7 % sensitivity (37/113; 95 % confidence interval [CI]: 24.2-42.2), 96.1 % specificity (374/389; 95 % CI: 93.7-97.8), 71.2 % positive predictive value (37/52; 95 % CI: 56.9-82.9), 83.1 % negative predictive value (374/450; 95 % CI: 79.3-86.5), and 81.9 % accuracy (411/502; 95 % CI: 78.2-85.1) for the diagnosis of marked CAC. The AUC of the marked BAC AI score for the diagnosis of marked CAC was 0.64 (95 % CI: 0.60-0.69).

CONCLUSION

The automated BAC AI score shows a very strong correlation with manual BAC scoring in this external validation cohort. The automated BAC AI score may be a useful tool to promote the integration of BAC into mammography reports and to improve awareness of a woman's cardiovascular risk status.

The Close Link Between Obesity and Cardiovascular Disease: Current Insights and Remaining Challenges

Obesity is a global public health crisis, contributing to chronic disease development and poor prognosis. A large body of evidence consistently demonstrates that increased adiposity leads to many cardiovascular diseases (CVDs) and complications, such as coronary artery disease, heart failure, and arrhythmias, via direct and indirect mechanisms. Therefore, weight management is crucial to reduce and prevent cardiovascular risk. The recent emergence of glucose-like peptide-1 receptor agonists shows remarkable weight reduction and cardiovascular prevention. Despite the clear benefits, controversies and challenges on obesity-related CVD remain. This review aims to provide a comprehensive understanding of obesity-related CVD and explore current remaining tasks.

Self-Management Interventions for Black Women at Risk for Cardiovascular Disease: A Systematic Literature Review

Cardiovascular disease (CVD) is the leading cause of death among Black women. When compared with their non-Hispanic White counterparts, Black women are about 50% more likely to have uncontrolled high blood pressure (BP). The disproportionate burden of CVD in Black women highlights the need for CVD prevention programs in this population. The present systematic literature review examined the updated literature on the efficacy of primary prevention self-management interventions for Black women with CVD risk factors. Searches were run on PubMed, Cochrane, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO databases based on the following inclusion criteria: papers published from September 22, 2018; English language; U.S. studies only; original research reports; prospective clinical trials; cardiovascular health promotion/self-management interventions that target at least two health practices for primary prevention; comorbid conditions without a cardiovascular event; at least one patient-level outcome; and Black women at least 18 years of age. Twelve papers met the inclusion criteria. Health practices targeted included physical activity, nutrition, weight loss, health knowledge, and BP control. Nine of the 12 papers reported statistically significant improvements on at least one CVD risk factor including weight loss, physical activity, BP control, waist circumference, and depression. Culturally tailored self-management interventions appear to be feasible with weak to moderately high evidence of efficacy for reducing CVD risk factors in Black women. Further research should focus on the influence that social determinants of health, including mental health, may have on self-management and CVD risk in this population.

Edoxaban treatment in routine clinical practice is highly concordant with the 2020 European Society of Cardiology atrial fibrillation guidelines: results from the noninterventional Global ETNA-AF programme

Aims

The 2020 European Society of Cardiology (ESC)-atrial fibrillation (AF) guidelines recommend a risk-based approach to oral anticoagulation (OAC) therapy in patients with AF; however, it is unknown if current practice aligns with these recommendations. This study assessed the associated effectiveness and safety of edoxaban in patients with AF according to the 2020 ESC-AF guidelines and the approved label in routine clinical care.

Methods and results

The Global ETNA-AF programme is a large prospective, noninterventional programme evaluating safety and effectiveness of edoxaban. Baseline characteristics and 2-year clinical event data were analysed in subgroups, defined by ESC-AF guidelines indication of OAC therapy according to CHA2DS2-VASc score [no OAC to be considered, OAC should be considered (2 for females/1 for males), and OAC recommended (≥3 for females/≥2 for males)] and modified HAS-BLED score [(≥3 (bleeding risk high) vs. <3 (bleeding risk low)]. Of 19 960 patients included, 16 912 (84.7%) were categorized as OAC recommended and 2501 (12.5%) as OAC should be considered; 547 (2.7%) were in the no OAC to be considered group. In the OAC recommended group, 12 006 (71.0%) had high bleeding risk. Clinical event rates were <5%/year across all risk groups, even in the OAC recommended and high bleeding risk groups. In the OAC recommended and high bleeding risk groups, patients had low ischaemic stroke and bleeding event rates, regardless of receiving the 30 or 60 mg dose.

Conclusion

This study demonstrated that edoxaban use in patients with AF largely aligns with 2020 ESC-AF guidelines, while maintaining low clinical event rates.

Registration

Europe (NCT02944019), Japan (UMIN000017011), and Korea/Taiwan (NCT02951039).

Prevalence and risk factors of frailty in older patients with coronary heart disease: A systematic review and meta-analysis

OBJECTIVE

To quantitatively synthesise evidence on the prevalence of and risk factors of frailty in older patients with coronary heart disease.

METHODS

Nine electronic databases were searched from the inception to July 20th 2024. Random-effects model was performed to calculate to estimate the prevalence of frailty in older patients with coronary heart disease. Meta-regression analysis and subgroup analysis were conducted to explore the potential sources of heterogeneity. Sensitivity analysis was conducted using a study-by-study exclusion method. Meta-analysis of risk factors was performed using the Mantel-Haenszel or inverse variance method and only on the risk factors that have been reported in a minimum of two studies.

RESULTS

A total of 42 studies from 5 countries met the inclusion criteria, involving 11954 older patients. The pooled prevalence in older adults with coronary heart disease was 36% (95%CI: 31%-40%) for frailty. We found a higher prevalence of frailty among older patients with coronary heart disease in females, ≥80 years, case-control studies, EFS evaluation tool and acute coronary syndrome. Age, female, cardiac classification, malnutrition, fall within 1 year, sleep disorder, hypoproteinemia (albumin<35g/L), low level of literacy, depression, anxiety, low BMI, polypharmacy, comorbidities, CCI, diabetes, hypertension, high level of BNP, ADL disability, gait speed, living alone, low level of 25(OH)D3 were risk factors of frailty among older patients with coronary heart disease.

CONCLUSIONS

Coronary heart disease patients have a significantly higher prevalence of frailty. Early screening and timely prevention of frailty by medical practitioners are needed to provide more targeted measures for CHD patients.

Usefulness of hypochloremia at the time of discharge to predict prognosis in patients with chronic heart failure after hospitalization

BACKGROUND

Hypochloremia has been suggested as a strong marker of mortality in hospitalized patients with heart failure (HF). This study aimed to clarify whether incorporating hypochloremia into pre-existing prognostic models improved the performance of the models.

METHODS

We tested the prognostic value of hypochloremia (<97 mEq/L) measured at discharge in hospitalized patients with HF registered in the REALITY-AHF and NARA-HF studies. The primary outcome was 1-year mortality after discharge.

RESULTS

Among 2496 patients with HF, 316 (12.6 %) had hypochloremia at the time of discharge, and 387 (15.5 %) deaths were observed within 1 year of discharge. The presence of hypochloremia was strongly associated with higher 1-year mortality compared to those without hypochloremia (log-rank: p < 0.001), and this association remained even after adjustment for the Get With the Guideline-HF risk model (GWTG-HF), anemia, New York Heart Association (NYHA) classification, and log-brain natriuretic peptide (BNP) [hazard ratio (HR) 1.64; p < 0.001]. Furthermore, adding hypochloremia to the prediction model composed of GWTG-HF + anemia + NYHA class + log-BNP yielded a numerically larger area under the curve (0.740 vs 0.749; p = 0.059) and significant improvement in net reclassification (0.159, p = 0.010).

CONCLUSIONS

Incorporating the presence of hypochloremia at discharge into pre-existing risk prediction models provides incremental prognostic information for hospitalized patients with HF.

Unraveling trends and disparities in acute myocardial infarction-related mortality among adult cancer patients: A nationwide CDC-WONDER analysis (1999-2020)

Background

Cancer patients are at an increased risk for the incidence and complications of acute myocardial infarction (AMI) due to shared risk factors and treatment-related adverse effects. Mortality trends for AMI-related deaths in adult cancer patients in the U.S. remain unexplored.

Methodology

This study used CDC WONDER data for death certificates from 1999 to 2020, identifying U.S. adults (≥25 years) with cancer (ICD-10: C00-D49) who died of AMI (ICD-10: I21) as the underlying cause. Age-adjusted mortality rates (AAMRs) and annual percent changes (APCs) were calculated and stratified by gender, age, race, and geographic location.

Results

Between 1999 and 2020, there were 109,462 AMI-related deaths in adult cancer patients. The AAMR decreased from 4.3 per 100,000 in 1999 to 1.4 in 2020. A significant decline occurred from 1999 to 2015 (APC: 6.65; 95 % CI: 6.95 to -6.40; p < 0.001), followed by a stable trend from 2015 to 2020 (APC: 1.36; 95 % CI: 2.69 to 0.91; p = 0.152). Men had higher AAMRs than women (3.5 vs. 1.5). AAMRs were highest in older adults (10.5) compared to middle-aged (0.7) and young adults (0.1). Racial disparities showed the highest AAMRs in non-Hispanic (NH) Black patients (2.7), followed by NH Whites (2.4), NH American Indian/Alaska Native (1.6), Hispanic/Latino (1.3), and NH Asian/Pacific Islander (1.1). Non-metropolitan areas had higher AAMRs than metropolitan areas (2.8 vs. 2.2).

Conclusions

This analysis highlights a significant decline in AMI-related mortality among cancer patients in the U.S., with persistent disparities by gender, age, race and geographical location.

Effects of sodium-glucose cotransporter-2 inhibitors in myocardial infarction patients: A systematic review and meta-analysis

AIMS

Sodium-glucose cotransporter-2 (SGLT2) inhibitors are known to improve cardiovascular outcomes in individuals with heart failure (HF), type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD). However, their efficacy following myocardial infarction (MI) remains unclear.

MATERIALS AND METHODS

A systematic search was conducted using PubMed, Embase, Cochrane Library, Web of Science and ClinicalTrials.gov. Primary outcomes included hospitalization for heart failure (HHF), cardiovascular (CV) death, a composite of HHF or CV death, all-cause death, major cardiovascular events (MACE), recurrent MI, severe arrhythmia, renal injury and stroke. Secondary outcomes targeted improvements in left ventricular ejection fraction (LVEF) and left ventricular end-diastolic volume (LVEDV).

RESULTS

Thirteen studies comprising 22 370 patients were included. Meta-analysis revealed that SGLT2 inhibitors reduced HHF (RR 0.69, 95% CI 0.61 to 0.78, p < 0.001), combined HHF or CV death (RR 0.87, 95% CI 0.77 to 0.99, p = 0.028), all-cause mortality (RR 0.82, 95% CI 0.73 to 0.93, p = 0.002), MACE (RR 0.68, 95% CI 0.53 to 0.88, p = 0.004), recurrent MI (RR 0.81, 95% CI 0.69 to 0.94, p = 0.007), severe arrhythmia (RR 0.54, 95% CI 0.34 to 0.85, p = 0.009) and renal injury (RR 0.68, 95% CI 0.53 to 0.87, p = 0.002). Improvement in LVEF (MD 3.96%, 95% CI 2.52 to 5.40; p < 0.001) and LVEDV (MD -5.52 mL, 95% CI -10.21 to -0.83; p = 0.021) was notably greater in the SGLT2 inhibitors group.

CONCLUSIONS

In post-MI patients, we first found that SGLT2 inhibitors significantly lowered the risk of HHF, combined CV death or HHF, all-cause death, MACE, recurrent MI, severe arrhythmias and renal injury. Additionally, SGLT2 inhibitors improved LVEF and LVEDV.

Endothelial dysfunction in middle-aged and older men with low testosterone is associated with elevated circulating endothelin-1

Low testosterone in middle-aged/older men contributes to accelerated vascular aging, including endothelial dysfunction. However, the mechanisms by which low testosterone affects endothelial dysfunction are not well understood. We sought to determine whether higher endothelin-1 (ET-1) levels are associated with reduced brachial artery flow-mediated dilation (FMD) in middle-aged/older men with low testosterone. Plasma ET-1 was quantified in 60 men categorized as young (n = 20, age = 30 ± 4 yr, testosterone = 510 ± 63 ng/dL), middle-aged/older with normal testosterone (n = 20, age = 59 ± 6 yr, testosterone = 512 ± 115 ng/dL), or middle-aged/older with low testosterone (n = 20, age = 60 ± 8 yr, testosterone = 265 ± 47 ng/dL). Endothelial function was determined via brachial artery FMD. Venous and arterial endothelial cells were harvested via endovascular biopsy in a subset of participants and stained for ET-1 expression. Middle-aged/older men with normal testosterone exhibited lower brachial artery FMD (5.7 ± 2.2%) compared with young men (7.3 ± 1.3%, P = 0.020), which was exaggerated in middle-aged/older men with low testosterone (4.0 ± 1.8%, P = 0.010 vs. middle-aged/older men with normal testosterone). Plasma ET-1 was not different between young (5.6 ± 0.9 ng/dL) and middle-aged/older men with normal testosterone (6.0 ± 1.4 ng/dL, P = 0.681) but was higher in middle-aged/older men with low testosterone (7.7 ± 2.8 ng/dL) compared with both groups (P < 0.001 vs. young men; P = 0.013 vs. middle-aged/older men with normal testosterone). There was no difference in venous (P = 0.616) or arterial (P = 0.222) endothelial cell ET-1 expression between groups. There was a significant inverse association between plasma ET-1 and FMD (r =-0.371, P = 0.004). These data suggest that the accelerated age-associated reduction in endothelial dysfunction in middle-aged/older men with low testosterone is related to higher circulating ET-1.NEW & NOTEWORTHY Middle-aged/older men with low testosterone have reduced vascular endothelial function compared with young and age-matched men with normal testosterone. In this manuscript, we demonstrate that men with low testosterone have higher plasma endothelin-1, which is associated with worse brachial artery flow-mediated dilation. The source of higher plasma endothelin-1 remains unknown; however, higher circulating endothelin-1 appears to be a mechanism contributing to reduced vascular endothelial function in men with low testosterone.

Atrial fibrillation in Black American patients: A review of genetics, risk factors, and outcomes

Atrial fibrillation (AF), the most common arrhythmia in the United States, affects 6 million Americans, with numbers projected to increase to 12 million by 2030. A racial paradox difference in the incidence and prevalence of AF exists between Black and White Americans. Black Americans are less prone than White Americans to development of AF, but they display a higher burden of modifiable risk factors for cardiovascular disease and higher rates of ischemic stroke. Data pertaining to the American Heart Association Life's Simple 7 (LS7) health metrics show that Black Americans have suboptimal LS7 scores compared with White Americans on average despite lower genetic predisposition to AF. This trend suggests the impact of cardiovascular health on the development and progression of AF. Social, genetic, and lifestyle risk factors have been shown to play a role in the racial paradox and AF outcomes in Black Americans. This review summarizes factors contributing to the racial paradox and discusses suggestions for improved health outcomes in Black Americans with AF.

Patient Characteristics and Real-World Treatment of Very Elderly Patients with Nonvalvular Atrial Fibrillation in Japan: An Administrative Claims Database Study

INTRODUCTION

Very elderly patients with nonvalvular atrial fibrillation (NVAF) are at high risk for both ischemic and hemorrhagic events. This study aimed to understand the characteristics and real-world treatment of very elderly patients with NVAF in Japan.

METHODS

We conducted a retrospective analysis of electronic health records and claims data from acute care hospitals for very elderly patients with NVAF with medical records available on or after their 80th birthday. The outcomes of interest were (1) characteristics of very elderly patients and (2) patterns of anticoagulation and impact of clinical condition on anticoagulation.

RESULTS

Of 1,278,404 patients with newly diagnosed atrial fibrillation (AF), 443,820 were eligible for the analysis. Mean ± standard deviation age was 84.5 ± 5.5 years, CHADS2 score was 2.4 ± 1.0, and CHA2DS2-VASc score was 4.3 ± 1.3. Among patients diagnosed with NVAF before age 80 years, 39.1% were not receiving anticoagulation therapy, while among those diagnosed with NVAF at age ≥ 90 years, 46.1% were not prescribed any anticoagulant. Patients diagnosed with NVAF before 80 years of age tended to stop anticoagulation therapy, especially those receiving warfarin, upon reaching 80 years of age. Among those who were newly diagnosed with NVAF after 80 years, most received reduced doses of direct oral anticoagulants (DOACs).

CONCLUSIONS

A significant proportion of very elderly patients with NVAF in Japan were diagnosed with NVAF after the age of 80 years and were not receiving anticoagulation therapy, particularly with increasing age. Furthermore, warfarin use declined with age, and patients on DOACs frequently received reduced doses.

Comparative Analysis of ChatGPT and Google Gemini in Generating Patient Educational Resources on Cardiac Health: A Focus on Exercise-Induced Arrhythmia, Sleep Habits, and Dietary Habits

INTRODUCTION

Patient education is crucial in cardiovascular health, aiding in shared decision-making and improving adherence to treatments. Artificial intelligence (AI) tools, including ChatGPT (OpenAI, San Francisco, CA) and Google Gemini (Google LLC, Mountain View, CA), are revolutionizing patient education by providing personalized, round-the-clock access to information, enhancing engagement, and improving health literacy. The paper aimed to compare the responses generated by ChatGPT and Google Gemini for creating patient education guides on exercise-induced arrhythmia, sleep habits and cardiac health, and "dietary habits and cardiac health.

METHODOLOGY

A comparative observational study was conducted evaluating three AI-generated guides: "exercise-induced arrhythmia," "sleep habits and cardiac health," and "dietary habits and cardiac health," using ChatGPT and Google Gemini. Responses were evaluated for word count, sentence count, grade level, ease score, and readability using the Flesch-Kincaid calculator and QuillBot (QuillBot, Chicago, IL) plagiarism tool for similarity score. Reliability was assessed with the modified DISCERN score. Statistical analysis was conducted using R version 4.3.2 (The R Core Team, R Foundation for Statistical Computing, Vienna, Austria).

RESULTS

ChatGPT-generated responses had an overall higher average word count when compared to Google Gemini; however, the difference was not statistically significant (p = 0.2817). Google Gemini scored higher on ease of understanding, though this difference was also not significant (p = 0.7244). There were no significant differences in sentence count or average words per sentence. ChatGPT tended to produce more complex content for certain topics, whereas Google Gemini's responses were generally easier to read. Similarity scores were higher for ChatGPT across all topics, while reliability scores varied by topic, with Google Gemini performing better for exercise-induced arrhythmia and ChatGPT for sleep habits and cardiac health.

CONCLUSIONS

The study found no significant difference in ease score, grade score, and reliability between AI-generated responses for a cardiology disorders brochure. Future research should explore AI techniques across various disorders, ensuring up-to-date and reliable public information.

Unique Treatment of Atrial Fibrillation: Simultaneous Dual Direct-Current Cardioversion in Morbidly Obese Patients

Atrial fibrillation (AFib) is a prevalent arrhythmia associated with substantial health complications and economic strain on the health care system in the United States. Obesity is a challenging comorbidity to manage in this scenario, as the incidence of AFib rises alongside increasing body mass index (BMI). Furthermore, obesity presents several challenges in applying traditional treatment modalities for AFib, such as pharmacological options, ablation, and direct-current cardioversion (DCCV). Currently, there is no specific regimen for treating AFib for morbidly obese patients. This case report describes and discusses a unique treatment option for a morbidly obese patient with poorly controlled AFib. A 43-year-old male with several comorbidities including morbid obesity with a BMI of 87 kg/m2 presented with AFib in the setting of sepsis and bacteremia. The patient was treated with increasing doses of metoprolol without effective control of his AFib and had previously received amiodarone as well without appropriate response. DCCV was performed under deep sedation using dexmedetomidine and propofol infusions with careful attention to maintaining spontaneous ventilation. AFib was successfully converted to normal sinus rhythm using dual biphasic DCCV (each at 200 J). Pharmacological treatment of AFib can be challenging in the obese population due to medications and traditional cardioversion being less effective with increasing BMI. The anesthetic plan was of important consideration in this case, given his BMI of 87 kg/m2 and the risk for obstruction and potential airway compromise. Nasal continuous positive airway pressure and the use of dexmedetomidine supported airway patency and maintained spontaneous respirations while ensuring adequate depth of anesthesia. Morbidly obese patients likely require increased energy for cardioversion; thus, we describe the effectiveness of using simultaneous dual DCCV with two sets of pads in this patient after an unsuccessful single biphasic shock with 200 J.

Deep learning survival model predicts outcome after intracerebral hemorrhage from initial CT scan

BACKGROUND

Predicting functional impairment after intracerebral hemorrhage (ICH) provides valuable information for planning of patient care and rehabilitation strategies. Current prognostic tools are limited in making long term predictions and require multiple expert-defined inputs and interpretation that make their clinical implementation challenging. This study aimed to predict long term functional impairment of ICH patients from admission non-contrast CT scans, leveraging deep learning models in a survival analysis framework.

METHODS

We used the admission non-contrast CT scans from 882 patients from the Massachusetts General Hospital ICH Study for training, hyperparameter optimization, and model selection, and 146 patients from the Yale New Haven ICH Study for external validation of a deep learning model predicting functional outcome. Disability (modified Rankin scale [mRS] > 2), severe disability (mRS > 4), and dependent living status were assessed via telephone interviews after 6, 12, and 24 months. The prediction methods were evaluated by the c-index and compared with ICH score and FUNC score.

RESULTS

Using non-contrast CT, our deep learning model achieved higher prediction accuracy of post-ICH dependent living, disability, and severe disability by 6, 12, and 24 months (c-index 0.742 [95% CI -0.700 to 0.778], 0.712 [95% CI -0.674 to 0.752], 0.779 [95% CI -0.733 to 0.832] respectively) compared with the ICH score (c-index 0.673 [95% CI -0.662 to 0.688], 0.647 [95% CI -0.637 to 0.661] and 0.697 [95% CI -0.675 to 0.717]) and FUNC score (c-index 0.701 [95% CI- 0.698 to 0.723], 0.668 [95% CI -0.657 to 0.680] and 0.727 [95% CI -0.708 to 0.753]). In the external independent Yale-ICH cohort, similar performance metrics were obtained for disability and severe disability (c-index 0.725 [95% CI -0.673 to 0.781] and 0.747 [95% CI -0.676 to 0.807], respectively). Similar AUC of predicting each outcome at 6 months, 1 and 2 years after ICH was achieved compared with ICH score and FUNC score.

CONCLUSION

We developed a generalizable deep learning model to predict onset of dependent living and disability after ICH, which could help to guide treatment decisions, advise relatives in the acute setting, optimize rehabilitation strategies, and anticipate long-term care needs.

TREM2 Impairs Glycolysis to Interrupt Microglial M1 Polarization and Inflammation via JAK2/STAT3 Axis

Cerebral ischemia/reperfusion injury (IRI) is a primary pathophysiological basis of ischemic stroke, a dreadful cerebrovascular event carrying substantial disability and lethality. Triggering receptor expressed on myeloid cells 2 (TREM2) is a membrane glycoprotein that has been notified as a protective factor for cerebral ischemic stroke. On this basis, the paper is thereby goaled to interpret the probable activity and downstream mechanism of TREM2 against cerebral IRI. Cerebral IRI was simulated in murine microglial BV2 cells under oxygen-glucose deprivation and reperfusion (OGD/R) conditions. Western blotting ascertained the expressions of TREM2 and janus kinase 2 (JAK2)/signal transducer and activator of transcription 3 (STAT3) axis-associated proteins. ELISA and RT-qPCR assayed the secretion of inflammatory cytokines. Immunofluorescence and western blotting estimated macrophage polarization. Glycolysis activation was measured through evaluating lactic acid and extracellular acidification rate (ECAR). RT-qPCR and western blotting examined the expressions of glycolytic genes. TREM2 was abnormally expressed and JAK2/STAT3 axis was aberrantly activated in BV2 cells in response to OGD/R. Elevation of TREM2 repressed the inflammatory reaction and glycolysis, inhibited the JAK2/STAT3 axis, whereas promoted M1-to-M2 polarization in OGD/R-injured BV2 cells. Upregulated TREM2 inactivated the glycolytic pathway to relieve OGD/R-induced inflammatory injury and M1 macrophage polarization. Besides, STAT3 activator, colivelin, aggravated the glycolysis, inflammatory injury and drove M1-like macrophage polarization in TREM2-overexpressing BV2 cells exposed to OGD/R. Collectively, TREM2 might produce anti-inflammatory potential in cerebral IRI, which might dependent on the inactivation of glycolytic pathway via intermediating the JAK2/STAT3 axis.

WMH Contributions to Cognitive Impairment: Rationale and Design of the Diverse VCID Study

As awareness of dementia increases, more individuals with minor cognitive complaints are requesting clinical assessment. Neuroimaging studies frequently identify incidental white matter hyperintensities, raising patient concerns about their brain health and future risk for dementia. Moreover, current US demographics indicate that ≈50% of these individuals will be from diverse backgrounds by 2060. Racial and ethnic minority populations bear a disproportionate burden of vascular risk factors magnifying dementia risk. Despite established associations between white matter hyperintensities and cognitive impairment, including dementia, no study has comprehensively and prospectively examined the impact of individual and combined magnetic resonance imaging measures of white matter injury, their risk factors, and comorbidities on cognitive performance among a diverse, nondemented, stroke-free population with cognitive complaints over an extended period of observation. The Diverse VCID (Diverse Vascular Cognitive Impairment and Dementia) study is designed to fill this knowledge gap through 3 assessments of clinical, behavioral, and risk factors; neurocognitive and magnetic resonance imaging measures; fluid biomarkers of Alzheimer disease, vascular inflammation, angiogenesis, and endothelial dysfunction; and measures of genetic risk collected prospectively over a minimum of 3 years in a cohort of 2250 individuals evenly distributed among Americans of Black/African, Latino/Hispanic, and non-Hispanic White backgrounds. The goal of this study is to investigate the basic mechanisms of small vessel cerebrovascular injury, emphasizing clinically relevant assessment tools and developing a risk score that will accurately identify at-risk individuals for possible treatment or clinical therapeutic trials, particularly individuals of diverse backgrounds where vascular risk factors and disease are more prevalent.

Ten-year Follow-up Study of Patients with Persistent Atrial Fibrillation Treated by Combined Pulmonary Vein Isolation and Complex Fractionated Electrogram Ablation

Aim

This study retrospectively investigated the clinical outcomes of patients with persistent AF treated with a combined approach of pulmonary vein isolation (PVI) and complex fractionated atrial electrogram (CFAE) ablation over a follow-up period of 10 years.

Methods

A total of 73 patients with persistent and long-standing persistent AF who underwent combined pulmonary vein isolation and CFAE ablation in the first procedure were included. A complete CFAE mapping of the left atrium and coronary sinus was performed with a 3D mapping system. All CFAEs defined as electrograms with continuous activity or mean cycle length detected by the system of <80 ms were excluded. Patients were controlled regularly during the first year followed by annual control. Any documented atrial tachyarrhythmia (ATA) was regarded as a recurrence.

Results

After index ablation, 18 (24.7%) were free of ATAs during 10-year follow-up. The proportion of atrial flutter (AFL) was 39.7%, with six typical AFL. A mean of 2.2 ± 1.2 ablation procedures were performed in each patient. After multiple procedures, 33 (45.2%) patients were free of ATA during the follow-up. The proportion of AFL was 23.2% with no typical AFL. Older age, female sex and a longer AF history were associated with ATA recurrence.

Conclusion

A high recurrence rate of ATA was observed after index procedure of pulmonary vein isolation plus CFAE ablation in patients with persistent AF. No significant difference in freedom of ATA was found between persistent and long-standing persistent AF groups beyond 1 year. The incidence of postablation AFL was particularly high, even after multiple ablations.

Association between the triglyceride glucose-body mass index and mortality risk in cardiovascular disease populations: a longitudinal cohort study

BACKGROUND

Cardiovascular disease (CVD) is a leading cause of global mortality, with increasing prevalence and impact, especially in the elderly and developing countries. Insulin resistance (IR) plays a significant role in CVD progression, and the triglyceride glucose-body mass index (TyG-BMI) index, combining fasting glucose and triglycerides, offers a simple, cost-effective method for assessing IR. However, its prognostic value in CVD populations remains underexplored. This study aims to investigate the relationship between TyG-BMI and mortality in CVD patients.

METHODS

Data from the National Health and Nutrition Examination Survey (NHANES) (1999-2018) combined with the linked National Death Index were analyzed. The CVD population was split into two groups (Q1 and Q2) based on the median TyG-BMI. The primary outcomes were all-cause mortality and cause-specific mortality.

RESULTS

The study ultimately included 2,576 participants, of which 56% were male. The median age of the participants was 69 years, and the median TyG-BMI was 256.59. After adjusting for potential confounders, a negative relationship was found between TyG-BMI and all-cause mortality in populations with CVD, coronary heart disease (CHD), congestive heart failure (CHF), and heart attack. The hazard ratios (HR) and 95% confidence intervals (CI) were 0.73 (0.64, 0.85), 0.67 (0.53, 0.84), 0.69 (0.54, 0.88), and 0.73 (0.59, 0.91), respectively. At the same time, a notable inverse relationship was noted between the TyG-BMI and non-CVD mortality in the CVD and CHD population, with HR and 95% CI of 0.70 (0.58, 0.84) and 0.61 (0.45, 0.82), respectively. In this study, there was no observed noteworthy relationship between TyG-BMI and CVD mortality. Furthermore, sensitivity analysis yielded similar results.

CONCLUSION

Among populations with CVD in the United States, a heightened TyG-BMI was notably correlated with a decreased likelihood of mortality. This index can effectively classify the risk levels of CVD patients and may serve as a valuable prognostic marker.

Risk of stroke in patients with inflammatory bowel disease: a systematic review and meta-analysis

BACKGROUND

Current studies suggest a potential link between inflammatory bowel disease (IBD), comprising Crohn's disease (CD) and ulcerative colitis (UC), and cardiovascular diseases, such as stroke. This study aimed to assess the risk of stroke in IBD patients compared to general population.

METHODS

Systematic search was done in PubMed, Embase, CENTRAL, Scopus, and CINAHL databases for studies published till September 2023. Using a random-effects model, the hazard ratios (HRs) with 95% confidence intervals (CIs) for stroke occurrence were calculated. Subgroup analyses were done to estimate pooled HR with 95%CI for CD, UC, and overall IBD cases separately. Publication bias assessment was done by Begg's and Egger's tests.

RESULTS

Thirteen studies with 2,802,955 participants were included. IBD patients in general had significantly higher risk of stroke, with HR of 1.30 [95% CI 1.21-1.39]. Subgroup analysis demonstrated an HR of 1.35 [95% CI 1.22-1.49] for CD and 1.15 [95% CI 1.09-1.22] for UC. Substantial heterogeneity was detected across studies, with no substantial publication bias. Sensitivity analyses affirmed the stability of findings.

CONCLUSION

IBD in general, and Crohn's disease in particular are associated with significantly higher risk of stroke. Our findings further emphasize the importance of cardiovascular risk assessment and management strategies in IBD care.

PROTOCOL REGISTRATION

PROSPERO, CRD42023470602.

Association of single and multiple cardiometabolic diseases with atrial fibrillation: a prospective cohort study

BACKGROUND

Individual cardiometabolic diseases (CMDs) increase atrial fibrillation (AF) risk; however, whether multiple CMDs exert a cumulative effect on AF risk remains unclear. Our objective was to examine the link between coexisting CMDs and AF, as well as their cumulative impact.

METHODS

This UK Biobank-based prospective cohort study included data from participants with information related to CMDs and AF. The assessment of CMDs and AF was based on participants' self-reported medical histories and electronic health records. Cox proportional hazard regression models were employed to analyse the link between the number of CMDs and AF and to determine the cumulative effect of multiple CMDs. Further, we performed stratified analyses and adjusted for confounding factors.

RESULTS

The study included 308 916 participants. The risk of AF was substantially associated with varying numbers of CMDs after multivariable adjustment in comparison to the reference group (all p<0.001). In the fully adjusted model, participants with 1, 2 and ≥3 CMDs exhibited elevated risks of 54% (HR: 1.54, 95% CI 1.48 to 1.59), 104% (HR: 2.04, 95% CI 1.94 to 2.15) and 212% (HR: 3.12, 95% CI 2.87 to 3.38), respectively. A significant cumulative dose-response relationship was noted between the number of CMDs and AF risk (HR: 1.45, 95% CI 1.42 to 1.48, p<0.001). A consistent dose-dependent cumulative relationship was observed in both stratified and sensitivity analyses.

CONCLUSIONS

Multiple CMDs increased AF risk and exhibited a significant cumulative effect based on the number of CMDs.

Association Between Response Time and Time from Emergency Medical Service Contact with the Patient to Hospital Arrival as well as Survival and Neurological Outcomes in Pediatric Out-of-Hospital Cardiac Arrest

OBJECTIVES

In out-of-hospital cardiac arrest (OHCA), prehospital time is crucial and can be divided into response time, from emergency call to emergency medical service (EMS) contact, and time from EMS contact to hospital arrival. To improve prehospital strategies for pediatric OHCA, it is essential to understand the association between these time intervals and patient outcomes; however, detailed investigations are lacking. The current study aimed to examine the association between response time and time from EMS contact to hospital arrival as well as survival and neurological outcomes in pediatric OHCA.

METHODS

This nationwide retrospective analysis used data from an OHCA registry in Japan between June 2014 and December 2021. Pediatric patients aged <18 years who had OHCA were included in the analysis. The primary outcome was 1-month survival, and the secondary outcome was 1-month favorable neurological outcome. Generalized additive model analyses and logistic regression analyses, adjusted for confounders, were performed to examine the non-linear and linear relationship between response time and patient care time (time from EMS contact with the patient to hospital arrival) and outcomes, respectively.

RESULTS

In the generalized additive model analyses of response time, both survival and neurological outcomes worsened with response time, with outcomes appearing to further decline with a response time of approximately 15 min. On the other hand, there was a linear association between patient care time as well as 1-month survival and favorable neurologic outcomes. In logistic regression analyses, shorter response times were significantly associated with survival (odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.79-0.91]) and a favorable neurological outcome (OR: 0.75, 95% CI: 0.59-0.93). In contrast, time from EMS contact to hospital arrival was not significantly associated with survival (OR: 0.99, 95% CI: 0.97-1.02) and favorable neurological outcomes (OR: 1.02, 95% CI: 0.97-1.07).

CONCLUSIONS

A response time of <15 min can be associated with better survival and neurological outcomes. However, there is no significant association between time from EMS contact to hospital arrival as well as survival and favorable neurological outcomes.

Neuropsychiatry of atrial fibrillation: dementia and beyond

Atrial fibrillation (AF) is the most frequent heart rhythm disorder worldwide with a prevalence of 1%-2% in general population. It is associated with increased mortality and morbidity, including increased risk of dementia. In addition to cognitive impairment, AF has been related to anxiety and mood disorders. Herein we review the literature on the association between AF and neuropsychiatric conditions, including anxiety and mood disorders. The mechanisms underlying the association between AF and dementia are complex, including stroke, chronic cerebral hypoperfusion, and systemic inflammation. There is a bidirectional interaction between AF and anxiety/mood disorders with shared mechanisms involving dysfunction of the autonomic, neuroendocrine and immune systems. Optimizing pharmacological treatment, avoiding drug interactions and implementing behavioral interventions can have a lasting impact on patients with AF undergoing rhythm/rate control therapies and/or catheter ablation.

Mechanisms of nebivolol-mediated effects on bFGF-induced vascular smooth muscle cell proliferation and migration

Background

Nebivolol is a β-adrenergic receptor antagonist that has intrinsic activity on β3-adrenergic receptors (β3-ARs). Previous studies suggest that nebivolol inhibits bFGF-induced vascular smooth muscle cell (VSMC) proliferation and migration and vascular injury-induced neointima formation through activation of β3-ARs. However, our recently published data shown that activation of β3-ARs produced the opposite results, suggesting that the mechanisms of nebivolol-mediated effects are not fully understood. The current project was to study the mechanisms of nebivolol's effects on bFGF-induced VSMC proliferation and migration by comparing to the selective β3-AR agonist, CL316,243.

Methods

VSMCs isolated from Sprague Dawley rat aortas were pretreated with nebivolol or CL316,243 followed by stimulation with bFGF. Cell proliferation and migration and phosphorylation of ERK and AKT were measured.

Results

We found that pretreatment of VSMCs with nebivolol produced biphasic effects on bFGF-induced VSMC proliferation, manifested as potentiation at lower concentrations and inhibition at the higher concentration. The effects of low concentrations of nebivolol on bFGF-induced VSMC proliferation was blocked by the selective β3-AR antagonist, SR59230A. Nebivolol inhibited bFGF-induced cell migration at all concentrations tested. In addition, only higher concentrations of nebivolol significantly inhibited bFGF-induced AKT phosphorylation but not ERK phosphorylation whereas CL316,243 at all concentrations tested significantly enhanced bFGF-induced VSMC proliferation and migration and higher concentrations of CL316,243 not only enhanced bFGF-induced AKT phosphorylation but also ERK phosphorylation.

Conclusion

Our data suggest that the effect of nebivolol on bFGF-induced cell proliferation is concentration-dependent. The enhancement on bFGF-induced cell proliferation at lower concentrations appears to be mainly mediated by activation of β3-ARs but the inhibitory effects on bFGF-mediated cell proliferation as well as migration may occur through different mechanisms. AKT signaling is only involved in high concentrations of nebivolol-mediated effects.

Magnitude and associated factors of atrial fibrillation, and its complications among adult rheumatic heart diseases patients in governmental hospitals in Bahir Dar Town, Northwest Ethiopia 2024

INTRODUCTION

Atrial fibrillation (AF) is characterized by high frequency stimulation of the atrium, causes dyssynchronous atrial contraction and irregular ventricular excitation. It is the most known cardiac arrhythmia in adults, doubles the risk of stroke five times and is associated with an increasing public health burden. This study was aimed to assess the magnitude and associated factors of atrial fibrillation and its complication among adult rheumatic heart diseases patients in governmental hospitals in Bahir Dar town, Northwest Ethiopia 2024.

METHODS

An institutional based cross-sectional study design was conducted with a sample size of 421. A simple random sampling technique was used to select participants. The data were entered into the Statistical Package for the Social Sciences (SPSS) version 26 for analysis. Adjusted Odds Ratio (AOR) with a 95% confidence interval was used to determine associated factors of atrial fibrillation. A binary logistic regression model was used, and a P-value < 0.05 in multivariate was considered as a statistically significant.

RESULTS

The response rate was 95% and atrial fibrillation was developed in 51.2% of patient. Majority of them were Female (56%). The median age of patients was 41, with an interquartile range (IQR) of 26-51. Age > 50 years old (AOR = 7.20(2.03-25.46)), sever tricuspid regurgitation 4.50(1.18-17.20)), and left ventricular ejection fraction (LVEF) % (AOR = 0.94(0.89-0.99)), left atrium size (AOR = 1.23(1.14-1.33)) were independently associated with atrial fibrillation. For every unit increment of left ventricular ejection fraction in percent, the odds of developing atrial fibrillation decreased by 6%. For every unit increment of left atrial size in millimeter2 (mm2), the odds of developing atrial fibrillation increased by 23%. The present study showed that complication related to AF was heart failure (HF) (72.8%), ischemic stroke (34.4%), systemic thromboembolism (12.1).

CONCLUSION

More than half of the study participants were found to have atrial fibrillation in patients with rheumatic heart disease. Being age > 50 years old, left atrium size, severity of tricuspid regurgitation (severe), and LVEF% were associated in developing atrial fibrillation. The atrial fibrillation was linked to an increased risk of ischemic stroke, heart failure, systemic thromboembolism, and death.

The correlation between the atherogenic index of plasma and the severity of coronary artery disease in acute myocardial infarction patients under different glucose metabolic states

The atherogenic index of plasma (AIP) is a recent biomarker linked to atherosclerosis that has been validated as a novel indicator for myocardial infarction (MI). However, the relationship between AIP and the severity of coronary artery disease (CAD) in MI patients is still ambiguous, particularly among individuals with different glucose metabolic conditions. A total of 741 participants who were immediately assessed with coronary angiography upon admission and diagnosed with acute MI were recruited. The severity of CAD was assessed based on the number of narrowed vessels. AIP tertiles were used to divide the patients into three groups (T1: AIP < 0.030; T2: 0.030 ≤ AIP ≤ 0.316; T3: AIP > 0.316). The American Diabetes Association's guidelines define three types of glucose metabolic state: diabetes mellitus (DM), prediabetes (Pre-DM), and normal glucose regulation (NGR). Logistic regression analysis was utilized to confirm an association between AIP and CAD severity in MI patients. ROC curves were employed to evaluate the diagnostic utility of AIP for CAD severity in MI patients. In MI patients, a statistically significant correlation was found between AIP and the severity of CAD, with logistic regression analysis revealing a strong association (OR: 2.055; 95% CI: 1.189-3.550; P = 0.009). Following adjustments for risk factors in the logistic regression model, AIP remained an independent predictor of multi-vessel CAD (OR: 2.902;95% CI: 1.555-5.521 ; P < 0.001). Moreover, compared with the T1 group, the odds ratios for multi-vessel CAD in the T2 and T3 groups were 2.039 (95% CI: 1.321-3.175; P = 0.001) and 2.087 (95% CI: 1.317-3.340; P = 0.001), respectively. The area under the curve for predicting CAD severity with AIP was 0.568 (95% CI: 0.520-0.616; p = 0.006). In addition, a significant association was observed between AIP and an increased risk of multi-vessel CAD in the Pre-DM group. In MI patients, AIP is closely associated with the risk of multi-vessel CAD and the prediction of the severity of CAD. In Pre-DM patients, AIP is clearly associated with the severity of CAD, whereas this association is absent in the NGR and DM groups.

Dietary Cholesterol and Myocardial Infarction in the Million Veteran Program

BACKGROUND

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

METHODS AND RESULTS

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

CONCLUSIONS

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

Mitochondrial DNA-Mediated Immune Activation After Resuscitation from Cardiac Arrest

Background

Post-cardiac arrest syndrome (PCAS) is characterized by a robust inflammatory response that contributes to significant morbidity and mortality among patients resuscitated from sudden cardiac arrest (SCA). Mitochondrial DNA (mtDNA), with its bacterial-like genomic motifs, has been implicated as a damage-associated molecular pattern in other inflammatory contexts, but its role as a pro-inflammatory stimulus in PCAS has not been studied. Accordingly, the present study was designed to determine if PCAS is characterized by a rise in circulating mtDNA and, if so, whether mtDNA is selectively released, how it activates immune cells, and if targeting mtDNA-sensing pathways attenuates leukocyte activation.

Methods

Plasma mtDNA and nuclear DNA (nucDNA) levels were measured in peripheral blood samples collected ∼4-hours post-ROSC from swine with PCAS (n=8) and patients hospitalized after resuscitation from out-of-hospital cardiac arrest (OHCA; n= 57). Additionally, in vitro studies were performed where porcine peripheral blood mononuclear cells (PBMCs) were treated with mtDNA or extracellular vesicles (EVs) isolated from post-ROSC plasma. Pharmacological inhibitors were utilized to inhibit toll-like receptor 9 (TLR9)- and cyclic GMP-AMP synthase (cGAS)-mediated mtDNA sensing.

Results

A significant ∼250-fold elevation in circulating mtDNA was observed shortly after ROSC in swine despite negligible changes in circulating nucDNA, suggesting selective release of mtDNA in PCAS. This finding was corroborated in human OHCA survivors, in which circulating mtDNA was similarly elevated during the early post-ROSC period. Circulating mtDNA was largely encapsulated within EVs in swine and humans, suggesting a conserved mechanism of release across species. In vitro studies demonstrated that PBMC internalization of mtDNA-containing-EVs was required for immune activation and promoted development of a pro-inflammatory leukocyte phenotype characterized by altered surface marker expression and increased release of TNFα, IL-1β, and IL-6. Disrupting EVs or degrading enclosed DNA attenuated these responses, which were partially restored upon reintroduction of mtDNA. Pharmacological blockade of TLR9 or cGAS pathways significantly reduced mtDNA-induced inflammation, providing insight regarding signaling pathways that may be targeted to modulate mtDNA-mediated immune activation in PCAS.

Conclusions

These novel findings demonstrate that brief whole-body ischemia and reperfusion in the context of resuscitation from SCA triggers selective mtDNA release, primarily within EVs, that acts as a potent driver of immune activation in PCAS. By linking EV-encapsulated mtDNA to TLR9 and cGAS activation, this study provides a foundation for the development of novel therapeutic interventions aimed at limiting mtDNA release or disrupting its downstream sensing pathways to enhance survival and improve outcomes after SCA.

Clinical Perspective

What is new?: Our study reveals that circulating mitochondrial DNA (mtDNA), primarily encapsulated in extracellular vesicles (EV), is selectively released into the bloodstream after resuscitation from sudden cardiac arrest.EV-encapsulated mtDNA triggers immune cell activation, evidenced by phenotypic shifts toward inflammatory dendritic cells and macrophages, as well as increased pro-inflammatory cytokine secretion.Pharmacological inhibition of TLR9 and cGAS pathways significantly attenuates the mtDNA-induced inflammatory response, pointing to novel therapeutic avenues for modulating post-resuscitation immune activation in patients with post-cardiac arrest syndrome (PCAS).What are the clinical implications?: Identification of mtDNA as a key driver of sterile inflammation in PCAS highlights a potential target for interventions aimed at reducing multi-organ damage and improving neurological outcomes.Therapeutic strategies to block mtDNA release or downstream signaling (e.g., TLR9/cGAS inhibition) may limit harmful pro-inflammatory cascades and bolster long-term survival following resuscitation from cardiac arrest.Early clinical screening for elevated EV-encapsulated mtDNA could help refine prognostic evaluations, complement current biomarkers, and guide personalized therapy to lessen the inflammatory burden of PCAS.

Multidisciplinary Clinical Study on Retinal, Circulatory, and Respiratory Damage in Smoking-Dependent Subjects

Background and Objectives: Cigarette smoking is a widely prevalent risk factor in the global population, despite its well-recognized systemic impact. In this pilot study, an association was hypothesized between alterations in hemorheological and respiratory characteristics and damage at the chorioretinal level, considering that traditional cigarette smoking may increase oxidative stress, platelet activation, and thrombotic phenomena at the systemic level. Fundoscopy can provide information about the characteristics of the cerebral district and the entire circulatory system. Therefore, the aim of this research was to evaluate the impact of cigarette smoking on chorioretinal vascularization and pulmonary and blood parameters through investigations with optical coherence tomography angiography (OCTA), spirometry, and the total thrombus formation analysis system (T-TAS). Materials and Methods: Thirty subjects were recruited, divided into 20 traditional cigarette smokers (SMs) and 10 non-SMs, who underwent a comprehensive ocular examination, including OCTA. Spirometric evaluation and blood sampling were also performed on both groups to study pulmonary functional capacity, as well as T-TAS. Results: An analysis of the obtained data confirmed the systemic impact of smoking, evidenced by an increase in T-TAS and a decrease in forced expiratory volume in 1 s expressed in liters (FEV1 L) in SMs compared to the non-SMs group. Additionally, OCTA revealed a statistically significant alteration in macular vascular density (FD) in the right eye (RE) of the examined SMs. The other parameters evaluated did not show statistically significant differences. Conclusions: It is believed that FD, FEV1, and T-TAS may be promising values in correlating the alterations observed in SMs, as highlighted by the changes detected with OCTA, spirometry, and hemorheological data. Further research is needed to confirm and expand the results already obtained and to evaluate the systemic vascular damage and oxidative stress caused by tobacco consumption.

Relationship between elevated serum direct bilirubin and atrial fibrillation risk among patients with coronary artery disease

Background

Observational studies have shown that the direct bilirubin (DBIL) is correlated with metabolic syndrome and cardiovascular disease. However, it remains unclear whether DBIL is associated with atrial fibrillation (AF) risk in the patients with coronary artery disease (CAD). This study aimed to investigate the association between serum DBIL levels and AF in CAD patients.

Methods

A total of 937 patients diagnosed with CAD were retrospectively included. Serum total bilirubin (TBIL), DBIL, lipid profiles, and other data were collected and analyzed between the AF and non-AF groups. The characteristics of participants were compared based on their DBIL tertiles. Univariate and multivariate logistic regression models, as well as restricted cubic spline (RCS) regression, were used to explore the relationship between DBIL and AF.

Results

AF was observed in 72 (7.7%) patients. There was a significant higher level of DBIL in the AF patients compared to non-AF patients (p < 0.001). Individuals from the DBIL T3 group, when compared to those from the T1 or T2 groups, were more likely to have a higher proportion of AF and lower levels of total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-C), apolipoprotein B (Apo B) and triglyceride-glucose (TyG) (all p < 0.001). Univariate logistic regression showed that the OR for AF in patients in T3 was 2.796 (95% CI, 1.528-5.116, p = 0.001) compared with participants in T1. The result remained consistent in the multivariate logistic regression (T3 versus 1: adjusted OR: 2.239). The RCS curve demonstrated a significant nonlinear association between DBIL and AF. Subgroup analysis revealed that this association was significant among patients aged ≥65 years old, with body mass index (BMI) < 25, and with diabetes mellitus (DM).

Conclusion

The study suggested a robust relationship between higher levels of DBIL and an increased risk of AF in CAD patients. The association of elevated DBIL with the incidence of AF was higher in CAD patients older than 65 years, with a BMI < 25, and those with DM.

In-hospital safety of cryoballoon and radiofrequency ablation in patients with atrial fibrillation-German nationwide analysis of more than 300,000 procedures

BACKGROUND

Pulmonary vein isolation can be performed by radiofrequency (RF) or cryoballoon (CB) ablation. Guidelines do not favor one technique, and knowledge about complication rates is limited.

OBJECTIVE

We aimed to report the procedural safety of RF and CB ablation using data from a German nationwide real-world registry.

METHODS

By use of health records, all left atrial catheter ablation procedures with RF or CB ablation in Germany from 2013 to 2021 were analyzed. After adjustment for confounders, safety performance end points were compared.

RESULTS

From 2013 to 2021, RF ablation was performed in 184,616 patients and CB ablation in 118,984 patients with increasing trends in patient numbers and performing centers for both procedures. Patients with RF ablation had slightly more comorbidities. In-hospital mortality (RF, 0.08%; CB, 0.06%) and other investigated complications were rare. After adjustment for patient baseline characteristics, the risk of in-hospital mortality, serious bleeding, stroke, intracerebral bleeding, and acute kidney injury did not differ. The risk of pericardiocentesis (relative risk, 0.50; 95% confidence interval, 0.46-0.55; P < .001), vascular complication (0.36; 0.33-0.39; P < .001), and ventilation >48 hours (0.81; 0.66-0.99; P = .042) was significantly lower for CB ablation. Pericardiocentesis risk negatively correlated with annual procedure numbers per center with a faster learning curve for CB ablation (both P < .01).

CONCLUSION

RF and CB ablation had low overall procedural complication rates, with CB ablation showing a 50% reduced risk of pericardiocentesis. Centers with higher volume provided a better in-hospital safety with a faster learning curve for CB ablation.

Association between Heavy metals and triglyceride-glucose-related index: a mediation analysis of inflammation indicators

BACKGROUND

In cardiovascular diseases (CVD) and insulin resistance (IR), elevated blood lipids and glucose are common. These abnormalities accelerate atherosclerosis and may impair insulin signaling via oxidative stress and inflammation. The triglyceride-glucose (TyG) index is a cost-effective marker for assessing IR and CVD risk, reflecting insulin resistance and early atherosclerosis. However, research on factors affecting the TyG index, especially mixed heavy metal exposure, is limited. Heavy metals might alter the TyG index by inducing oxidative stress and inflammation, affecting lipid and glucose metabolism. This study explores the link between heavy metal exposure and TyG index changes, focusing on inflammation's mediating role, aiming to offer new strategies for CVD and IR prevention and management.

METHOD

This research explores the association between heavy metal concentrations and TyG indicators, drawing on data from the National Health and Nutrition Examination Survey spanning 2011 to 2016. It employs a range of statistical approaches, such as linear and non-linear analyses, multiple linear regression, weighted quantile sum regression, and Bayesian kernel machine regression. Additionally, a mediation analysis investigates the role of inflammation in modifying the effects of heavy metal exposure.

RESULT

The research analyzed data from a sample of 2,050 individuals, finding notable links between mixed heavy metals and variations in TyG markers. Specifically, the presence of heavy metal mixtures was associated with significant increases in these indicators. Additionally, six inflammatory markers were identified that act as intermediaries in the process leading from heavy metal exposure to alterations in TyG indicators.

CONCLUSION

The study establishes a clear association between heavy metal and adverse changes in TyG markers, influenced in part by inflammation. These insights highlight the urgent need for improved monitoring of environmental health and specific strategies to decrease heavy metal exposure, thus lessening their harmful impact on cardiovascular health. The research enhances understanding of the dynamic interactions between environmental exposures and metabolic health, laying groundwork for public health initiatives aimed at curtailing chronic disease risks linked to heavy metals.

Negative Association between Vitamin E Intake and Remnant Cholesterol: The National Health and Nutrition Examination Survey 2007-2020

BACKGROUND

Remnant cholesterol (RC) is a risk factor for the development of atherosclerosis. Vitamin E has antioxidant properties, making it a potentially effective management tool for preventing cardiovascular disease (CVD). However, the relationship between vitamin E intake and RC remains unclear.

METHODS

We conducted a cross-sectional study using data from the National Health and Nutrition Examination Survey (NHANES) Survey 2007-2020. 11,585 participants (aged ≥20, 48% male) were included. Information on vitamin E intake (dietary vitamin E intake and total vitamin E intake) was collected. RC was defined as serum total cholesterol minus high-density lipoprotein and low-density lipoprotein cholesterol. Survey-weighted linear regression models and a restricted cubic spline (RCS) were used to test the relationship between vitamin E intake and RC. Subgroup analyses and interaction tests were also performed to verify the robustness of the results.

RESULTS

After adjusting for all potential confounders (demographics, socioeconomic status, lifestyle, diet, and comorbidities), dietary vitamin E intake was negatively associated with RC (β = -0.21, 95% CI: (-0.29, -0.12), p < 0.0001), and this negative association was also present between total vitamin E intake and RC (β = -0.12, 95% CI: (-0.18, -0.06), p < 0.0001). The RCS analysis revealed a nonlinear negative association between vitamin E intake and RC. The negative correlation existed in different subgroups, with no interaction except for the "use of vitamin E supplements" subgroup.

CONCLUSION

Vitamin E intake showed a protective association with RC. The results suggest that increasing dietary vitamin E intake may help reduce RC levels and CVD risk.

Sex Differences in Clinical Presentation of Women and Men Evaluated at a Comprehensive Stroke Center for Suspected Stroke

INTRODUCTION

Understanding sex differences in the clinical presentation of patients with suspected stroke is important to reduce sex-related disparities and improve care. We aimed to characterize presenting symptoms in women and men with suspected stroke evaluated at our comprehensive stroke center.

METHODS

This was a retrospective analysis of consecutive patients with suspected stroke treated at the University Hospital Essen between January 2017 and December 2021. Patient characteristics, signs and symptoms as well as final diagnoses in women and men were compared. Logistic regression analysis was performed to assess the association of individual symptoms with a diagnosis of cerebrovascular disease.

RESULTS

We included 6,069 patients in our analysis. Cerebrovascular disease was diagnosed in 85.2% (2,576/3,022) of women and 88.0% (2,681/3,047) of men (p = 0.002). Aphasia (31.4% vs. 27.7%, p = 0.002), neglect (15.5% vs. 12.8%, p = 0.003), gaze deviation (21.0% vs. 18.8%, p = 0.034), as well as nonfocal symptoms including impairments in consciousness (17.0% vs 14.6%, p = 0.012), orientation (42.5 vs. 36.4%, p < 0.001), and completion of tasks (31.2% vs. 26.0%, p < 0.001) were more common among women. Limb ataxia (8.1% vs. 11.2%, p < 0.001) and dysarthria (44.0% vs. 46.8%, p = 0.030) were less frequent in women. Neglect and gaze deviation were independent positive predictors of cerebrovascular disease in women but not in men.

CONCLUSION

Although clinical presentation was similar in both sexes, cortical and nonfocal symptoms were more common among women with suspected stroke. Awareness of sex differences and acknowledgment of the full clinical picture are important to ensure optimal management for women and men with suspected stroke. Our findings might serve as a target for educational programs in order to improve preclinical stroke detection in patients with predominantly nonfocal or subtle symptoms.

Immune cells and arrhythmias

Cardiac arrhythmias are a significant cause of morbidity and mortality worldwide. Emerging evidence has demonstrated that resident and infiltrating cardiac immune cells play direct, mechanistic roles in arrhythmia onset and progression. In this review, we provide a comprehensive summary and expert commentary on the role of each immune cell subtype in the pathogenesis of atrial and ventricular arrhythmias.

Trends and projections of hypertensive heart disease burden in China: a comprehensive analysis from 1990 to 2030

BACKGROUND

Hypertensive heart disease (HHD) is a significant public health concern in China. We intend to provide an updated estimate of the burden of HHD in China between 1990 and 2030.

METHODS

HHD prevalence, mortality, and disability-adjusted life years (DALYs) data were obtained from Global Burden of Disease (GBD) 2019 databases. Temporal trends of HHD from 1990 to 2019 were analyzed using Joinpoint regression models, and projections through 2030 were estimated by Bayesian age-period-cohort model.

RESULTS

In 2020, an estimated 334,695 newly prevalent cases and 13,196 deaths due to HHD occurred in China. From 1990 to 2019, age-standardized rate of prevalence (ASPR), mortality (ASMR) and DALYs (ASDR) showed a decreasing trend. The behavior-related risk, diet risk and excessive BMI were the most common reasons of death in HHD. According to our prediction, ASMRs and ASDRs will continue to decrease from 2020 to 2030. However, ASPRs will have a moderate rise.

CONCLUSION

HHD continues to pose a significant threat to public health in China. To achieve the Healthy China 2030 objective, a tailored approach involving comprehensive strategies is essential. These strategies should include, but are not limited to, enhancing public awareness about hypertension through educational campaigns, improving access to healthcare services for early diagnosis and treatment, implementing policies to promote healthy lifestyles, such as regular physical activity and a balanced diet, and strengthening the surveillance and monitoring systems to track the prevalence and impact of HHD over time.

Characterisation of cardiovascular disease (CVD) incidence and machine learning risk prediction in middle-aged and elderly populations: data from the China health and retirement longitudinal study (CHARLS)

BACKGROUND

Due to the ageing population and evolving lifestyles occurring in China, middle-aged and elderly populations have become high-risk groups for cardiovascular disease (CVD). The aim of this study was to analyse the incidence characteristics of CVD in these populations and develop a prediction model by using data from the China Health and Retirement Longitudinal Study (CHARLS).

METHODS

We used follow-up data from the CHARLS to analyse CVD incidence in the Chinese middle-aged and elderly population over a time span of 9 years. Five machine learning (ML) algorithms were employed for risk prediction. Data preprocessing included missing value imputation via random forest. Feature selection was performed using the Least Absolute Shrinkage and Selection Operator (Lasso CV) method with cross-validation prior to model training. The application of the synthetic minority over-sampling technique (SMOTE) to address class imbalance. Model performance was evaluated via analyses including the area under the ROC curve (AUC), precision, recall, F1 score, and SHAP plots for interpretability.

RESULTS

In accordance with the exclusion criteria, 12,580, 12,061, 11,545, and 11,619 participants were enrolled in four follow-up rounds. The cumulative incidence (CI) of CVD at 2, 4, 7, and 9 years was 2.846%, 8.971%, 17.869% and 20.518%,, respectively. Significant differences in CVD incidence were observed across gender, age, ethnicity, and region, with higher rates observed in females and in the northeast region. Ultimately, 8,080 participants and 24 features were analysed for CVD risk prediction. Five ML models were built based on these features. Although the LGB model achieves an AUC of 0.818, indicating strong overall performance, its F1 score and recall rate are relatively low, at 0.509 and 43.1%, respectively. Shapley additive explanations (SHAP) analyses revealed the importance of key features, such as night sleep duration, TG levels, and waist circumference, in predicting outcomes, and highlighted the nonlinear relationships between these features and CVD risk.

CONCLUSIONS

Gender, age, ethnicity, and region are significant factors influencing CVD incidence. Although the LGB model demonstrates good overall performance, its low F1 score and recall rate reveal limitations in identifying high-risk cardiovascular disease patients.

Elevated Lipoprotein(a) Levels Linked to New-Onset Atrial Fibrillation: Insights from a Retrospective Cohort Study

AIMS

Atrial fibrillation (AF) is the most common cardiac arrhythmia. Although lipoprotein(a) [Lp(a)] is known to be a well-established risk factor for atherosclerotic cardiovascular disease (ASCVD), its role in development of AF, independent of this association, remains unclear.

METHODS

Adult patients from the three Mayo Clinic sites with a baseline Lp(a) and without AF history were included. Patients were categorized into two groups based on their Lp(a) levels: high Lp(a) (≥50 mg/dL) and low Lp(a) (<50 mg/dL). Survival probabilities free from incident AF were compared between Lp(a) groups, during a follow-up period up to 15 years, using the Kaplan-Meier curve and the Log-Rank test. Multivariable Cox regression analysis was also conducted.

RESULTS

A total of 75,376 patients were included (median age: 55 years, 59% males), with a median follow-up duration of 8.8 [inter quartile range (IQR): 3.4, 14.8] years. Incident AF was detected in 5738 (7.6%) patients. Survival probability free from incident AF was significantly lower in patients with elevated Lp(a) (86%) compared with those with low Lp(a) (88%, log rank P<0.001). Multivariable analysis adjusted for potential risk factors of AF showed a statistically significant association of elevated Lp(a) with a 11% increase in AF risk (adjusted HR: 1.11, 95% CI: 1.05 to 1.18).

CONCLUSIONS

Our study suggests that elevated Lp(a) (≥50 mg/dL) is an independent risk factor for incident AF. Future prospective studies are warranted to validate our results and to test the if reducing Lp(a) could mitigate the burden of AF.

Comparison of the efficacy of different protocols of repetitive transcranial magnetic stimulation and transcranial direct current stimulation on motor function, activities of daily living, and neurological function in patients with early stroke: a systematic review and network meta-analysis

BACKGROUND

The application of transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) in patients with early stroke has recently received considerable attention, but the optimal protocol remains inconclusive. This study intends to evaluate and compare the effects of different protocols of tDCS and rTMS on improving motor function, activities of daily living (ADL), and neurological function in patients with early stroke, and to comprehensively assess their efficacy and safety.

METHODS

MEDLINE, Embase, Cochrane Library, and Web of Science were searched. Risk of bias (RoB) was assessed using the Cochrane Risk of Bias 2.0 tool, and Bayesian NMA was conducted using R4.3.1 and Stata16.

RESULTS

The results of NMA showed that after early intervention, bilateral application of high- and low-frequency rTMS (BL-rTMS) performed best in improving the upper extremity motor function at the end of intervention (SUCRA: 92.8%) and 3 months (SUCRA: 95.4%). Besides, low-frequency rTMS (LF-rTMS) performed best in improving the lower extremity motor function (SUCRA: 67.7%). BL-rTMS was the most effective in ameliorating the ADL at the end of intervention (SUCRA: 100%) and 3 months (SUCRA: 85.6%). In terms of the NIHSS scores, BL-rTMS had the highest probability of being the most effective measure at the end of intervention (SUCRA: 99.7%) and 3 months (SUCRA: 97.05%). Besides, LF-rTMS (0%), 5 Hz-rTMS (0%), and intermittent theta-burst stimulation (iTBS) (0%) all exhibited a good safety profile.

CONCLUSION

BL-rTMS is the optimal stimulation protocol for improving upper extremity motor function, ADL, and neurological function in early stroke, with long-term efficacy.

Neural progenitor cell-derived exosomes in ischemia/reperfusion injury in cardiomyoblasts

The physiologic relationship between the brain and heart is emerging as a novel therapeutic target for clinical intervention for acute myocardial infarction. In the adult human brain, vestigial neuronal progenitor stem cells contribute to neuronal repair and recovery following cerebral ischemic injury, an effect modulated by secreted exosomes. Ischemia conditioned neuronal cell derived supernatant and experimental stroke has been shown to be injurious to the heart. However, whether unconditioned neuronal progenitor cell derived-exosomes can instead protect myocardium represents a profound research gap. We investigated the effects of unconditioned neural stem cell derived exosomes as post-injury treatment for cardiomyoblasts from three neuronal culture conditions; adherent cultures, neurosphere cultures and bioreactor cultures. Small extracellular vesicles were enriched with serial ultracentrifugation, validated via nanoparticle tracking analysis, transmission electron microscopy and Western blot analysis prior to utilization as post-injury treatment for H9c2 cardiomyoblasts following oxygen and glucose deprivation. LDH assay was used to assess viability and Seahorse XF high-resolution respirometry analyzer to investigate post-injury cardiomyocyte bioenergetics. We found no evidence that unconditioned neural stem cell derived exosomes are cardiotoxic nor cardioprotective to H9c2 cardiomyoblasts following ischemia-reperfusion injury. Based on our findings, utilizing unconditioned neural stem cell derived exosomes as post-injury treatment for other organs should not have adverse effects to the damaged cardiac cells.

An institutional framework to support ethical fair and equitable artificial intelligence augmented care

Coordinated access to multi-domain health data can facilitate the development and implementation of artificial intelligence-augmented clinical decision support (AI-CDS). However, scalable institutional frameworks supporting these activities are lacking. We present the PULSE framework, aimed to establish an integrative and ethically governed ecosystem for the patient-guided, patient-contextualized use of multi-domain health data for AI-augmented care. We describe deliverables related to stakeholder engagement and infrastructure development to support routine engagement of patients for consent-guided data abstraction, pre-processing, and cloud migration to support AI-CDS model development and surveillance. Central focus is placed on the routine collection of social determinants of health and patient self-reported health status to contextualize and evaluate models for fair and equitable use. Inaugural feasibility is reported for over 30,000 consecutively engaged patients. The described framework, conceptually developed to support a multi-site cardiovascular institute, is translatable to other disease domains, offering a validated architecture for use by large-scale tertiary care institutions.

Adaptive wavelet base selection for deep learning-based ECG diagnosis: A reinforcement learning approach

Electrocardiogram (ECG) signals are crucial in diagnosing cardiovascular diseases (CVDs). While wavelet-based feature extraction has demonstrated effectiveness in deep learning (DL)-based ECG diagnosis, selecting the optimal wavelet base poses a significant challenge, as it directly influences feature quality and diagnostic accuracy. Traditional methods typically rely on fixed wavelet bases chosen heuristically or through trial-and-error, which can fail to cover the distinct characteristics of individual ECG signals, leading to suboptimal performance. To address this limitation, we propose a reinforcement learning-based wavelet base selection (RLWBS) framework that dynamically customizes the wavelet base for each ECG signal. In this framework, a reinforcement learning (RL) agent iteratively optimizes its wavelet base selection (WBS) strategy based on successive feedback of classification performance, aiming to achieve progressively optimized feature extraction. Experiments conducted on the clinically collected PTB-XL dataset for ECG abnormality classification show that the proposed RLWBS framework could obtain more detailed time-frequency representation of ECG signals, yielding enhanced diagnostic performance compared to traditional WBS approaches.

State-dependent effects of responsive neurostimulation depend on seizure localization

Brain-responsive neurostimulation (RNS) is firmly ensconced among treatment options for drug-resistant focal epilepsy, but over a quarter of patients treated with the RNS® System do not experience meaningful seizure reduction. Initial titration of RNS therapy is typically similar for all patients, raising the possibility that treatment response might be enhanced by consideration of patient-specific variables. Indeed, small, single-centre studies have yielded preliminary evidence that RNS System effectiveness depends on the brain state during which stimulation is applied. The generalizability of these findings remains unclear, however, and it is unknown whether state-dependent effects of responsive neurostimulation are also stratified by location of the seizure onset zone where stimulation is delivered. We aimed to determine whether state-dependent effects of the RNS System are evident in the large, diverse, multi-centre cohort of RNS System clinical trial participants and to test whether these effects differ between mesiotemporal and neocortical epilepsies. Eighty-one of 256 patients treated with the RNS System across 31 centres during clinical trials met the criteria for inclusion in this retrospective study. Risk states were defined in relation to phases of daily and multi-day cycles of interictal epileptiform activity that are thought to determine seizure likelihood. We found that the probabilities of risk state transitions depended on the stimulation parameter being changed, the starting seizure risk state and the stimulated brain region. Changes in two commonly adjusted stimulation parameters, charge density and stimulation frequency, produced opposite effects on risk state transitions depending on seizure localization. Greater variance in acute risk state transitions was explained by state-dependent responsive neurostimulation for bipolar stimulation in neocortical epilepsies and for monopolar stimulation in mesiotemporal epilepsies. Variability in the effectiveness of RNS System therapy across individuals may relate, at least partly, to the fact that current treatment paradigms do not account fully for fluctuations in brain states or locations of simulation sites. State-dependence of electrical brain stimulation may inform the development of next-generation closed-loop devices that can detect changes in brain state and deliver adaptive, localization-specific patterns of stimulation to maximize therapeutic effects.