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

Advances in the pharmacological management of hyperlipidemia through the use of combination therapies

INTRODUCTION

Lipid-lowering therapies are well established for the treatment of cardiovascular disease (CVD). Historically monotherapy studies have been performed, but the introduction of statins has led to these drugs being recognized as baseline therapies and to the investigation of combination therapy of both older and newer medications with them.

AREAS COVERED

Surrogate marker studies have shown additive effects on LDL-C, triglycerides and HDL-C of combination therapies with statins and these have extended to lipoprotein (a). Imaging studies have often shown benefits paralleling lipid studies. However, outcome studies have failed to show added benefits with niacin or fibrates while confirming the benefits of ezetimibe, bempedoic acid and proprotein convertase subtilisin kexin-9 (PCSK-9) inhibitors and icosapent ethyl.

EXPERT OPINION

Combination therapy for LDL-C in dual combinations is well validated. Data for intervention on triglycerides is limited to icosapent ethyl, but this may exert effects independent of lipids. New drugs targeting triglycerides through apolipoprotein C3 and angiopoietin-like peptides are in development. Studies on combination therapy raising HDL-C have generally disappointed, though cholesterol ester transfer protein (CETP) inhibition remains a target. Lipoprotein (a) is recognized as a CVD risk factor and effective therapies are in development but results on CVD events are lacking.

Risk of Sarcopenia Following Long-Term Statin Use in Community-Dwelling Middle-Aged and Older Adults in Japan

BACKGROUND

Inconsistent results have been reported concerning the association between statin administration and muscle health, specifically its potential to increase the risk of sarcopenia. Given the widespread long-term use of statins among the elderly population, the exploration of this association remains a crucial yet insufficiently examined matter. This study aimed to assess the association between the prolonged administration of statins and the risk of sarcopenia, diminished muscle strength, reduced skeletal muscle mass and impaired physical performance.

METHODS

This population-based cohort study was conducted in Japan utilizing data derived from the National Institute for Longevity Sciences-Longitudinal Study of Aging (NILS-LSA). The study participants, enlisted from the 2nd to the 6th waves (spanning from April 2000 to July 2010) of NILS-LSA, were those who aged 40 years or older and had initiated statin therapy (n = 348, age: 64.1 years, female: 63.5%). Individuals who were not administered statins (n = 2559, age: 55.5 years, female: 48.4%) were arbitrarily chosen using a combined approach of propensity score (PS) matching and risk set sampling to form the control group (with a 1:4 matching ratio). The primary outcome of this study was the occurrence of sarcopenia, as defined by the 2019 consensus of the Asian Working Group for Sarcopenia (AWGS). The secondary outcomes included low muscle mass (< 7.0 kg/m2 for men and below 5.4 kg/m2 for women by DXA), reduced skeletal muscle strength (handgrip strength < 28 kg in men and < 18 kg in women) and subpar physical performance (6-min walking speed < 1.0 m/s). The relationship between the use of statins and the outcomes was estimated using a Cox proportional hazard model with time-varying covariates, which included the status of statin use and other variables (two-tailed p < 0.05 was considered statistically significant). Stratification based on age and sex, along with five sensitivity analyses-including propensity score overlap weighting and a negative control-was conducted.

RESULTS

After applying PS matching, we identified 342 statin initiators and 1294 non-statin users, with well-balanced baseline characteristics between the groups. The use of statins was not associated with an increased risk of incident sarcopenia (adjusted hazard ratio [aHR], 1.43 [95% CI, 0.86, 2.36]), diminished muscle strength (aHR, 1.11 [95% CI, 0.80, 1.54]), reduced muscle mass (aHR, 1.09 [95% CI, 0.66, 1.82]) or impaired physical performance (aHR, 0.73 [95% CI, 0.46, 1.17]). These findings were consistent across age and sex stratifications, as well as all sensitivity analyses.

CONCLUSIONS

Statin use was not associated with an elevated risk of sarcopenia or impaired muscle health among community-dwelling middle-aged and older adults in Japan.

Percutaneous Coronary Interventional Treatment of Left Main Trifurcation Lesion: A Case Report

Coronary artery disease (CAD) remains a leading cause of morbidity and mortality worldwide, particularly among complex high-risk and indicated patients (CHIP). Revascularization is often beneficial for these patients; however, it requires thorough risk stratification and close multidisciplinary collaboration between cardiologists and cardiac surgeons to optimize outcomes. Personalized treatment plans, including percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), are crucial in this context. In this report, we present a case of a 70-year-old man with left main trunk bifurcation lesions, referred to as a "Four Forks Lesion," who was successfully revascularized using a PCI strategy, resulting in a favorable prognosis.

Dehydrocorydaline attenuates myocardial ischemia-reperfusion injury via the FoXO signalling pathway: A multimodal study based on network pharmacology, molecular docking, and experimental study

ETHNOPHARMACOLOGICAL RELEVANCE

Dehydrocorydaline (DHC), an active component of Corydalis yanhusuo (Y.H. Chou & Chun C. Hsu) W.T. Wang ex Z.Y. Su & C.Y. Wu (Papaveraceae), exhibits protective and pain-relieving effects on coronary heart disease, but the underlying mechanism still remains unknown.

AIM OF THE STUDY

Network pharmacology and experimental validation both in vivo and in vitro were applied to assess whether DHC can treat myocardial ischemia-reperfusion injury (MIRI) by regulating the forkhead box O (FoxO) signalling pathway to inhibit apoptosis.

MATERIALS AND METHODS

DHC and MIRI targets were retrieved from various databases. Molecular docking and microscale thermophoresis (MST) determined potential binding affinity. An in vivo mouse model of MIRI was established by ligating the left anterior descending coronary artery. C57BL/6N mice were divided into sham, MIRI, and DHC (intraperitoneal injection of 5 mg/kg DHC) groups. Haematoxylin and eosin, Masson, and immunohistochemical stainings verified DHC treatment effects and the involved signalling pathways. In vitro, H9c2 cells were incubated with DHC and underwent hypoxia/reoxygenation. TUNEL, JC-1, and reactive oxygen species stainings and western blots were used to explore the protective effects of DHC and the underlying mechanisms.

RESULTS

Venny analysis identified 120 common targets from 121 DHC and 23,354 MIRI targets. DHC exhibited high affinity for CCND1, CDK2, and MDM2 (<-7 kcal/mol). In vivo, DHC attenuated decreases in left ventricular ejection fraction and fractional shortening, reduced infarct sizes, and decreased cTnI and lactate dehydrogenase levels. In vitro, DHC alleviated apoptosis and oxidative stress in the hypoxia/reoxygenation model by attenuating ΔΨm disruption; reducing the production of reactive oxygen species; upregulating Bax and CCND1 via the FoxO signalling pathway, as well as cleaved-caspase 8; downregulating the apoptosis-associated proteins Bcl-2, Bid, cleaved-caspase 3, and cleaved-caspase 9; and promoting the phosphorylation of FOXO1A and MDM2.

CONCLUSION

By upregulating the FoxO signaling pathway to inhibit apoptosis, DHC exerts a cardioprotective effect, which could serve as a potential therapeutic option for MIRI.

Sexual life experiences after myocardial infarction: a systematic review and synthesis of qualitative studies

AIMS

This study aims to systematically interpret and synthesize the data obtained from qualitative research about the sexual lives of individuals who have experienced myocardial infarction (MI).

METHODS AND RESULTS

A thorough literature review was conducted between November and December 2023 across five electronic databases: PubMed, Web of Science, CINAHL, EBSCO, and Science Direct Embase. This article includes 12 studies published in English since 2000 that have examined the sexual experiences of individuals who have experienced MI. This research adhered to the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines. We utilized the Critical Appraisal Skills Programme tool for qualitative research to evaluate the quality of all the papers included. To synthesize the data, the deductive and interpretation technique according to Sandelowski and Barroso's approach has been used. The sexual experiences of individuals who have experienced MI were summarized under four main themes: changes in sexual life, barriers to engaging in sexual intercourse, an unmet need: information, and sexuality as a part of routine care.

CONCLUSION

Patients' expectations from counselling services regarding sexuality after MI are oriented towards these services providing more comprehensive information and incorporating multidisciplinary approaches. This demand clearly indicates the complex and multidimensional changes in sexual life after MI and underscores the necessity for healthcare professionals to play a more active role in this area.

REGISTRATION

PROSPERO: CRD42023483112.

Exploring the underlying mechanisms of Danshen-Shanzha Decoction on coronary heart disease: An integrated analysis combining pharmacoinformatics and experimental validation

ETHNOPHARMACOLOGICAL RELEVANCE

The Danshen-Shanzha Decoction (DSD) is a renowned herbal combination consisting of the root of Salvia miltiorrhiza Bunge (known as Danshen in Chinese) and the fruits of Crataegus pinnatifida Bunge (known as Shanzha in Chinese), which has exhibited remarkable clinical efficacy in the treatment of coronary heart disease (CHD) in traditional Chinese medicine, with its earliest recorded application dating to around 202 BCE during the Han Dynasty. Despite significant advancements in the fundamental research and clinical applications of DSD over the past few decades, the precise bioactive components as well as the underlying mechanisms responsible for its protective effect on CHD remain unelucidated.

AIM OF THE STUDY

The present study was designed to elucidate the bioactive components and potential mechanism of DSD in the treatment of CHD using in silico technologies integrated with pharmacoinformatic methods and experimental validation.

MATERIALS AND METHODS

The chemical components of DSD were analyzed and identified using UPLC-Q-TOF-MS. Pharmacoinformatic-based methods were employed to comprehensively investigate the principal active components and targets of DSD for treating CHD. GO and KEGG pathway analyses were utilized to elucidate the underlying mechanism responsible for DSD's efficacy against CHD. Molecular docking and molecular dynamics simulation were performed to assess the binding affinity between active components and putative targets. Furthermore, surface plasmon resonance (SPR) was carried out to verify the affinity and kinetic characteristics of major components to STAT3 protein. Subsequently, a series of in vitro experiments, including cell viability test, flow cytometric analysis, ELISA and western blotting, were conducted to validate the predicted results in an oxygen-glucose deprivation (OGD)-stimulated H9c2 model.

RESULTS

A total of 96 compounds were characterized by UPLC-Q-TOF-MS, and 281 overlapping targets were identified through pharmacoinformatic-based methods. Among these, ten critical compounds were determined as the core active components of DSD. The core targets associated with the development of CHD included STAT3, SRC, TP53, JUN, and AKT1. Notably, Dihydrotanshinone I and (+)-Epicatechin exhibited strong binding affinity towards STAT3. The potential mechanisms by which DSD modulates the pathological progression of CHD were predicted to involve inflammation, oxidative stress, and apoptosis. Importantly, the cytoprotective effect of DSD against apoptosis was confirmed in OGD-stimulated H9c2 cells, as evidenced by the upregulation of Bcl-2 expression and downregulation of both Bax and cleaved caspase-3 expressions upon DSD treatment. Furthermore, DSD significantly enhanced the phosphorylated protein expressions of JAK2 and STAT3 compared to the OGD group, suggesting its potential role in modulating related signaling pathways.

CONCLUSIONS

The current study successfully fills the gap in the understanding of the chemical profiles of DSD, predicting its active components, potential targets, and molecular mechanisms in the treatment of CHD. These findings not only provide a valuable strategy but also robust data support for future investigations into DSD, thereby facilitating the identification of novel therapeutic targets for traditional Chinese medicines in the battle against CHD.

Emerging Implications of Elevated Lipoprotein(a) Levels in Coronary Artery Bypass Graft Surgery: A Narrative Review

BACKGROUND

Coronary artery bypass grafting (CABG) remains a cornerstone in the management of coronary artery disease (CAD). In nonurgent surgical revascularization cases, preoperative optimization of modifiable risk factors can improve outcomes. There is increasing interest in the relationship between lipoprotein(a) levels and the risk for ischemic cardiovascular disease, particularly how CABG outcomes are in turn affected. This review highlights the role of lipoprotein(a) in the pathogenesis of CAD and CABG outcomes and discusses future directions for its optimal management in the perioperative period.

METHODS

The PubMed/MEDLINE database was reviewed until March 2024 to capture publications that evaluated and/or described the relationship between lipoprotein(a) and CABG surgery or CAD outcomes.

RESULTS

The available literature supports lipoprotein(a) as a causal and independent risk factor for the pathogenesis of CAD. Elevated lipoprotein(a) levels are associated with an increased risk of adverse post-CABG outcomes, including graft occlusion incidence and major adverse cardiovascular events. Genetic variations influencing lipoprotein(a) levels play a role in disease progression and surgical outcomes. Several therapies aimed at reducing lipoprotein(a) levels, currently in phase III clinical trials, show promise for improving the prognosis after CABG.

CONCLUSIONS

Among individuals undergoing surgical revascularization for CAD, lipoprotein(a) levels may help define risk and inform best practices for perioperative management. We advocate for the routine measurement of lipoprotein(a) in all patients undergoing CABG. Emerging lipoprotein(a)-lowering agents show promise for secondary prevention of cardiac events, although dedicated analyses in cardiac surgical subcohorts will be important to evaluate their role in improving CABG outcomes.

Beating-Heart Coronary Artery Bypass grafting (BH-CABG) in patients with End-Stage Renal Disease (ESRD): comparison of the Society of Thoracic Surgeons (STS) predicted risk with actual outcomes

BACKGROUND

End-Stage Renal Disease (ESRD) is an independent risk factor in outcomes for traditional coronary artery bypass grafting (TRAD-CAB) utilizing aortic cross-clamping and cardioplegic arrest. In order to determine if Beating-Heart CABG (BH-CABG) techniques offer benefit in patients with ESRD, an analysis of the Society of Thoracic Surgeons (STS) predicted risk versus the actual outcomes was performed.

METHODS

Between March 2017 - October 2023, all ESRD patients underwent BH-CABG by a single surgeon at a single institution. Patients were kept normothermic, ventilation was maintained, and intra-coronary shunts with flow-probe graft assessment were utilized during the procedure. The STS predicted risk calculator was used to compare outcomes with actual results.

RESULTS

There were 55 patients- 37 men and 18 women with a mean age of 61.5 years (41-77 years). Co-medical conditions consisted of the following: HTN (100%), DM (85%), Pulmonary HTN (49%), PVD (45%), CVD with CVA (18%), and COPD (9%). Fifty-one patients underwent Pump-Assisted Direct Coronary Artery Bypass Grafting (PADCAB) and four underwent Off-Pump CABG (OP-CAB). There were 16 Elective, 35 Urgent, and 4 Emergent cases. Case presentation included: 24 NSTEMI, 4 STEMI, 6 Unstable Angina, 7 CHF, 1 Cardiac Arrest, and 13 with a positive exercise stress test (EST) for renal transplant screening. The mean EF was 47% (range: 15-75%). The mean number of grafts was 2.4 (1-4) and CPB time was 78 min (34-128 min) for the PAD-CAB group. Nine of the thirteen patients (69%) listed for kidney transplant underwent the transplant, one of whom was a combined liver-kidney. There was 1 hospital mortality (1.8%) compared to a predicted 6.2%. There was 1 stroke (1.8%) compared to a predicted 3.3%. There was 1 prolonged ventilation (1.8%) compared to a predicted 20.2%. There were no return to OR and no sternal wound infections. Prolonged Lengths of Stay occurred in 3 patients (5.5%) compared to a predicted 16.9%. One-year mortality occurred in 8 patients (14.5%). The observed-to-expected outcomes was < 1 in all categories.

CONCLUSIONS

The BH-CABG appears to demonstrate superior outcomes compared to the STS predicted risk for CABG. The Beating-Heart technique may offer advantages by avoidance of aortic cross-clamping and cardioplegia, maintenance of normothermia and ventilation, as well as preservation of coronary blood flow during construction of bypass grafting.

Exposure to major coronary heart disease events reduces lung cancer risk: a mendelian randomization study based on a European population

OBJECTIVE

This study seeks to elucidate the causal relationship between major coronary heart disease events (MCHDE) and lung cancer incidence through mendelian randomization (MR), with the goal of providing evidence to inform more effective lung cancer screening and prevention strategies.

METHODS

Utilizing data from the IEU OpenGWAS project and FinnGen, this study employed a two-sample MR approach, with genetic variants serving as instrumental variables. Relevant single nucleotide polymorphisms (SNPs) associated with MCHDE and lung cancer were carefully selected, with particular attention given to mitigating potential confounders, such as smoking behaviors and statin use.

RESULTS

The MR analysis, utilizing FinnGen's MCHDE as the exposure factor, revealed a significant reduction in the incidence of non-small cell lung cancer (NSCLC) [odds ratio (OR) 0.893, 95% confidence interval (CI) 0.800-0.998] and small cell lung cancer (SCLC) [OR 0.684, 95% CI 0.500-0.936], highlighting the protective effect of MCHDE against these cancer subtypes. However, this protective effect was not observed for other types of lung cancer. Furthermore, substituting FinnGen's MCHDE with that from IEU OpenGWAS did not yield similar protective effects across various lung cancer subtypes.

CONCLUSIONS

This study suggests that MCHDE reduce the risk of NSCLC in the U.K. population and SCLC in the Finnish population. However, given that the underlying mechanism through which MCHDE reduces the risk of NSCLC and SCLC remains unclear, it is premature to conclude that individuals exposed to MCHDE do not require lung cancer screening.

Angina Severity and Symptom Improvement Are Associated With Diagnostic Acetylcholine Provocation Dose in Vasospastic Angina

BACKGROUND

A coronary function test (CFT) is the recommended diagnostic test to identify coronary vasomotor dysfunction as a cause of symptoms in patients with angina and nonobstructive coronary arteries (ANOCA). Acetylcholine is the commonly used pharmacological agent for spasm provocation. We aimed to investigate an association between severity of symptoms and provocative acetylcholine dose.

METHODS AND RESULTS

We included ANOCA patients undergoing clinically indicated CFT from the Netherlands Registry of Invasive Coronary Vasomotor Function Testing: NL-CFT. Patients with epicardial spasm (n=251) were divided according to acetylcholine spasm triggering dose: low (2-20 mcg, EpiLOW), middle (100 mcg, EpiMIDDLE) or high (200 mcg, EpiHIGH). Patients with microvascular spasm (n=157) were analyzed irrespective of triggering dose. The patient groups were compared to each other and to a control group with negative CFT results (n=101). We assessed mean Seattle Angina Questionnaire angina frequency and summary scores at baseline and follow-up and the proportion of patients improving or deteriorating. An inverse relationship between provocation dosage and angina frequency at baseline was found in epicardial spasm: the lower the triggering dose, the more frequently patients experienced angina (EpiLOW 48±20, EpiMIDDLE 53±21, EpiHIGH 57±19, microvascular spasm 61±21, controls 64±21, overall P=0.003). A trend was seen toward most patients improving in the high triggering dose group, and most patients deteriorating in the low triggering dose group.

CONCLUSIONS

A significant dose-dependent relationship between spasm provocation and anginal complaints exists. Acetylcholine provocation dose could be incorporated as a risk stratification factor or surrogate outcome in future clinical trials.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT06083155.

Fractional Flow Reserve and Instantaneous Wave-Free Ratio as Predictors of the Placebo-Controlled Response to Percutaneous Coronary Intervention in Stable Coronary Artery Disease

BACKGROUND

ORBITA-2 (the Placebo-Controlled Trial of Percutaneous Coronary Intervention for the Relief of Stable Angina) provided evidence for the role of percutaneous coronary intervention (PCI) for angina relief in stable coronary artery disease. Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are often used to guide PCI; however, their ability to predict placebo-controlled angina improvement is unknown.

METHODS

Participants with angina, ischemia, and stable coronary artery disease were enrolled, and anti-anginal medications were stopped. Participants reported angina episodes daily for 2 weeks using the ORBITA smartphone symptom application (ORBITA-app). At the research angiogram, FFR and iFR were measured. After sedation and auditory isolation, participants were randomized to PCI or placebo before entering a 12-week blinded follow-up phase with daily angina reporting. The ability of FFR and iFR, analyzed as continuous variables, to predict the placebo-controlled effect of PCI was tested using Bayesian proportional odds modeling.

RESULTS

Invasive physiology data were available for 279 patients (140 PCI and 139 placebo). The median (interquartile range) age was 65 years (59.0-70.5), and 223 (79.9%) were male. Median FFR was 0.60 (0.46-0.73), and median iFR was 0.76 (0.50-0.86). The lower the FFR or iFR, the greater the placebo-controlled improvement with PCI across all end points. There was strong evidence that a patient with an FFR at the lower quartile would have a greater placebo-controlled improvement in angina symptom score with PCI than a patient at the upper quartile (FFR, 0.46 versus 0.73: odds ratio, 2.01; 95% credible interval, 1.79-2.26; probability of interaction, >99.9%). Similarly, there was strong evidence that a patient with an iFR at the lower quartile would have greater placebo-controlled improvement in angina symptom score with PCI than a patient with an iFR at the upper quartile (iFR, 0.50 versus 0.86: odds ratio, 2.13; 95% credible interval, 1.87-2.45; probability of interaction, >99.9%). The relationship between benefit and physiology was seen in both Rose angina and Rose nonangina.

CONCLUSIONS

Physiological stenosis severity, as measured by FFR and iFR, predicts placebo-controlled angina relief from PCI. Invasive coronary physiology can be used to target PCI to those patients who are most likely to experience benefit.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03742050.

Long-term outcomes of second-generation drug-eluting stents versus coronary artery bypass graft: a systematic review and meta-analysis of randomized trials and multivariable adjusted data

Long-term data are limited comparing percutaneous coronary intervention (PCI) with second-generation drug-eluting stents (S-DES) vs coronary artery bypass grafting (CABG) in patients with complex coronary artery disease (CAD). We aimed to conduct a systematic review and meta-analysis comparing these interventions in patients with left main or multivessel CAD. We systematically reviewed PubMed, Embase, and Cochrane for studies that compared PCI with S-DES and CABG in patients with left main or multivessel CAD with a minimum mean follow-up period of 3 years. Outcomes of interest were all-cause mortality, myocardial infarction (MI), stroke, and major adverse cardiovascular events (MACE). We extracted data from observational studies as multivariable-adjusted or propensity score-matched hazard ratio to minimize confounding and pooled hazard ratios with 95% confidence intervals (CIs) using a random effects model in Review Manager 5.4.1. We included 10 studies, 3 of which were randomized controlled trials, comprising a total of 26964 patients, of whom 14928 underwent PCI. As compared with CABG, S-DES had a significantly higher risk of all-cause mortality (hazard ratio 1.35; 95% CI 1.22-1.49; P < 0.001; I2 = 0%), MACE (hazard ratio 1.27; 95% CI 1.08-1.50; P = 0.005; I2 = 67%), and MI (hazard ratio 2.43; 95% CI 1.80-3.28; P < 0.01; I2 = 0%). There was no significant difference between groups in incidence of stroke. In this meta-analysis of patients with complex CAD, PCI with S-DES was associated with an increased risk of mortality, MI, and MACE compared with CABG.

Long-Term Survival After Coronary Artery Bypass Graft Surgery

BACKGROUND

Management guidelines for stable 3-vessel coronary artery disease have become a subject of debate. We aim to provide a benchmark for the survival of patients with normal ejection fraction, stable 3-vessel disease, and elective coronary artery bypass graft (CABG) surgery.

METHODS

Data from consecutive patients with normal ejection fraction undergoing elective primary isolated CABG for 3-vessel disease in a diverse 11-center surgical network between 2008 and 2020 were analyzed. Survival data were obtained from the Centers for Disease Control and Prevention National Death Index and compared with an age- and sex-matched United States population. Mixed-effects modeling with "hospital" as a random effect was used to evaluate factors associated with all-cause mortality.

RESULTS

Of 4061 patients included in this analysis, 893 (22%) were women, and the median age was 68 years (interquartile range, 61-74 years). Patients with elective CABG surgery for 3-vessel disease and normal ejection fraction demonstrated improved survival compared with an age- and sex-matched United States population, with significantly increasing relative survival over time. Factors associated with mortality included age ≥65 years (hazard ratio [HR], 1.71; P < .001), male sex (HR, 1.32; P = .028), diabetes (HR, 1.4; P = .002), dialysis (HR, 2.41; P = .03), moderate or severe chronic lung disease (HR, 1.68; P < .001), and peripheral arterial disease (HR, 2.05; P < .001).

CONCLUSIONS

Patients with stable 3-vessel disease and normal ejection fraction who underwent elective CABG demonstrated improved survival compared with an age- and sex-matched United States population. With this benchmark, further research can better elucidate the relative role of surgery and medical therapy in this patient population.

Advancing translational research in digital cardiac rehabilitation: The preparation phase of the Multiphase Optimization Strategy

While digital cardiac rehabilitation (CR) is an effective alternative to center-based CR, its components and mechanisms of change remain poorly understood. The Multiphase Optimization Strategy (MOST) provides a framework that allows the effects of individual components of complex interventions to be studied. There is limited guidance within MOST on how to develop a conceptual model. This article describes the development of a conceptual model of digital CR. The conceptual model was developed based on several strands of evidence: (i) a systematic review of 25 randomized controlled trials to identify the behavior change techniques in digital CR interventions, (ii) a qualitative study of patients' (n = 11) perceptions of the mechanisms of digital CR, and (iii) a review of international guidelines. Tools and frameworks from behavioral science, including the Behaviour Change Wheel, Capability, Opportunity, Motivation and Behavior model, and Theoretical Domains Framework were used to integrate the findings. An initial conceptual model of digital CR was developed and then refined through discussion. The conceptual model outlines the causal process through which digital CR can enhance outcomes for patients with cardiovascular disease. The model illustrates the key intervention components (e.g. goal setting and self-monitoring, education, exercise training), targeted outcomes (e.g. physical activity, healthy eating, medication adherence), and theorized mediating variables (e.g. knowledge, beliefs about capability). The article provides an example of how behavioral science frameworks and tools can inform the preparation phase of MOST. The developed conceptual model of digital CR will inform guide decision-making in a future optimization trial.

Exercise type and settings, quality of life, and mental health in coronary artery disease: a network meta-analysis

BACKGROUND AND AIMS

Individuals with coronary artery disease have poorer mental health, health-related quality of life (HR-QoL), and cognition compared with (age-matched) controls. Exercise training may attenuate these effects. The aim is to systematically review and meta-analyse the effects of different exercise types and settings on brain structure/function, cognition, HR-QoL, mental health (e.g. depression, anxiety), and sleep in patients with coronary artery disease.

METHODS

A systematic search was conducted and a network meta-analysis compared (i) exercise types, high-intensity interval training (HIIT), HIIT + resistance (HIIT + R), moderate-intensity training (MIT), MIT + R and stretching-toning-balance training, and (ii) exercise settings, in-person and home-based.

RESULTS

A total of 42 randomized controlled trials with a parallel group design were identified, of which 36 were included in the meta-analysis. Few studies included cognition (n = 2), sleep (n = 2), and none brain structure/function (n = 0). Most studies examined HR-QoL (n = 30), depression (n = 15), and anxiety (n = 9), in which outcomes were meta-analysed. HIIT + R, HIIT, and MIT were associated with improved HR-QoL vs. no exercise (i.e. usual care) [standardized mean difference, SMD: 1.53 (95% confidence interval 0.83; 2.24), 0.44 (0.15; 0.73), and 0.44 (0.20; 0.67), respectively]. In-person exercise was associated with larger and significant improvements [HR-QoL SMD: 0.51 (0.28; 0.74), depressive SMD: -0.55 (-1.03; -0.07), and anxiety symptoms SMD: -1.16 (-2.05; -0.26)] compared with no exercise, whereas home-based programmes were not significantly associated with improvements in these outcomes. Findings were robust in secondary (i.e. intervention duration and volume) and sensitivity analyses excluding high risk of bias studies.

CONCLUSIONS

Exercise training, especially in-person sessions, was associated with improved HR-QoL, depression and anxiety, independently of exercise type. However, this study raises concern about the effectiveness of home-based programmes in improving these outcomes.Study protocol was registered in PROSPERO (ID: CRD42023402569).

Perioperative Risk: Short Review of Current Approach in Non Cardiac Surgery

The rate of major surgery is constantly increasing worldwide, and approximately 85% are non-cardiac surgery. More than half of patients over 45 years presenting for non-cardiac surgical interventions have cardiovascular risk factors, and the most common: chronic coronary syndrome and history of stroke. The preoperative cardiovascular risk is determined by the comorbidities, the clinical condition before the intervention, the urgency, duration or type. Cardiovascular risk scores are necessary tools to prevent perioperative cardiovascular morbidity and mortality and the most frequently used are Lee/RCRI (Revised Cardiac Risk Index), APACHE II (Acute Physiology and Chronic Health Evaluation), POSSUM (Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity), The American University of Beirut (AUB)-HAS2. To reduce the perioperative risk, there is a need for an appropriate preoperative risk assessment, as well as the choice of the type and timing of surgical intervention. Quantification of surgical risk as low, intermediate, and high is useful in identifying the group of patients who are at risk of complications such as myocardial infarction, thrombosis, arrhythmias, heart failure, stroke or even death. Currently there are not enough studies that can differentiate the risk according to gender, race, elective versus emergency procedure, the value of cardiac biomarkers.

Pertussis Vaccination for Adults: An Updated Guide for Clinicians

Pertussis, or whooping cough, is a highly contagious respiratory infection caused by the Gram-negative bacterium Bordetella pertussis. Although traditionally associated with children, pertussis is increasingly prevalent among adults, particularly those with comorbidities or weakened immune systems, where it can lead to severe complications. Diagnosing pertussis in adults can be challenging due to its nonspecific symptoms, underreporting, and the limited sensitivity of available diagnostic tests. While treatment with macrolides is generally effective, it may not significantly alter the clinical course of the disease, and growing concerns about macrolide resistance are emerging. Vaccination remains the cornerstone of prevention, offering proven immunogenicity, efficacy, and safety. However, vaccination uptake remains low, partly due to limited patient awareness and insufficient prioritization by healthcare professionals. This review aims to provide clinicians with critical insights into pertussis epidemiology, vaccination strategies, and the latest guideline recommendations, empowering them to engage in meaningful discussions with adult patients and advocate for increased vaccination to combat this often-overlooked infection.

Impact of drug-coated balloon for vascular luminal dilatational remodeling after balloon angioplasty in intracranial atherosclerotic stenosis - a retrospective cohort study

OBJECTIVE

This study aimed to examine the effect of drug-coated balloons (DCBs) on vascular luminal dilatational remodeling (VLDR) following simple balloon angioplasty.

METHODS

A retrospective cohort study was conducted using data from patients diagnosed with intracranial atherosclerotic stenosis (ICAS), who were treated exclusively with balloon angioplasty at Henan Provincial People's Hospital between June 2019 and April 2023. Inverse probability weighting (IPW) was used to create balanced cohorts of patients who underwent drug-coated balloon angioplasty (DCBA) and plain old balloon angioplasty (POBA). The primary endpoint was VLDR occurrence during follow-up, with the effect of DCBA on VLDR assessed by adjusted multivariate regression.

RESULTS

The study included 110 patients who underwent simple percutaneous transluminal angioplasty, with 60 in the DCBA group and 50 in the POBA group. At follow-up, the stenosis rate in the DCBA group was lower than in the POBA group (P<0.001). The decrease in stenosis rate (DSR) was greater in the DCBA group compared with the POBA group (P<0.001). Nineteen patients (31.7%) in the DCBA group experienced VLDR, whereas only four (8%) in the POBA group developed VLDR, a statistically significant difference (P=0.002). After IPW adjustment, differences in stenosis rate (34.17 (20.00, 46.72) vs 46.00 (37.88, 70.00), P<0.001), DSR (-1.66 (-16.71, 11.40) vs -18.00 (-28.00, -3.00), P<0.001) and VLDR incidence (32.2% vs 9.9%, P<0.001) between the DCBA and POBA groups remained significant. Multivariate regression analysis identified DCBA as an independent factor influencing VLDR occurrence.

CONCLUSION

This study demonstrated that, compared with POBA, DCBA increases VLDR occurrence in ICAS patients during follow-up.

Complex Left Main Trifurcation: A Case Study of Successful Treatment

Objectives: True trifurcation disease of the left main coronary artery is a rare situation encountered in clinical practice. To date, there is no evidence for a standardized strategy of percutaneous coronary intervention in this type of lesion. Methods: This article describes a novel three-stent strategy using a combination of Triple-Kissing Balloon Crush in both of the side branches. This technique is based on a well-established bifurcation stenting technique, namely, the Double-Kissing Crush technique. Results: This strategy was implemented successfully, demonstrating technical feasibility and optimal stent apposition in the trifurcation lesion, ensuring the preservation of all three branches. Conclusions: Although more data and clinical trials are needed to develop proper evidence-based guidelines, three-stent implantation with Double-Trissing Crush should be taken into consideration as a viable strategy for LM trifurcation lesions in the proper set of patients.

Comprehensive diagnosis in chronic coronary syndromes combining angiography and intracoronary testing: the AID-ANGIO study

BACKGROUND

The diagnostic yield of invasive coronary angiography (ICA) in patients with chronic coronary syndromes (CCS) in contemporary practice is uncertain.

AIMS

We investigated the value of an advanced invasive diagnosis (AID) strategy combining angiography and intracoronary testing.

METHODS

AID-ANGIO is an all-comers, prospective, multicentre study enrolling CCS patients referred for ICA. Obstructive coronary artery disease (CAD) was investigated with angiography and pressure guidewires. In the absence of obstructive CAD, intracoronary testing for ischaemia with non-obstructive coronary arteries (INOCA) was performed. The primary endpoint was the proportion of patients with a cause of ischaemia identified by the AID strategy. To assess the effect of AID on decision-making, an initial therapeutic plan was first prepared by clinical cardiologists based on ICA and medical information. Subsequently, based on AID data, a final therapeutic plan was drafted by clinical and interventional cardiologists (Ischaemia Team).

RESULTS

We enrolled 317 patients (44.2% female). Based on ICA, obstructive CAD was diagnosed in 32.2% of patients. With the AID strategy, a cause of myocardial ischaemia was identified in 84.2% (p<0.001): obstructive CAD in 39.1% and INOCA in 45.1%. Only 15.8% of patients did not show any abnormalities. Modification of the original treatment plan with the AID strategy occurred in 59.9% of cases.

CONCLUSIONS

In assessing ischaemia-generating coronary abnormalities, prespecified use of the AID strategy was associated with a 2.6-fold increase in diagnostic yield compared with ICA (84.2% vs 32.2%, respectively), largely due to the identification of INOCA. Modification of the therapeutic plan with the AID strategy occurred in 59.9% of cases. (ClinicalTrials.gov: NCT05635994).

A systematic review of enrolment criteria and treatment efficacy for microvascular angina

BACKGROUND

Microvascular angina (MVA) is an important contributor to morbidity and mortality in patients with non-obstructive coronary artery disease. Despite improvements in its recognition and diagnosis, uncertainty remains around the most effective treatment strategy, and more data are needed.

AIMS

We aimed to evaluate the quality of patient selection in treatment studies of MVA and provide a contemporary overview of the evidence base for the treatment of MVA.

METHODS

PubMed, the Cochrane Library and Google Scholar were searched from inception to 4 November 2023 for all treatment studies in patients with angina and non-obstructive coronary artery disease or coronary microvascular dysfunction. Populations with acute coronary syndrome were excluded (PROSPERO: CRD42023383075).

RESULTS

Forty-three studies were included. By contemporary definitions of MVA according to the Coronary Vasomotor Disorders International Study Group criteria, 11 (26%) studies enrolled patients with "definitive" MVA, 24 (56%) with "suspected" MVA, and 8 (19%) did not enrol patients who met the diagnostic criteria. A total of 24 unique treatment interventions were investigated. Most studies were observational and single armed (12/24, 50%) or had a single randomised study (9/24, 38%). Ranolazine is the most well-studied intervention drug. Double-blind randomised controlled trials of ranolazine (n=6) have shown inconsistent improvements in Seattle Angina Questionnaire scores and coronary flow reserve with short-term follow-up.

CONCLUSIONS

Treatment studies of MVA enrolled a heterogeneous population, with only a quarter meeting contemporary diagnostic criteria for definitive MVA. There is a paucity of high quality, randomised data to support any specific treatment intervention. Larger studies with robust selection criteria, blinded patient-reported outcomes, and long-term follow-up are needed.

Machine learning-based interpretation of non-contrast feature tracking strain analysis and T1/T2 mapping for assessing myocardial viability

Assessing myocardial viability is crucial for managing ischemic heart disease. While late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) is the gold standard for viability evaluation, it has limitations, including contraindications in patients with renal dysfunction and lengthy scan times. This study investigates the potential of non-contrast CMR techniques-feature tracking strain analysis and T1/T2 mapping-combined with machine learning (ML) models, as an alternative to LGE-CMR for myocardial viability assessment. A retrospective analysis was conducted on 79 patients with myocardial infarction (MI) 2-4 weeks post-event. Patients with prior ischemia or poor imaging quality were excluded to ensure robust data acquisition. Various ML algorithms were applied to data from LGE-CMR and non-contrast CMR techniques. Random forest (RF) demonstrated the highest predictive accuracy, with area under the curve (AUC) values of 0.89, 0.90, and 0.92 for left anterior descending (LAD), right coronary artery (RCA), and left circumflex (LCX) coronary artery territories, respectively. For the LAD territory, RF, k-nearest neighbors (KNN), and logistic regression were the top performers, while RCA showed the best results from RF, neural networks (NN), and KNN. In the LCX territory, RF, NN, and logistic regression were most effective. The integration of T1/T2 mapping and strain analysis significantly enhanced myocardial viability prediction, positioning these non-contrast techniques as promising alternatives to LGE-CMR. ML models, particularly RF, provided superior diagnostic accuracy across coronary territories. Future studies should validate these findings across diverse populations and clinical settings.

Comparison of 10-year atherosclerotic cardiovascular disease (ASCVD) risk in metropolitan and rural areas of South of Iran

The first step to reducing the growing burden of cardiovascular disease (CVD) is to find modifiable risk factors with the highest burden in each population. Urban and rural citizens may have different priorities in this regard. This study aimed to compare the 10-year incidence probability of CVD events and its associated risk factors between rural and urban areas in Iran. Data was extracted from two big cohorts, Fasa Adults Cohort Study (FACS) and Shiraz Heart Study (SHS), with participation of over 12,000 general population. Linear regression models were used to test the difference in CVD risk between two populations. Totally, 6,258 FACS and 6,101 SHS participants entered the study. Urban participants had a significantly higher mean ASCVD score (4.43% vs. 5.51%, p-value < 0.001). Also, they significantly showed higher body mass index, waist circumference, cholesterol level, fasting blood glucose level, systolic blood pressure, educational attainment, and occupational status. However, the prevalence of smoking was higher in rural areas. Notably, socioeconomic parameters including marital, occupational, and educational statuses seem to have strong impact on cardiovascular risk factors. After adjustment for all confounders, living in the urban areas seemed to be associated with higher atherosclerotic CVD risk (β = 0.78, 95%CI: [0.69-1.05]), which was consistent across both sexes. Given the higher risk of cardiovascular events in urban areas and different profiles of risk factors between these two regions, preventive strategies should be precisely and separately designed for each population by the health authorities and policymakers in order to reduce the CVD toll efficiently.

Atherosclerosis and the Bidirectional Relationship Between Cancer and Cardiovascular Disease: From Bench to Bedside, Part 2 Management

The first part of this review highlighted the evolving landscape of atherosclerosis, noting emerging cardiometabolic risk factors, the growing impact of exposomes, and social determinants of health. The prominent role of atherosclerosis in the bidirectional relationship between cardiovascular disease and cancer was also discussed. In this second part, we examine the complex interplay between multimorbid cardio-oncologic patients, cardiometabolic risk factors, and the harmful environments that lend a "syndemic" nature to these chronic diseases. We summarize management strategies targeting disordered cardiometabolic factors to mitigate cardiovascular disease and explore molecular mechanisms enabling more tailored therapies. Importantly, we emphasize the early interception of atherosclerosis through multifactorial interventions that detect subclinical signs (via biomarkers and imaging) to treat modifiable risk factors and prevent clinical events. A concerted preventive effort-referred to by some as a "preventome"-is essential to reduce the burden of atherosclerosis-driven chronic diseases, shifting from mere chronic disease management to the proactive promotion of "chronic health".

ANti-Thrombotic strAtegy for the management of nonocclusive thRombus with ST-segment elevation myocardial infarCtion in young pAtients - ANTARTICA study

INTRODUCTION

Various cardiovascular thrombo-embolic clinical entities use combined ATS for prevention and treatment. After PCI, AF patients are typically prescribed DOAC, DAPT/SAPT, as component of ATS to minimize stroke risk and treat pulmonary embolism and venous thromboembolism. Some small observational studies have shown that a combined ATS can clear small thrombi in LV dysfunction and/or apical aneurysms. Therefore, we present a practical, cost-effective, and proof-of-concept ATS for non-occlusive significant coronary thrombus in young, clinically stable STEMI patients based on the aforementioned experiences.

METHODS

We retrospectively reviewed 145 stable STEMI cases with nonocclusive thrombus and thrombolysis in myocardial infarction flow 2/3 who received dabigatran and clopidogrel (ATS arm). They were compared to 147 comparable patients who received standard-of-care PCI (Control arm). At presentation and 6-months after ATS, NYHA functional class and LVEF were measured in all subjects. All the patients in the ATS arm underwent CT-CAG at 6-months. We examined significant safety outcomes like hemorrhage, reinfarction, and cardiac mortality.

RESULTS

The primary angiographic outcome demonstrated complete resolution of the thrombus in all the cases of ATS arm. In the ATS arm, the clinical secondary outcome showed a greater improvement in NYHA class, from 3.53 to 1.07, compared to the control group's 3.6 to 1.49 (p = 0.013). Also, the secondary echocardiographic outcome demonstrated a significant improvement in LVEF from a mean of 45.1 %-49.2 % in the ATS arm vs. 44.0 %-44.9 % in the control arm (p < 0.001). Clinical safety indicated TIMI bleeding and reinfarction reductions. There was no mortality in either arm.

CONCLUSION

Delaying PCI and treating STEMI patients with antithrombotic drugs reduced no-reflow, distal embolization, and intraprocedural thrombotic events. The medical intervention improved myocardial preservation alone.

Evaluation of the quality and self-management related content of websites promoting physical activity engagement after myocardial infarction or cardiac surgery: A scoping review

INTRODUCTION

Uncertainty about safe engagement in activity during early recovery after cardiac events is common. Websites are a potential source of health information, especially for those unable to access follow-up support from health professionals. The variability in online health information quality is concerning as poor web-based information can negatively impact patient health outcomes and the ability to self-manage.

OBJECTIVE

To evaluate the quality and self-management-related content of websites providing information about physical activity following an MI or cardiac surgery.

METHODS

Patient-facing websites were searched using three search engines (Google, Bing, and Yahoo). Information about activities of daily living (ADLs), exercise (aerobic and resistance), and safety considerations were explored. Self-management strategies for physical activity were evaluated using a customized 9-item checklist. Website quality was assessed using the 4-item JAMA framework criteria.

RESULTS

31 websites were included. Aerobic exercise, ADLs, and safety considerations were the most comprehensively covered topics. Resistance exercise was less frequently and comprehensively covered. The median self-management checklist score was 3/9 (with nine being the highest possible score). Partnering with healthcare professionals, decision-making, action planning, and verbal persuasion were the most common self-management skills addressed by the websites. In contrast, ten or fewer websites modelled mastery experiences, vicarious experiences, reflection, problem-solving, and resource utilization. The median JAMA score for website quality was 2/4 (with four being the highest possible score).

CONCLUSIONS

The findings highlight quality improvement opportunities for web providers and provide insight for patients and clinicians regarding the highest quality websites that best meet the information and self-management needs following an MI or cardiac surgery.

Time Since Prior NSTEMI and Major Adverse Cardiovascular and Cerebrovascular Events After Noncardiac Surgery

Importance

Delaying elective noncardiac surgery after a recent acute myocardial infarction is associated with better outcomes, but current American Heart Association recommendations are based on data that are more than 20 years old.

Objective

To examine the association between the time since a non-ST-segment elevation myocardial infarction (NSTEMI) and the risk of postoperative major adverse cardiovascular and cerebrovascular events (MACCE).

Design, Setting, and Participants

This cross-sectional study examined Medicare claims data between 2015 and 2020 for patients 67 years or older who had major noncardiac surgery. Data were analyzed from September 21, 2023, to February 1, 2024.

Exposure

Time elapsed between a prior NSTEMI and surgery.

Main Outcomes and Measures

MACCE (30-day mortality, in-hospital myocardial infarction, heart failure, or stroke) and all-cause 30-day mortality. Multivariable logistic regression was used to estimate the association between outcomes and time since a prior NSTEMI.

Results

The sample included 5 227 473 surgeries. The mean (SD) age was 75.7 (6.6) years; 2 981 239 (57.0%) were female, and 2 246 234 (43%) were male. There were 42 278 patients (0.81%) with a previous NSTEMI. Compared with patients without a prior NSTEMI, patients with an NSTEMI within 30 days of elective surgery had higher odds of MACCE, regardless of whether they had undergone coronary revascularization (adjusted odds ratio [aOR], 2.15; 95% CI, 1.09-4.23; P = .03) or not (aOR, 2.04; 95% CI, 1.31-3.16; P = .001). The odds of postoperative MACCE leveled off after 30 days in patients who had undergone any coronary revascularization procedure (and after 90 days in patients with drug-eluting stents) and then increased after 180 days (any revascularization at 181-365 days: aOR, 1.46; 95% CI, 1.25-1.71; P < .001; patients with drug-eluting stents at 181-365 days: aOR, 1.73; 95% CI, 1.42-2.12; P < .001). The odds of MACCE did not level off for patients who did not have revascularization. Findings for all-cause 30-day mortality were similar to those for MACCE, except that the odds of mortality in patients with previous NSTEMI who had revascularization leveled off after 60 days in elective surgeries and 90 days for nonelective surgeries (elective 30-day: aOR, 2.88; 95% CI, 1.30-6.36; P = .009; elective 61- to 90-day: aOR, 1.03; 95% CI, 0.57-1.86; P = .92; nonelective 30-day: aOR, 1.91; 95% CI, 1.52-2.40; P < .001; nonelective 91- to 120-day: aOR, 1.00; 95% CI, 0.73-1.37; P = .99).

Conclusions and Relevance

This study found that among older patients undergoing noncardiac surgery who had revascularization, the odds of postoperative MACCE and mortality leveled off between 30 and 90 days and then increased after 180 days. The odds did not level off for patients who did not have revascularization. Delaying elective noncardiac surgery to occur between 90 and 180 days after an NSTEMI may be reasonable for patients who have had revascularization.

Aortic versus distal pressure for derivation of hyperaemic microvascular resistance: From the ILIAS registry

BACKGROUND

In patients with angina and non-obstructive coronary arteries (ANOCA), intracoronary function testing typically involves assessing the minimal microvascular resistance. This can be derived from the coronary flow and the distal pressure (Pd) during maximal hyperaemia. Theoretically, in ANOCA patients, resistance and pressure have minimal impact along the epicardial vessel, suggesting the possibility of deriving hyperaemic microvascular resistance (HMR) using aortic pressure (Pa) instead of Pd, but this has not been studied previously.

METHODS AND RESULTS

Data from the ILIAS registry, a global multicentre registry pooling lesion-level coronary pressure and flow data, were used to compare HMR calculated with Pa versus Pd. A total of N = 1321 evaluated vessels were included. The study population consisted predominantly of men (68 %) with a mean age of 62 ± 10 years, and stable anginal symptoms (93 %). The overall correlation between HMR calculated with Pa and with Pd was good (Pearson's correlation coefficient: 0.84, p ≤0.005). The Bland-Altman plot showed a mean difference between HMR based on Pa and Pd of 0.53 (limits of agreements ±1.35). An adjusted Bland-Altman showed that the difference between HMR based on Pa and Pd was significantly related to the functional severity of the epicardial lesion (R2 = 0.71, coef.: -4.5, p < 0.005). In patients with a FFR >0.80 there were no considerable outliers, and with a FFR <0.80 outliers increased significantly.

CONCLUSIONS

In ANOCA patients, defined by a FFR above 0.80, HMR can be accurately measured with aortic pressure instead of distal pressure. However, in patients with a FFR below 0.80, there is a significant difference between HMR measured with Pa and Pd.

Effects of fortified eggs and time-restricted eating on cardiometabolic health: The prosperity trial

BACKGROUND

Given the increasing interest in dietary interventions to improve cardiovascular health, this trial assessed the impact of fortified eggs (FE) versus nonegg supplemented diet and time-restricted eating (TRE) versus usual care diet on cardiovascular biomarkers.

METHODS

The study was a unblinded, 2-by-2 factorial design, which randomized patients, with either a prior cardiovascular event or 2 cardiovascular risk factors, to FE or a nonegg supplemented diet and TRE or usual care diet. Patients randomized to FE were instructed to consume at least 12 FE/week (with eggs provided); those on a nonegg supplemented diet restricted egg consumption to <2 eggs/week. TRE participants were instructed to consume all calories within an 8-hour window daily and fasted for the remaining 16 hours. Patients randomized to usual diet were advised to maintain current dietary habits. Follow-up was performed in-person at 1 and 4 months, and telephone calls at 2 and 3 months. Co-primary endpoints were 4-month LDL- and HDL-cholesterol. Secondary endpoints included additional lipids, cardiometabolic- and inflammatory biomarkers and micronutrient levels at 4-months.

RESULTS

Overall, 140 patients were randomized with median (25th, 75th percentiles) age 66 (58, 73) years; 72 (51%) women, 38 (27%) Black, and 33 (24%) with diabetes mellitus. The difference in least squares (LS) means from baseline to 4-months for HDL and LDL levels revealed no significant clinical difference between FE vs nonegg supplemented diet (HDL: -0.64 mg/dL [95% CI: -3.86, 2.58]; LDL: -3.14 mg/dL [-10.81, 4.52]) and TRE vs usual care diet (HDL: 1.51 mg/dL [-1.65, 4.68]; LDL 1.17 mg/dL [-6.36, 8.70]). Prespecified subgroups revealed a nonsignificant HDL increase and LDL decrease with FE in patients ≥65 years.

CONCLUSIONS

These data did not demonstrate clinically relevant differences in changes in LDL and HDL levels over 4 months with FE and TRE compared with nonegg supplemented diet and usual care diet, respectively, providing evidence that adverse short-term lipid and biomarker changes did not occur with FE consumption.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04673721.

Dual Antiplatelet and Anticoagulation Regimens for Women Undergoing Percutaneous Coronary Intervention

Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention is necessary for preventing stent thrombosis and ensuring long-term cardiovascular protection. It is important to be thoughtful in balancing thrombotic and bleeding risk when deciding therapy regimen and duration. Revascularization randomized trials have studied many specific, at-risk populations; however, women remain underrepresented. Although there is evidence to support shortened DAPT duration in women, especially those at higher bleeding risk or on chronic oral anticoagulation, we need trials specifically enrolling and focusing on women.

Dietary patterns to promote cardiometabolic health

Multiple professional societies recommend the Mediterranean and/or Dietary Approaches to Stop Hypertension dietary patterns in their cardiovascular disease prevention guidelines because these diets can improve cardiometabolic health and reduce the risk of cardiovascular events. Furthermore, low sodium intake can be particularly beneficial for patients with hypertension. Carbohydrate restriction, with an emphasis on including high-quality carbohydrates and limiting refined starches and foods and beverages with added sugars, can promote weight loss and cardiometabolic benefits in the short term, compared with higher carbohydrate intake. Evidence is lacking for sustained, long-term effects of low carbohydrate and very low carbohydrate intake on cardiometabolic risk and cardiovascular outcomes. Time-restricted eating, in the context of an overall healthy dietary pattern, can promote cardiometabolic health by aligning food intake with the circadian rhythm, although its effect on hard clinical outcomes remains to be proven. Although there is no one dietary pattern that is appropriate for all patients, engaging in shared decision-making with patients, utilizing behaviour-change principles and engaging members of the health-care team, such as registered dietitian nutritionists, can lead to substantial improvement in the lifestyle and overall health trajectory of a patient. Emphasizing the similarities, rather than differences, of recommended dietary patterns, which include an emphasis on vegetables, fruits, legumes, nuts, whole grains and minimally processed protein foods, such as fatty fish or plant-based proteins, can simplify the process for both patients and clinicians alike.

Accurate diagnosis of ischemic heart disease without exposure to radiation using non-stress unshielded magnetocardiography

Study objectives

To evaluate the capability and accuracy of magnetocardiography (MCG) to identify patients with ischemic chest pain from those with non-ischemic pain and to verify normalcy in the MCG in healthy subjects.

Design

We studied 133 patients (mean age 59 ± 14 years, 69 % male) with chronic or acute chest pain syndrome and 63 healthy subjects (mean age 41.7 ± 12.2 years, 51 % male) using unshielded cryogenically cooled MCG systems (Cardiomag Imaging Inc., 9 and 36 channels) in a general clinical setting. Scan time was 90 s to 6 min. Interventions: The MCG data were processed with the same automated analysis software and results were immediately available. All patients were chest pain free at the time of scanning.

Results

A diagnosis of ischemic chest pain was established in 41 % after non-invasive and invasive testing. Rest MCG was normal in all healthy subjects. An abnormal rest MCG was strongly associated with ischemic chest pain, p < 0.0001 (sensitivity of 86 %, specificity of 80 %, positive (PPV) and negative predictive value (NPV) of 75 % and 89 %, respectively). In comparison, the sensitivity, specificity, PPV and NPV of stress SPECT was 93 %, 72 %, 77 % and 91 %, respectively.

Conclusion

Resting MCG is a rapid risk-free method for the detection of ischemic chest pain without the use of radiation or contrast with results comparable with stress SPECT.

10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

2024 Latin American Society of Hypertension guidelines on the management of arterial hypertension and related comorbidities in Latin America

Hypertension is responsible for more than two million deaths due to cardiovascular disease annually in Latin America (LATAM), of which one million occurs before 70 years of age. Hypertension is the main risk factor for cardiovascular morbidity and mortality, affecting between 20 and 40% of LATAM adults. Since the publication of the 2017 LASH hypertension guidelines, reports from different LATAM countries have confirmed the burden of hypertension on cardiovascular disease events and mortality in the region. Many studies in the region have reported and emphasized the dramatically insufficient blood pressure control. The extremely low rates of awareness, treatment, and control of hypertension, particularly in patients with metabolic disorders, is a recognized severe problem in LATAM. Earlier implementation of antihypertensive interventions and management of all cardiovascular risk factors is the recognized best strategy to improve the natural history of cardiovascular disease in LATAM. The 2024 LASH guidelines have been developed by a large group of experts from internal medicine, cardiology, nephrology, endocrinology, general medicine, geriatrics, pharmacology, and epidemiology of different countries of LATAM and Europe. A careful search for novel studies on hypertension and related diseases in LATAM, together with the new evidence that emerged since the 2017 LASH guidelines, support all statements and recommendations. This update aims to provide clear, concise, accessible, and useful recommendations for health professionals to improve awareness, treatment, and control of hypertension and associated cardiovascular risk factors in the region.

Association between cardiovascular risk factors and dilated and hypertrophic cardiomyopathy: Mendelian randomization analysis

BACKGROUND AND AIM

Dilated cardiomyopathy is a major cause of heart failure, and hypertrophic cardiomyopathy is a common cause of sudden cardiac death in young adults. Epidemiological studies reporting the association between these cardiomyopathies and common cardiovascular risk factors, including smoking, alcohol, and obesity, are limited, and the published studies are mostly observational, making them vulnerable to bias.

METHODS AND RESULTS

We performed a two-sample Mendelian randomization analysis to assess whether cardiovascular risk factors were causally associated with dilated and hypertrophic cardiomyopathies. Independent genetic variants associated with body mass index, smoking, and alcohol were selected as instrumental variables, with two sets of instrumental variables utilized for alcohol. Dilated cardiomyopathy data on 355,318 samples and hypertrophic cardiomyopathy data on 489,727 samples were obtained from a European population-based genome-wide association study (GWAS) meta-analysis. The large GWAS data sample size improved the statistical power. Our results showed significant associations between a genetic predisposition for smoking and the risk of dilated cardiomyopathy (odds ratio (OR) = 1.33; 95 % confidence level (CI): 1.07-1.67; p = 0.012) and between a genetic predisposition for obesity and the risk of dilated cardiomyopathy (OR = 1.62; 95 % CI, 1.30-2.02; p = 1.51 × 10-5). The results of the other associations were not significant.

CONCLUSIONS

This study suggests that smoking and obesity are causally associated with an increased risk of dilated cardiomyopathy.

Dual antiplatelet therapy duration and stent type in patients with high bleeding risk: A systematic review and network meta-analysis

BACKGROUND

It is uncertain whether the efficacy and safety of dual antiplatelet therapy (DAPT) in patients with high bleeding risk (HBR) vary according to DAPT duration and stent type (eg, durable polymer drug-eluting stents (DP-DESs), biodegradable polymer DESs (BP-DESs), or polymer-free drug-coated stents (PF-DCSs)). We aimed to study the stent type and DAPT duration appropriate for patients with HBR.

METHODS

PubMed and EMBASE were searched until October 2023. Randomized controlled trials (RCTs) involving patients with HBR that compared standard DAPT (6-12 months) with DP- or BP-DES versus short DAPT (≤3 months) with DP- or BP-DES or PF-DCS or bare-metal stent (BMS) were identified. The primary efficacy outcome was major adverse cardiovascular events (MACEs), defined as cardiovascular death, myocardial infarction (MI), and stroke. The primary safety outcome was major bleeding. Secondary outcomes included MI and stent thrombosis (ST). We performed a network meta-analysis using a random effects model.

RESULTS

Thirteen RCTs with a total of 19,418 patients with HBR were included. Compared to standard DAPT with DP-DES, short DAPT with BMS was associated with a higher risk of MACE and MI. For major bleeding, short DAPT strategies were associated with a lower risk than standard DAPT strategies (e.g. short DAPT with DP-DES vs standard DAPT with DP-DES; HR[95% CI]: 0.48[0.28-0.82]). Interestingly, the use of BP-DES was associated with a higher risk of ST than DP-DES (e.g. standard DAPT with BP-DES vs short DAPT with DP-DES; HR[95% CI]: 2.65[1.03-6.79]).

CONCLUSIONS

In patients with HBR who underwent percutaneous coronary intervention, a short DAPT strategy with DP-DES should be used since it offers the best combination of efficacy and safety.

The Clinical Approach to Angina in Women

Women presenting with angina are more likely to have cardiac chest pain accompanied more frequently by associated symptoms like abdominal pain and lightheadedness. The evaluation of women with suspected coronary disease can be complex because many have microvascular dysfunction, coronary vasospasm, and altered coagulation that require specific testing protocols beyond the conventional stress testing and a coronary angiogram. Therefore, terms such as angina, ischemia, and myocardial infarction with no obstructive coronary disease have been introduced in recent years. More studies are required to elaborate guidelines on the diagnosis and management of these entities.

How cardiac computed tomography angiography and positron emission tomography play complementary roles in a Practice's business model

Cardiovascular imaging is fundamental and crucial for providing accurate diagnosis and guiding treatment. There are unique clinical benefits and uses of Cardiac CT as well as cardiac PET. There have been advances in cardiac PET as well as Cardiac CT which have led to novel applications. These novel applications also expand clinical practice and increase downstream referrals, testing and procedures which therefore increases business revenue. Cardiac CT adoption in practice expands business by incrementally increased use in a larger patient population. Cardiac CT does not decrease utility of other imaging modalities but ensures more appropriate use of other imaging modalities. There are upfront costs that need to be considered when adopting cardiac CT or cardiac PET. Although the upfront costs for both modalities are high and the Medicare reimbursement of cardiac CT relative to cardiac PET is lower, the ability to perform five times more cardiac CT studies per day compared with cardiac PET studies offsets the decreased reimbursement for cardiac CT. Additionally, there is a good return on investment for cardiac CT especially resulting from increased downstream testing and referrals for procedures and cardiology clinic follow up and from more efficient use of cardiac catheterization lab resources. Cardiac PET also allows for more targeted revascularization in multivessel CAD. Adopting both modalities improves patient outcomes, streamlines care, and increases downstream revenue.

Patient Management Following Percutaneous Coronary Intervention

Percutaneous coronary intervention (PCI) is a mainstay procedure for the treatment of coronary artery disease. PCI techniques have evolved considerably since the advent of PCI in 1978, and with this evolution in techniques has come changes in the best practices for patient management following PCI. The objective of this review is to provide a comprehensive overview of key considerations in patient management following PCI. The long-term management of patients post-PCI should follow 3 main principles: 1) lifestyle modification and reduction of risk factors; 2) implementation of secondary prevention therapies; and 3) timely detection of restenosis. Best practices in achieving these principles include promotion of smoking cessation, regular physical activity, and a healthy diet, as well as blood pressure, diabetes mellitus, lipid, and weight management; prescription of secondary prevention therapies balancing ischemic and bleeding risk; and avoidance of routine surveillance for restenosis.

LncRNA LUCAT1 offers protection against human coronary artery endothelial cellular oxidative stress injury through modulating hsa-miR-6776-5p/LRRC25 axis and activating autophagy flux

BACKGROUND

Coronary artery disease (CAD) has become a dominant economic and health burden worldwide, and the role of autophagy in CAD requires further clarification. In this study, we comprehensively revealed the association between autophagy flux and CAD from multiple hierarchies. We explored autophagy-associated long noncoding RNA (lncRNA) and the mechanisms underlying oxidative stress-induced human coronary artery endothelial cells (HCAECs) injury.

METHODS

(1) Autophagy-related proteins including LC3, p62, Beclin1, ATG5, and ATG7 were immunohistochemical stained in coronary specimens; (2) The levels and function of autophagy in the HCAEC oxidative stress model were evaluated using western blot (WB), transmission electron microscopy (TEM), and mRFP-GFP-LC3 adenovirus transfection experiments; (3) The competing endogenous RNA (ceRNA) network of lncRNA LUCAT1/hsa-miR-6776-5p/LRRC25 axis was constructed and validated; (4) The expression levels of above autophagy-related RNAs in peripheral blood mononuclear cells (PBMCs) were verified by qPCR, and their diagnostic performance was subsequently analyzed using receiver operating characteristic (ROC) analysis.

RESULTS

(1) The expression of LC3, Beclin1, ATG5, and ATG7 demonstrated a consistent decline whereas p62 expression exhibited an opposite increase as atherosclerosis progressed; (2) Autophagy levels was significantly elevated in HCAECs under oxidative stress, while inhibition of the initial stage of autophagy with 3-MA exacerbated cellular damage; (3) The lncRNA LUCAT1/hsa-miR-6776-5p/LRRC25 axis was established through bioinformatic prediction and validated by dual-luciferase reporter assay, which resulted in a significant decrease in autophagy levels in HCAECs; (4) In total, p62, ATG7, lncRNA LUCAT1 and LRRC25 were validated as robust diagnostic biomarkers for CAD.

CONCLUSIONS

Our results delineated the dynamic disruption of the autophagy landscape during the progression of human coronary atherosclerosis and identified the lncRNA LUCAT1/hsa-miR-6776-5p/LRRC25 axis, uncovered through transcriptomic profiling, as a protective mechanism against endothelial cell injury through autophagy activation. Furthermore, we recognized p62, ATG7, lncRNA LUCAT1, and LRRC25 as dependable autophagy-related diagnostic biomarkers in circulating PBMCs, correlating with CAD severity. Collectively, Our findings furnish novel insights into the intricate autophagy landscape at various levels of coronary atherosclerosis and propose potential diagnostic biomarkers, and a theoretical foundation for managing CAD patients.

Predictive value of system immune-inflammation index for the severity of coronary stenosis in patients with coronary heart disease and diabetes mellitus

Coronary heart disease (CHD) has been recognized as a chronic progressive inflammatory disorder, and Diabetes mellitus (DM) is an independent risk factor for the pathogenesis of CHD. Recent research has underscored the systemic immune-inflammation index (SII) as a potent prognostic indicator for individuals suffering from acute coronary syndrome (ACS). This study aimed to delve into the relationship between SII and the degree of coronary atherosclerotic stenosis in non-acute myocardial infarction patients with or without DM. We enrolled a total of 2760 patients with cardiovascular disease between November 2023 and May 2024. All eligible participants were divided into the CHD group and the DM & CHD group according to the existence of comorbid DM. Our study revealed that the SII values were significantly higher in diabetic patients with CHD compared to those with CHD alone (P < 0.05). Furthermore, among patients with both CHD and DM, higher SII values were associated with a greater likelihood of developing complex, triple-branch coronary artery lesions, while the opposite trend was observed in CHD populations (P < 0.05). In the regression model completely adjusted for potential confounders, the correlation between high SII levels and co-existing DM status in CHD patients persisted as statistically significant even after attaining guideline-recommended LDL-C and TG goals (P < 0.05). Moreover, our findings demonstrated a significant link between SII levels and the severity of coronary artery stenosis as assessed by coronary angiography, particularly in the DM and CHD patient cohorts (P < 0.05). Further stratified analysis revealed a novel finding that SII levels in DM and CHD patients maintained a positive linear relationship with coronary plaque burden even under stringent glycemic control (P < 0.01, r = 0.37), whereas this correlation was absent in CHD patients who had FBG of 7 mmol/L or lower upon admission (P < 0.01, r < 0.30). These important findings underscore the SII as an independent predictor of the severity of coronary plaque burden in diabetic patients with CHD, offering valuable insights that can aid clinicians in refining risk stratification and implementing personalized management strategies for those at elevated risk.

Safety assessment of ezetimibe: real-world adverse event analysis from the FAERS database

BACKGROUND

Ezetimibe is known for its lipid-lowering safety and tolerability, but its real-world adverse effects have not been fully evaluated. In this study, adverse events associated with ezetimibe were investigated using the FAERS database for the period 2004 to 2023.

RESEARCH DESIGN AND METHODS

Adverse events data for ezetimibe, spanning from the first quarter of 2004 to the fourth quarter of 2023, were standardized and analyzed using signal quantification methods like Reporting Odds Ratio (ROR), Proportional Reporting Ratio (PRR), Bayesian Confidence Propagation Neural Network (BCPNN), and Multi-item Gamma Poisson Shrinker (EBGM).

RESULTS

Among 11,550 adverse drug events reports with ezetimibe as the primary suspect drug, 211 preferred terms (PTs) were identified across 24 different system organ classes (SOCs).Notably, in addition to the adverse reactions already specified in the instruction manual, unstable angina (n = 120, ROR 30.53(25.47-36.58), PRR 30.41(25.49-36.28), IC 4.9(4.64), EBGM 29.85(25.66)), crush syndrome(n = 19,ROR 298.83(182.95-488.09), PRR 298.65(182.96-487.49), IC 7.97(7.29),EBGM 251.12(166.57)), and autoscopy (n = 7, ROR 28.81(13.64-60.85), PRR 28.80(13.68-60.65), IC 4.82(3.81), EBGM 28.30(15.14))were new adverse reactions that emerged as strong signals.

CONCLUSIONS

Ezetimibe is effective in lowering blood lipids, but there is a risk of adverse reactions such as unstable angina, rhabdomyolysis and autoscopy, which require careful monitoring by physicians.

Obesity modulates NK cell activity via LDL and DUSP1 signaling for populations with adverse social determinants

African American (AA) women are disproportionately affected by obesity and hyperlipidemia, particularly in the setting of adverse social determinants of health (aSDoH) that contribute to health disparities. Obesity, hyperlipidemia, and aSDoH appear to impair NK cells. As potential common underlying mechanisms are largely unknown, we sought to investigate common signaling pathways involved in NK cell dysfunction related to obesity and hyperlipidemia in AA women from underresourced neighborhoods. We determined in freshly isolated NK cells that obesity and measures of aSDoH were associated with a shift in NK cell subsets away from CD56dim/CD16+ cytotoxic NK cells. Using ex vivo data, we identified LDL as a marker related to NK cell function in an AA population from underresourced neighborhoods. Additionally, NK cells from AA women with obesity and LDL-treated NK cells displayed a loss in NK cell function. Comparative unbiased RNA-sequencing analysis revealed DUSP1 as a common factor. Subsequently, chemical inhibition of Dusp1 and Dusp1 overexpression in NK cells highlighted its significance in NK cell function and lysosome biogenesis in a mTOR/TFEB-related fashion. Our data demonstrate a pathway by which obesity and hyperlipidemia in the setting of aSDoH may relate to NK cell dysfunction, making DUSP1 an important target for further investigation of health disparities.

A Life Course Approach to Cardiovascular Disease Prevention

ABSTRACT

During the past 3 decades, life course socio-ecological frameworks have received considerable attention from clinical and public health professionals; developmental, social, and behavioral scientists; and scholars. Substantial evidence underscores the importance of a life course approach to prevention of cardiovascular (CV) disease and the promotion of optimal CV health. This article provides an overview of evidence on early origins and progression of CV disease (CVD) processes across the life course of individuals from diverse populations. Emphasis is placed on the evidence-based guidelines designed to prevent CVD and promote CV health with recommendations for implementation by CV health professionals and directions for future research in global CVD prevention.