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

Adverse Pregnancy Outcomes and Long-Term Risk of Heart Failure in Women: National Cohort and Co-Sibling Study

BACKGROUND

Adverse pregnancy outcomes, such as preterm delivery and hypertensive disorders of pregnancy, may be associated with higher future risks of heart failure (HF). However, the comparative effects of different adverse pregnancy outcomes on long-term risk of HF, and their potential causality, are unclear.

OBJECTIVES

The authors sought to examine 5 major adverse pregnancy outcomes in relation to long-term risk of HF in a large population-based cohort.

METHODS

A national cohort study was conducted of all 2,201,638 women with a singleton delivery in Sweden in 1973-2015, followed up for HF identified from nationwide outpatient and inpatient diagnoses through 2018. Cox regression was used to compute HRs for HF associated with preterm delivery, small for gestational age, preeclampsia, other hypertensive disorders of pregnancy, and gestational diabetes, while adjusting for other adverse pregnancy outcomes and maternal factors. Co-sibling analyses assessed for potential confounding by shared familial (genetic or environmental) factors.

RESULTS

In 48 million person-years of follow-up, 667,774 women (30%) experienced an adverse pregnancy outcome, and 19,922 women (0.9%) were diagnosed with HF (median age, 61 years). All 5 adverse pregnancy outcomes were independently associated with long-term increased risk of HF. With up to 46 years of follow-up after delivery, adjusted HRs for HF associated with specific adverse pregnancy outcomes were: gestational diabetes, 2.19 (95% CI: 1.95-2.45); preterm delivery, 1.68 (95% CI: 1.61-1.75); other hypertensive disorders, 1.68 (95% CI: 1.48-1.90); preeclampsia, 1.59 (95% CI: 1.53-1.66); and small for gestational age, 1.35 (95% CI: 1.31-1.40). All HRs remained significantly elevated (1.3- to 3.0-fold) even 30 to 46 years after delivery. These findings were only partially explained by shared familial factors. Women with multiple adverse pregnancy outcomes had further increases in risk (eg, up to 46 years after delivery, adjusted HRs associated with 1, 2, or ≥3 adverse pregnancy outcomes were 1.51 [95% CI: 1.47-1.56], 2.31 [95% CI: 2.19-2.45], and 3.18 [95% CI: 2.85-3.56], respectively).

CONCLUSIONS

In this large national cohort, women who experienced any of 5 major adverse pregnancy outcomes had increased risk for HF up to 46 years later. Women with adverse pregnancy outcomes need early preventive actions and long-term clinical care to reduce the risk of HF.

AutoFOX: An automated cross-modal 3D fusion framework of coronary X-ray angiography and OCT

Coronary artery disease (CAD) is the leading cause of death globally. The 3D fusion of coronary X-ray angiography (XA) and optical coherence tomography (OCT) provides complementary information to appreciate coronary anatomy and plaque morphology. This significantly improve CAD diagnosis and prognosis by enabling precise hemodynamic and computational physiology assessments. The challenges of fusion lie in the potential misalignment caused by the foreshortening effect in XA and non-uniform acquisition of OCT pullback. Moreover, the need for reconstructions of major bifurcations is technically demanding. This paper proposed an automated 3D fusion framework AutoFOX, which consists of deep learning model TransCAN for 3D vessel alignment. The 3D vessel contours are processed as sequential data, whose features are extracted and integrated with bifurcation information to enhance alignment via a multi-task fashion. TransCAN shows the highest alignment accuracy among all methods with a mean alignment error of 0.99 ± 0.81 mm along the vascular sequence, and only 0.82 ± 0.69 mm at key anatomical positions. The proposed AutoFOX framework uniquely employs an advanced side branch lumen reconstruction algorithm to enhance the assessment of bifurcation lesions. A multi-center dataset is utilized for independent external validation, using the paired 3D coronary computer tomography angiography (CTA) as the reference standard. Novel morphological metrics are proposed to evaluate the fusion accuracy. Our experiments show that the fusion model generated by AutoFOX exhibits high morphological consistency with CTA. AutoFOX framework enables automatic and comprehensive assessment of CAD, especially for the accurate assessment of bifurcation stenosis, which is of clinical value to guiding procedure and optimization.

Colchicine reduces neointima formation and VSMC phenotype transition by modulating SRF-MYOCD activation and autophagy

Vascular smooth muscle cell (VSMC) phenotype transformation significantly contributes to vascular intimal hyperplasia. However, effective preventive and therapeutic measures are lacking. Colchicine, a binary alkaloid derived from Colchicum autumnale, is traditionally used for treating inflammatory diseases. Its role in neointima formation is not fully understood. Here, we investigated the role of colchicine in vascular intimal hyperplasia. We found that colchicine significantly reduced vascular intimal hyperplasia in an animal model at 7, 14, and 28 days post carotid artery ligation and increased the number of contractile-phenotype VSMCs (SMA-positive cells) in the neointimal areas. In vitro experiments demonstrated that colchicine facilitated the transition of VSMCs from a proliferative phenotype to a contractile phenotype. Additionally, colchicine attenuated PDGF-BB-induced phenotypic conversion and upregulated the expression of serum response factor (SRF) and myocardin (MYOCD). Further molecular mechanistic studies revealed that colchicine inhibited the expression of forkhead box protein O3A (FOXO3A) to increase the activation of the SRF‒MYOCD complex. FOXO3A can bind to MSX1/2, thereby inhibiting the expression of SRF-MYOCD and contractile genes. Moreover, colchicine maintains vascular homeostasis and stabilizes the contractile phenotype by affecting the expression of autophagy-related genes (LC3II, p62, and Beclin-1) induced by FOXO3A. Additionally, colchicine inhibited monocyte/macrophage infiltration and inflammatory cytokine expression. In summary, this study suggests that colchicine inhibits vascular intimal hyperplasia by modulating FOXO3A-mediated SRF-MYOCD activation and autophagy, providing new insights for future therapeutic approaches targeting occlusive vascular diseases.

Cell adhesion molecules and incident hypertension in black and white adults: the REGARDS study

BACKGROUND

Higher C-reactive protein-quantified inflammation associates with greater incident hypertension risk. E-selectin, intercellular adhesion molecule 1 (ICAM-1), and vascular cell adhesion molecule 1 (VCAM-1) are cell adhesion molecules that aid leukocyte adhesion during inflammation. Their association with incident hypertension is unclear.

METHODS

REGARDS enrolled 30 239 Black and White US adults aged ≥45 years from across the contiguous United States in 2003-2007, with a second exam in 2013-2016. The Biomarkers as Mediators of Racial Disparities in Risk Factors (BioMedioR) study included 4400 REGARDS participants who attended both exams. We excluded participants with hypertension or missing biomarkers at baseline. Hypertension used a 140/90 mmHg threshold or self-reported use of blood pressure (BP) lowering medications. Modified Poisson regression estimated relative risk (RR) of incident hypertension by tertile of baseline E-Selectin, ICAM-1, and VCAM-1.

RESULTS

Among 1879 nonhypertensive participants (mean [SD] age 62 [8] years, 25% Black race, 55% women) with 9 years median follow up, 36% developed hypertension. E-selectin and ICAM-1 were higher among Black participants; VCAM-1 was higher among White participants. Higher E-selectin was associated with greater risk of incident hypertension among White but not Black adults in some models (e.g., minimally adjusted: RR 1.27; 95% confidence interval (CI) 1.04-1.44 comparing tertile 3 vs. 1) ICAM-1 was associated with greater hypertension risk in only an unadjusted model.

CONCLUSION

In a prospective study of Black and White US adults, E-selectin was associated with incident hypertension among White adults and ICAM-1 in White and Black adults in partially or unadjusted models. Modification of E-selectin might be tested to lower risk of hypertension development.

Gender disparities in delayed angina diagnosis: insights from 2001-2020 NHANES data

BACKGROUND

Women with coronary artery disease (CAD) are more likely than men to experience a delay in diagnosis, which is attributed to differences in clinical presentation. The objective of this study is to examine any persistent disparities in timely CAD diagnosis in the United States (U.S.) among women who present with clinically similar symptoms and demographic characteristics to their male counterparts.

METHODS

From the 2001 - 2020 National Health and Nutrition Examination Survey (NHANES) data, participants were categorized as having missed angina if they experienced angina and did not self-report a prior diagnosis of angina pectoris or CAD. We assessed the association between gender and missed angina using weighted multivariate logistic regression models representative of the U.S.

POPULATION

Mortality follow-up data were available for participants up to December 31, 2018.

RESULTS

Of 874 participants with missed angina, 551 (63%) were women and 323 (37.0%) were men. Baseline characteristics showed that women and men with missed angina were more likely than their diagnosed counterparts to be younger, of ethnic minorities, uninsured, and smokers. Women with missed angina were more likely to be in a relationship than diagnosed women, while the opposite pattern was observed in men. The odds ratio of missed angina in women compared to men was 2.61 (95% CI: 1.73, 3.94) after adjusting for age, race, education, body mass index, smoking, alcohol use, income, insurance, and comorbidities. Among participants who had a cardiac cause of death, the odds of missed angina in women compared to men was 3.02 (95% CI: 1.18, 7.75) in the adjusted model.

CONCLUSION

Women with similar CAD symptoms to their male counterparts still have higher odds of going undiagnosed. This relationship extends to individuals who ultimately die of cardiac causes. Potential solutions to this disparity include addressing overgeneralized perceptions of differences in the prevalence and presentation of CAD between genders and exploring targeted screening programs for women with risk factors. Further research accounting for healthcare access and proximity to care is needed to support our findings. Timely recognition of CAD in women is essential to decreasing preventable mortality.

Automated lifestyle interventions and weight loss: a systematic review of randomized controlled trials

BACKGROUND/OBJECTIVES

Overweight and obesity drive cardiometabolic disease and high-intensity lifestyle interventions are standard. However, many health-systems cannot offer these interventions and many patients cannot participate even when available. Trials have assessed automated digital lifestyle interventions to improve accessibility. This systematic review identified automated digital lifestyle interventions and assessed their impact on weight loss.

SUBJECTS/METHODS

The review (CRD42023435700) identified randomized controlled trials of at least 3-months duration assessing automated digital lifestyle interventions' impact on weight loss. Data were managed through Covidence with double-blinded screening of titles/abstracts and double-blinded full-text review to determine study inclusion. Data extraction was completed by one reviewer (NWC) and verified by a second (MM, JS, TE, CE). The Cochrane Collaboration's tool was used to assess bias risk and study quality was rated as High, Moderate, Low, or Very Low.

RESULTS

The search identified 1817 citations. The full-text of 60 reports were assessed and 17 reports of 16 studies were included. The majority (63%) were of moderate quality. No intervention produced 5% weight loss from baseline. Intervention components with the largest impact were text message encouragement and education with a cognitive behavioral approach. No specific form of self-monitoring was most effective, though some form of self-monitoring was included in most trials.

CONCLUSIONS

Some components of the automated digital lifestyle interventions showed promise. Research is needed to optimize these components (e.g., tailored messaging, cognitive-behavioral approaches) balanced with human contact. Considering the magnitude of the problem and its disproportionate impact on low socioeconomic and minority patients, interventions optimized for effect and scalability are needed to address overweight and obesity.

Effects of global Ripk2 genetic deficiency in aged mice following experimental ischemic stroke

Besides the loss of blood and oxygen reaching the ischemic tissue, many secondary effects of ischemic stroke can cause additional tissue damage, including inflammation, oxidative stress, and proteomic disturbances. Receptor-interacting serine/threonine kinase 2 (RIPK2) is an important mediator in the post-stroke inflammatory cascade that responds to signals and molecular patterns released by dead or dying cells in the ischemic area. We hypothesize that RIPK2 signaling worsens injury and neurological recovery post-stroke and that global deletion of Ripk2 is protective following ischemic stroke in aged mice. Aged (18-24 months) male mice were subjected to permanent middle cerebral artery occlusion (pMCAO). Vertical grid, weight grip, and open field were conducted at baseline and on days 1, 2, 3, 8, 15, and 22 post-stroke. Cognitive tests (novel object recognition and Y-maze) were performed at baseline and day 28 post-stroke. Infarct size was measured using cresyl violet staining, and reactive gliosis was measured using Iba1 and GFAP staining at day 28 post-stroke. Global deletion of Ripk2 (Ripk2-/- ) in aged mice resulted in smaller infarct volume and improved performance on vertical grid and weight grip tests compared to aged wildtype (WT) mice. Additionally, aged Ripk2 -/- mice had less Iba1 staining in the ipsilateral cortex than the aged WT control mice. This study further elucidates the role of RIPK2 signaling in the ischemic cascade and expands our knowledge of RIPK2 in stroke to aged mice. These results support the hypothesis that RIPK2 signaling worsens injury post-stroke and may be an attractive candidate for therapeutic intervention.

Pharmacist-Initiated Team-Based Intervention for Optimizing Guideline-Directed Lipid Therapy of Hospitalized Patients With Acute Coronary Syndrome: Pilot Study Using a Stepped-Wedge Cluster Design

Background

Clinical guidelines recommend high-intensity statin therapy for patients with acute coronary syndrome (ACS). However, high-intensity statins have been underused in this population.

Objective

The objective of this study was to evaluate the feasibility of a pharmacist-initiated, team-based intervention for the delivery of individualized, guideline-directed, lipid-lowering therapy for patients with ACS.

Methods

Patients admitted with ACS to cardiology hospital services at Mayo Clinic from August 1, 2021, to June 19, 2022, were assigned to a pharmacist-initiated, team-based intervention group or control group using a stepped wedge cluster study design. For the intervention group, pharmacists reviewed electronic health records and provided recommendations for lipid lowering therapy in hospital and at follow-up. In the control group, patients received usual care. Neither care team, nor study team were blinded to study assignments. The primary outcome was the proportion of patients with ACS discharged on high-intensity statins in the intervention group compared to controls. Secondary outcomes were (1) proportion of patients in the intervention group with a specific templated pharmacist intervention note in their electronic health records, (2) frequency of low-density lipoprotein (LDL) measurements in hospital, (3) proportion of patients with information related to lipid follow-up in their discharge summary, and (4) proportion of patients that received LDL monitoring at the outpatient follow-up 4 to 12 weeks post discharge.

Results

There were 410 patients included in this study (median age 68, IQR 60-78 years) of whom 285 (69.5%) were male. Of the 402 patients alive at discharge, 355 (88.3%) were discharged taking a high-intensity statin, with no significant difference (P=.89) observed between groups. Lipid levels were measured in the hospital for 176/210 (83.8%) patients in the intervention group and 155/200 (77.5%) patients in the control group (P=.14). Fifty-four of 205 (26.3%) intervention patients alive at discharge had lipid-related recommendations in their discharge summary compared to 27/197 (13.7%) controls (P=.002). Forty-seven of 81 (58%) patients with lipid management recommendations provided in the discharge summary had LDL measured in the follow-up period compared with only 119/321 (37.1%) patients without these recommendations (P=.001). Of the 402 patients who survived to discharge, 166 (41.3%) had LDL measured at follow-up; the median LDL level was 63.5 (IQR 49-79) mg/dL, and distributions were similar by group (P=.95). Only 101/166 (60.8%) patients had follow-up LDL values below the target of 70 mg/dL.

Conclusions

During hospitalization, there was no group difference in the primary outcome of high-intensity statin therapy. Feasibility of an effective pharmacist-initiated intervention for improvement of lipid management was demonstrated by entry of recommendations in the discharge summary and related adjustment in outpatient statin therapy. The main opportunity for future improvement in lipid management of patients with ACS is in longitudinal patient follow-up.

Associations of Naples prognostic score with stroke in adults and all cause mortality among stroke patients

This study seeks to assess the associations of Naples Prognostic Score with stroke in adults and all cause mortality among stroke patients. We analyzed data from 44,601 participants in the 2005-2018 National Health and Nutrition Examination Survey (NHANES). The Naples Prognostic Score (NPS) was derived from total cholesterol, serum albumin, neutrophil-to-lymphocyte ratio (NLR), and lymphocyte-to-monocyte ratio (LMR). Participants were classified into three groups based on their NPS. Stroke incidence was determined through self-reported questionnaires, and mortality data were diligently tracked using the National Death Index. We investigated the relationship between NPS and stroke prevalence using multiple logistic regression analysis. To explore the association between NPS and all cause mortality in stroke survivors, we applied Kaplan-Meier survival analysis and Cox proportional hazards models. Furthermore, we conducted a detailed subgroup analysis to assess interaction effects on all cause mortality risk within this population. The median age of the participants was 50.00 years [interquartile range: 35.00-64.00], with males comprising 49.36% of the study. The overall stroke prevalence was 3.93%. Participants were categorized into three groups based on their NPS: 6,328 (18.1%) in Group 0 (NPS 0), 24,015 (68.8%) in Group 1 (NPS 1 or 2), and 4,580 (13.1%) in Group 2 (NPS 3 or 4). After adjusting for covariates, individuals in Group 2 exhibited a significantly higher stroke prevalence compared to Group 0, with an odds ratio (OR) of 1.82 [95% confidence interval: 1.48-2.23]. Among the 1372 patients with a history of stroke, with a median follow-up duration of 5.94 years, we utilized Cox proportional hazards models to assess the relationship between NPS and all cause mortality risk. The analysis revealed that, after adjusting for covariates, stroke patients in Group 2 faced a significantly elevated risk of all cause mortality (hazard ratio [HR] = 2.21 [95% confidence interval: 1.44-3.11]) compared to those in Group 0. Subsequent subgroup analyses to explore interaction effects on all cause mortality risk among stroke patients shown no significant interactions (p for interaction > 0.05). This study indicate a positive correlation between NPS and the risk of stroke in adults, as well as all cause mortality in stroke patients.

Sex-Specific Associations of Cardiovascular Risk Factors With Subclinical Cardiac Remodelling: A Magnetic Resonance Imaging Study

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death in women, yet sex-specific risk factor influences remain understudied. Cardiac magnetic resonance (CMR) imaging detects early remodelling via left ventricular mass-to-volume ratio (LVMV), a validated concentricity marker. This study examines sex differences in the association of cardiovascular (CV) risk factors, diet, and cardiac remodelling.

METHODS

We analyzed 622 age-matched adults (51% female, mean age 50.8 ± 9.5) from the Courtois Cardiovascular Signature Program. LVMV was defined as left ventricular (LV) systolic mass divided by end-diastolic volume. Alcohol and sugar intake was self-rated on a Likert scale. Mann-Whitney U and regression analyses assessed sex-specific associations between CV risk factors and LVMV.

RESULTS

Hypertension was present in 20.6% of men and 17.4% of women: diabetes in 9.8% and 6.0%. Men had higher triglycerides, alcohol/sugar intake, and LVMV (0.92 ± 0.20 vs 0.77 ± 0.18 g/mL). Hypertension correlated with higher LVMV in both sexes (men: ß = 0.099, P < 0.001; women: ß = 0.078, P < 0.05), whereas triglycerides (ß = 0.032, P < 0.05) and alcohol intake (H = 19.41, P < 0.0001) were male-specific predictors. In female patients, diabetes and sugar intake were significantly associated with LVMV (ß = 0.102, ß = 0.062, P < 0.05).

CONCLUSIONS

CV risk factors affect cardiac remodelling differently by sex. In men, LVMV was linked to triglycerides and alcohol intake, whereas in women, diabetes and sugar intake showed stronger associations. These results underscore the need for tailored CV prevention strategies that account for sex differences in metabolic and lifestyle risk factors.

CLINICAL TRIAL REGISTRATION

▪▪▪.

Evaluating patients with chest pain in the emergency department

Identifying patients with chest pain that is of cardiac origin is crucial owing to the high mortality and morbidity of cardiovascular diseases. History, electrocardiogram, and cardiac biomarkers are the core elements of the assessment. High sensitivity cardiac troponins (hs-cTn) are the preferred biomarkers for diagnosing acute myocardial infarction, allowing for more accurate detection and exclusion of myocardial injury. However, elevations in hs-cTn can occur in patients who are not experiencing acute myocardial infarction. Therefore, it is important for clinicians to recognize how to integrate hs-cTn levels into their clinical decision making process. Structured risk assessments, using evidence based diagnostic protocols, should be employed to estimate the risk of acute coronary syndrome and adverse events in patients with chest pain. Clinical decision pathways should be used routinely in emergency departments. Patients at intermediate or high risk of obstructive coronary artery disease might benefit from cardiac imaging and further testing. Patients should be involved in decision making, with information provided about risks, radiation exposure, costs, and alternative options to facilitate informed decision making.

HELicobacter Pylori screening to prevent gastrointestinal bleeding in patients with acute Myocardial Infarction (HELP-MI SWEDEHEART) - Design and rationale of a cluster randomized, crossover, registry-based clinical trial

BACKGROUND

The role of Helicobacter pylori (H. pylori) screening and eradication on reducing upper gastrointestinal bleeding (UGIB) complications after acute myocardial infarction (MI) is uncertain. The HELicobacter pylori screening to prevent gastrointestinal bleeding in patients with acute MI (HELP-MI SWEDEHEART) trial aims to determine whether systematic H. pylori screening compared to usual care reduces UGIB, mortality, and cardiovascular outcomes after MI.

METHODS

A cluster randomized, crossover, registry-based clinical trial using SWEDEHEART as trial platform for study population definition and source for data collection in combination with nationwide Swedish health data registries. Thirty-five Swedish hospitals, organized into 18 clusters based on percutaneous coronary intervention networks, were randomized to either routine H. pylori screening for adults with acute type-1 MI or usual care. After 1 year, a 2-month blanking period was followed by a crossover to the alternate allocation for 1 year. The trial enrolment was concluded after one additional year of registry-based follow-up. The primary endpoint is UGIB. Secondary endpoints include all-cause death, cardiovascular death, readmission for MI, stroke, or heart failure. Endpoints will be reported combined (Net Adverse Clinical Events; Major Adverse Cardiac or Cerebrovascular Events) and separately. The primary analysis will include all available follow-up time corresponding to a maximum follow-up time of 3 years and 2 months.

CONCLUSION

HELP-MI SWEDEHEART aims to determine the utility of routine H. pylori screening to reduce UGIB and improve cardiovascular outcomes after MI. By integrating national registry follow-up data with a pragmatic trial design, it has the potential to provide evidence for the effect of the implementation of routine H. pylori screening as part of acute MI care.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05024864.

Supporting Physical and Mental Health in Rural Veterans Living With Heart Failure: Protocol for a Nurse-Led Telephone Intervention Study

BACKGROUND

Heart failure (HF) remains a disease of notable disparity for rural veterans, despite recent advancements in clinical treatment. Managing HF in the home is stressful and complex for rural veterans who experience unique barriers to optimal physical and mental health, necessitating adequate support and problem-solving skills.

OBJECTIVE

This study aims to (1) adapt, to the rural sociocultural context, a culturally sensitive, tailored, telephone support and problem-solving intervention (CARE-HF [Supporting Physical and Mental Health in Rural Veterans With Heart Failure]) using findings from preliminary qualitative research and (2) evaluate the effects of CARE-HF on problem-solving and physical and mental health outcomes among rural veterans with HF.

METHODS

This study involves a repeated-measures, single-group design. The intervention content was adapted and tailored to the rural sociocultural context using preliminary qualitative data and guided by the Theories of Social Problem-Solving and Stress, Appraisal, and Coping. Veterans are recruited from Veterans Administration home-based cardiac rehabilitation clinics, cardiology clinics that serve veterans, veterans-based community resource centers, and social media campaigns. Veterans with HF (N=100) receive the CARE-HF intervention. This nurse-led intervention comprises 8 telephone sessions that use a five-step, problem-solving process to manage common HF problems in the home: (1) identifying the problem and viewing it in a positive manner, (2) goal setting, (3) generating potential strategies for problem management, (4) choosing and implementing strategies to manage the problem, and (5) evaluating strategy effectiveness. Veterans receive initial problem-solving training during the first session, with follow-up sessions focusing on problem-solving skill reinforcement and assisting veterans in applying these principles to manage self-identified, HF-related problems experienced in the home. Data are collected at baseline and 3, 6, 12, and 18 months from baseline on problem-solving and outcomes of interest (ie, HF self-care; HF symptoms; health care utilization; depressive symptoms; anxiety; HF-specific, health-related quality of life; stress; resilience; and coping). Demographic data will be analyzed using descriptive statistics and multilevel growth curve modeling with restricted maximum likelihood estimation to compare a series of models using Akaike information criteria and Bayesian information criteria fit indices while controlling for covariates.

RESULTS

Recruitment started in April 2023. As of December 2024, we have enrolled 56 veterans. Recruitment is anticipated to end in June 2025, with data collection continuing until all enrolled veterans have completed the 18-month follow-up period.

CONCLUSIONS

Adapting and testing a culturally sensitive, tailored, telephone intervention to aid support and problem-solving in the home has the potential to provide individualized care to rural veterans where they reside, thereby reducing travel burden while also increasing access to evidence-based care programs. If effective, telephone support and problem-solving interventions could be a low-cost, accessible method to improve physical and mental health in rural veterans with HF.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05839067; https://clinicaltrials.gov/study/NCT05839067.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/63498.

Changes in non-high-density lipoprotein to high-density lipoprotein ratio (NHHR) and cardiovascular disease: insights from CHARLS

BACKGROUND

The established association between the non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio (NHHR) and cardiovascular disease (CVD) risk has been well-documented. Nevertheless, the relationship between changes in NHHR and CVD events remains to be elucidated. The present study aims to clarify the correlation between NHHR change patterns and the incidence of CVD across a broad population.

METHODS

The current study recruited participants from the China Health and Retirement Longitudinal Study (CHARLS). The NHHR index was calculated using the formula: NHHR = (TC-HDL-c)/HDL-c. Temporal changes in NHHR were assessed with latent profile analysis, and cumulative NHHR was also evaluated. Multivariable Cox proportional hazards regression models and multivariate-adjusted restricted cubic spline (RCS) analyses were employed to examine the association between the NHHR index and incident CVD.

RESULTS

A total of 4,629 individuals were recruited for the study. The average age of the participants was 57.47 years, with 53.7% being female. Over the follow-up period, 879 cases of CVD were documented. Compared to participants in the lowest tertile, those in the highest tertile for both baseline NHHR and cumulative NHHR exhibited a significantly increased risk of CVD, with adjusted hazard ratios (HRs) of 1.43 (95% confidence interval [CI]: 1.21-1.70) and 1.45 (95% CI: 1.23-1.72), respectively. Participants classified in Class 2 demonstrated a 27% higher risk of CVD, while those in Class 3 showed a 41% greater risk compared to the Class 1 group. Further analysis revealed that this relationship was linear. Stratified analyses corroborated the primary findings.

CONCLUSION

Baseline NHHR, cumulative NHHR, and changes in NHHR are significantly associated with an increased risk of CVD among individuals aged 45 years and older, thereby confirming their potential as valuable tools for risk stratification in CVD.

Enhancing Stroke Awareness and Activation Among High-Risk Populations: A Randomized Direct Mail Intervention in Diverse Healthcare Settings

BACKGROUND

Many patients are unaware of their stroke risk. The purpose of this research was to compare the effect of behaviorally tailored mailed messages on patient activation to reduce stroke risk.

METHODS

Randomized parallel group clinical trial. We used electronic health records to construct Framingham Stroke Risk Scores in primary care patients from 1 Veterans Health Administration (VA) and 1 non-VA healthcare system, Eskenazi Health System (EHS). Four stroke risk messages were developed through patient interviews: standard, incentive ($5 gift card), salience, and incentive plus salience. The standard message served as the comparison group. Patients in the highest Framingham Stroke Risk Score quintile were randomly assigned to receive one of the messages. All letters asked the patient to call a stroke prevention coordinator, the primary outcome. Response to the messages was modeled separately in the 2 cohorts using logistic regression.

RESULTS

In total, 2084 EHS patients (mean age, 65.6; 36% male; 68% Black; mean Framingham Stroke Risk Score, 13.1) and 1759 VA patients (mean age, 75.6; 99% male; 86% White; mean Framingham Stroke Risk Score, 18.6) received a letter. Rates of calls to the coordinator were 13% among the EHS and 23% among the VA cohort. The EHS cohort was significantly more likely to respond to the incentive message compared with the standard message (odds ratio, 1.97 [95% CI, 1.17-3.09]), and the VA cohort was more likely to respond to the incentive plus salience message (odds ratio, 1.50 [95% CI, 1.02-2.22]). Among individuals calling the coordinator, 31% of the EHS cohort and 27% of the VA cohort were unaware they had stroke risk factors.

CONCLUSIONS

A mailed message including a $5 incentive was more effective than a standard message in engaging high-risk patients with their healthcare system, including a salience message may also be important in some patient populations. Many primary care patients are unaware of their stroke risk.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02721446.

Association of dietary vitamin E intake with peripheral arterial disease: A retrospective cross-sectional study

BACKGROUND

The relationship between the amount of dietary vitamin E consumed and the development of peripheral arterial disease (PAD) remains a topic of debate. This relationship is of the utmost importance in the realms of healthcare and public health and is currently a highly researched and prominent topic. This study aimed to present the relationship between dietary vitamin E intake and PAD.

METHODS

In a retrospective cross-sectional analysis, data from 6,588 participants in the National Health and Nutrition Examination Survey of the United States were examined during the period 1999-2004. We collected data on age, sex, race, marital status, education, physical activity, income, smoking, hypertension, diabetes, cardiovascular disease, body mass index, total cholesterol and HbA1c. Logistic regression and smooth curve fitting were used to support the research objectives.

RESULTS

After accounting for all relevant factors, a negative correlation between dietary vitamin E intake and the likelihood of PAD was observed (OR: 0.981, 95% CI: 0.957-1.004). The overall prevalence of PAD was 5.9%, with 49.6% in males and 50.4% in females. Individuals in the third quartile of dietary vitamin E intake had a lower occurrence rate of peripheral artery disease than those in the first quartile (OR: 0.68, 95% CI: 0.51, 0.91). Similar patterns of association were observed in the subgroup analysis (all P values for interaction were > 0.05).

CONCLUSIONS

Our study suggests a negative association between dietary vitamin E intake and incidence of PAD. Therefore individuals with insufficient dietary vitamin E intake, especially those with a very low intake, should consider increasing their vitamin E intake to lower the risk of developing PAD. These findings should be considered when offering dietary guidance and nutrition education to prevent PAD.

Cross-sectional study on smoking types and stroke risk: development of a predictive model for identifying stroke risk

Background

Stroke, a major global health concern, is responsible for high mortality and long-term disabilities. With the aging population and increasing prevalence of risk factors, its incidence is on the rise. Existing risk assessment tools have limitations, and there is a pressing need for more accurate and personalized stroke risk prediction models. Smoking, a significant modifiable risk factor, has not been comprehensively examined in current models regarding different smoking types.

Methods

Data were sourced from the 2015-2018 National Health and Nutrition Examination Survey (NHANES) and the 2020-2021 Behavioral Risk Factor Surveillance System (BRFSS). Tobacco use (including combustible cigarettes and e-cigarettes) and stroke history were obtained through questionnaires. Participants were divided into four subgroups: non-smokers, exclusive combustible cigarette users, exclusive e-cigarette users, and dual users. Covariates such as age, sex, race, education, and health conditions were also collected. Multivariate logistic regression was used to analyze the relationship between smoking and stroke. Four machine-learning models (XGBoost, logistic regression, Random Forest, and Gaussian Naive Bayes) were evaluated using the area under the receiver-operating characteristic curve (AUC), and Shapley's additive interpretation method was applied for feature importance ranking and model interpretation.

Results

A total of 273,028 individuals were included in the study. Exclusive combustible cigarette users had an elevated stroke risk (β: 1.36, 95% CI: 1.26-1.47, P < 0.0001). Among the four machine-learning models, the XGBoost model showed the best discriminative ability with an AUC of 0.794 (95% CI = 0.787-0.802).

Conclusion

This study reveals a significant association between smoking types and stroke risk. An XGBoost-based stroke prediction model was established, which has the potential to improve the accuracy of stroke risk assessment and contribute to personalized interventions for stroke prevention, thus alleviating the healthcare burden related to stroke.

Acute Myocardial Infarction Mortality in the Older Population of the United States: An Analysis of Demographic and Regional Trends and Disparities from 1999 to 2022

Background/Objectives: Acute myocardial infarction (AMI) has been a leading cause of mortality in the US. Though AMI mortality has been decreasing in the US, significant disparities have persisted. We aim to evaluate disparities in AMI-related deaths in the US from 1999 to 2022. Methods: Data from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) multiple causes of death database were used to analyze death certificates from 1999 to 2022 for AMI-related deaths among United States older adults (aged ≥ 65) for overall trend and disparities based on demographic (sex, race/ethnicity, and ten-year age groups) and regional (census regions, rural-urban status, and states) subgroups. Rural and urban status were distinguished using definitions set by the 2013 NCHS Urban-Rural Classification scheme for counties. These data come from the 2010 Census report and are updated from the 2006 NCHS Urban-Rural Classification scheme for counties. The crude mortality rate (CMR) and age-adjusted mortality rates (AAMRs) per 100,000 people were used to calculate annual percentage changes (APCs) and average annual percentage changes (AAPCs) using Joinpoint regression analysis. Results: From 1999 to 2022, there were 3,249,542 deaths due to AMI. Overall, age-adjusted mortality rates (AAMRs) decreased by 62.78% from 563.2 * (95% CI 560.3-565.7) in 1999 to a nadir at 209.6 * (208.3-210.8) in 2019, with an AAPC of -4.96 * (95% CI -5.11 to -4.81). There were a total of 355,441 deaths from AMI from 2020 to 2022; 21,216 (5.97%) of those were from AMI with COVID-19 infection. An increase of 11.4% was observed from an AAMR of 209.6 * (95% CI 208.3-210.8) in 2019 to 233.5 * (95% CI 232.2-234.8) in 2021. From 2021 to 2022, the AAMR of AMI decreased from 233.5 * (95% CI 232.2-234.8) to 209.8 * (95% CI 208.6-211), recovering to the 2019 levels. The AAMR for AMI excluding associated COVID-19 infection was 217.2 at its peak in 2021, which correlates to only a 3.63% increase from 2019. Significant disparities in AMI mortality were observed, with higher mortality rates in men, African Americans, the oldest age group (age ≥ 85), and those living in southern states and rural areas. Conclusions: AMI mortality in the older adult population of the US has significantly decreased from 1999 to 2019, with a brief increase during the pandemic from 2019 to 2021, followed by recovery back to the 2019 level in 2022. The majority of the rise observed during the pandemic was associated with COVID-19 infection. Despite remarkable improvement in mortality, significant disparities have persisted, with men, African Americans, and those living in rural areas and the southern region of the US having disproportionately higher mortality.

Investigating mortality trends and disparities in tricuspid valve disorder: a U.S. nationwide study from 1999 to 2023

Tricuspid valve disorder (TVD), a critical aspect of valvular heart disease (VHD), significantly impacts cardiovascular health, yet its mortality trends are not well understood. This study aimed to investigate demographic and geographic disparities in TVD-related mortality across the United States from 1999 to 2023. Using data from the CDC WONDER database, death certificates were analyzed to identify TVD-related fatalities, and age-adjusted mortality rates (AAMRs) were calculated per 1,000,000 individuals. Joinpoint regression analysis was conducted to assess annual percent changes (APCs) in mortality rates. A total of 72,805 deaths were attributed to TVD. An initial steep increase in mortality rate from 1999 to 2003 (APC: 7.9%; 95% CI: 3.9 to 14.1) followed by a stable period from 2003 to 2014 (APC: 0.1%; 95% CI: -2.7 to 1.0) and a sharp increase in AAMR from 2014 to 2023 (APC: 6.5%; 95% CI: 5.2 to 8.4). Females consistently had higher mortality rates than males, with a sharper increase after 2012. Racial and ethnic disparities were evident, with American Indian and white populations experiencing higher mortality rates than black populations. Geographic disparities were also noted, with states like Oregon, Minnesota, and Vermont, as well as the West census region, showing significantly higher mortality rates. Rural areas had higher mortality rates compared to urban areas. TVD-related mortality trends have followed a complex trajectory, with marked disparities across demographic and geographic factors. Further research is required to fully understand the factors driving these trends and their public health implications.

Effects of 1-year exercise in patients with atrial fibrillation: study protocol for the Norwegian Exercise in Atrial Fibrillation (NEXAF) randomised controlled trial

INTRODUCTION

Atrial fibrillation is the most prevalent sustained arrhythmia worldwide and is expected to increase substantially within the coming years. Although lifestyle changes and risk factor modification are now acknowledged as central components of atrial fibrillation management, the effects of exercise on disease-specific outcomes are still not extensively documented due to few high-quality randomised trials. The primary objective of the Norwegian Exercise in Atrial Fibrillation Trial (NEXAF) is to assess the effects of exercise over 12 months on key clinical and patient-reported outcomes in previously inactive patients with atrial fibrillation.

METHODS AND ANALYSIS

NEXAF is a multicentre, two-arm, randomised controlled trial inviting patients 18-80 years with a confirmed diagnosis of paroxysmal or persistent atrial fibrillation. Eligible patients are randomised 1:1 to either a combined supervised and eHealth-based exercise intervention or usual care for 12 months. The primary outcomes are total time in atrial fibrillation measured by insertable cardiac monitors, and disease-specific quality of life measured by the Atrial Fibrillation Effect on Quality-of-Life questionnaire.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Regional Ethics Committee in Mid-Norway in April 2021 (ID 213848).

TRIAL REGISTRATION NUMBER

NCT05164718.

Sexual Health After a Stroke: A Topical Review and Recommendations for Health Care Professionals

The devastating physical, emotional, and social effects of stroke can disrupt all aspects of life for the stroke survivor. Ensuring that survivor and caregiver needs are met after a stroke is essential in ongoing care to ensure optimal quality of life. Despite health care professionals making significant strides in poststroke symptom management, education, and rehabilitative support, the common poststroke symptom of sexual dysfunction is rarely addressed. Multiple barriers across health care settings and systems have contributed to this gap. The purpose of this article is to provide evidence that supports the importance of addressing sexual health by health care providers with the stroke survivor and their partner as they transition through the recovery process. We have the following recommendations to optimize care and quality of life for stroke survivors: (1) comprehensive sex education must include information on healthy sex and sexuality for people with neurological disabilities; (2) rehabilitation programs offered in postacute settings should include a structured culturally sensitive interprofessional sexual rehabilitation component that addresses sexuality of the stroke survivor in collaboration with their intimate partners; (3) sexual rehabilitation programs should be tailored for each person based on a thorough assessment of the person's health literacy and learning needs; and (4) the American Heart Association should develop an extensive toolkit for health care providers and survivors that is easily and readily available to the public. Health care providers, survivors, and their partners have a stake in optimal stroke recovery. Sexuality and sexual function are important quality of life indicators thus conversations addressing issues must be included as part of the recovery process. This discussion is best initiated by a health care provider to address system barriers and misconceptions across care transitions. Likewise, survivors and their partners must be encouraged to take ownership to address sexuality issues and initiate the conversation with their health care partners to achieve full recovery.

Observational studies of exposure to tobacco and nicotine products: Best practices for maximizing statistical precision and accuracy

Non-randomized observational studies can track risk-induction and -reduction associated with real-world use of non-combusted nicotine and tobacco products. The objective of this analysis was to evaluate the precision and accuracy of recent studies and to identify opportunities for further optimizing future study designs. The ROBINS framework for minimizing statistical bias was translated to specific considerations that spanned the selection and quantification of cohorts, exposure, and outcomes. These principles were then considered within the context of a recent comprehensive meta-analysis, representing 107 observational studies, which evaluated the effects of using electronic cigarettes (ECs), combusted cigarettes (CCs) and dual use of both. The meta-analysis had previously reported the relative risk from all-sources, including tobacco use and non-tobacco use. We now report the product use-specific risk associated with displacing CCs with ECs indicated from the primary references, along with observations regarding the precision of characterization of CC and EC exposure in the cited studies.

Sex as a prognostic factor for mortality in adults with acute symptomatic pulmonary embolism

BACKGROUND

Pulmonary embolism (PE) is relatively common worldwide. It is a serious condition that can be life-threatening. Studies on the relationship between adverse outcomes of this condition and whether a patient is male or female have yielded inconsistent results. Determining whether there is an association between sex and short-term mortality in patients with acute PE is important as this information may help guide different approaches to PE monitoring and treatment.

OBJECTIVES

To determine whether sex (i.e. being a male or a female patient) is an independent prognostic factor for predicting mortality in adults with acute symptomatic pulmonary embolism.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials register up to 17 February 2023. We scanned conference abstracts and reference lists of included studies and systematic reviews. We also contacted experts to identify additional studies. There were no restrictions with respect to language or date of publication.

SELECTION CRITERIA

We included phase 2-confirmatory prognostic studies, that is, any longitudinal study (prospective or retrospective) evaluating the independent association between sex (male or female) and mortality in adults with acute PE.

DATA COLLECTION AND ANALYSIS

We followed the Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of prognostic factor studies (CHARMS-PF) and the Cochrane Prognosis Methods Group template for prognosis reviews. Two review authors independently screened the studies, extracted data, assessed the risk of bias according to the Quality in Prognosis Studies (QUIPS) tool, and assessed the certainty of the evidence (GRADE). Meta-analyses were performed by pooling adjusted estimates. When meta-analysis was not possible, we reported the main results narratively.

MAIN RESULTS

We included seven studies (726,293 participants), all of which were retrospective cohort studies with participants recruited and managed in hospitals between 2000 and 2018. Studies took place in the USA, Spain, and Japan. Most studies were multicentre. None were conducted in low- or middle-income countries. The participants' mean age ranged from 62 to 69 years, and the proportion of females was higher in six of the seven studies, ranging from 46% to 60%. Sex and gender terms were used inconsistently. Participants received different PE treatments: reperfusion, inferior vena cava filter, anticoagulation, and haemodynamic/respiratory support. The prognostication time (the point from which the outcome was predicted) was frequently omitted. The included studies provided data for three of our outcomes of interest. We did not consider any of the studies to be at an overall low risk of bias for any of the outcomes analysed. We judged the certainty of the evidence as moderate to low due to imprecision and risk of bias. We found moderate-certainty evidence (due to imprecision) that for female patients there is likely a small but clinically important reduction in all-cause mortality at 30 days (odds ratio (OR) 0.81, 95% confidence interval (CI) 0.72 to 0.92; I2 = 0%; absolute risk difference (ARD) 24 fewer deaths in women per 1000 participants, 95% CI 35 to 10 fewer; 2 studies, 17,627 participants). However, the remaining review outcomes do not indicate lower mortality in female patients. There is low-certainty evidence (due to serious risk of bias and imprecision) indicating that for females with PE, there may be a small but clinically important increase in all-cause hospital mortality (OR 1.11, 95% CI 1.00 to 1.22; I2 = 21.7%; 95% prediction interval (PI) 0.76 to 1.61; ARD 13 more deaths in women per 1000 participants, 95% CI 0 to 26 more; 3 studies, 611,210 participants). There is also low-certainty evidence (due to very serious imprecision) indicating that there may be little to no difference between males and females in PE-related mortality at 30 days (OR 1.08, 95% CI 0.55 to 2.12; I2 = 0%; ARD 4 more deaths in women per 1000 participants, 95% CI 22 fewer to 50 more; 2 studies, 3524 participants). No study data was found for the other outcomes, including sex-specific mortality data at one year. Moreover, due to insufficient studies, many of our planned methods were not implemented. In particular, we were unable to conduct assessments of heterogeneity or publication bias or subgroup and sensitivity analyses.

AUTHORS' CONCLUSIONS

The evidence is uncertain about sex (being male or female) as an independent prognostic factor for predicting mortality in adults with PE. We found that, for female patients with PE, there is likely a small but clinically important reduction in all-cause mortality at 30 days relative to male patients. However, this result should be interpreted cautiously, as the remaining review outcomes do not point to an association between being female and having a lower risk of death. In fact, the evidence in the review also suggested that, in female patients, there may be a small but clinically important increase in all-cause hospital mortality. It also showed that there may be little to no difference in PE-related mortality at 30 days between male and female patients. There is currently no study evidence from longitudinal studies for our other review outcomes. Although the available evidence is conflicting and therefore cannot support a recommendation for or against routinely considering sex to quantify prognosis or to guide personalised therapeutic approaches for patients with PE, this Cochrane review offers information to guide future primary research and systematic reviews.

Neuroplasticity changes in cortical activity, grey matter, and white matter of stroke patients after upper extremity motor rehabilitation via a brain-computer interface therapy program

Objective. Upper extremity (UE) motor function loss is one of the most impactful consequences of stroke. Recently, brain-computer interface (BCI) systems have been utilized in therapy programs to enhance UE motor recovery after stroke, widely attributed to neuroplasticity mechanisms. However, the effect that the BCI's closed-loop feedback can have in these programs is unclear. The aim of this study was to quantitatively assess and compare the neuroplasticity effects elicited in stroke patients by a UE motor rehabilitation BCI therapy and by its sham-BCI counterpart.Approach. Twenty patients were randomly assigned to either the experimental group (EG), who controlled the BCI system via UE motor intention, or the control group (CG), who received random feedback. The elicited neuroplasticity effects were quantified using asymmetry metrics derived from electroencephalography (EEG), functional magnetic resonance imaging (fMRI), and diffusion tensor imaging (DTI) data acquired before, at the middle, and at the end of the intervention, alongside UE sensorimotor function evaluations. These asymmetry indexes compare the affected and unaffected hemispheres and are robust to lesion location variability.Main results. Most patients from the EG presented brain activity lateralisation to one brain hemisphere, as described by EEG (8 patients) and fMRI (6 patients) metrics. Conversely, the CG showed less pronounced lateralisations, presenting primarily bilateral activity patterns. DTI metrics showed increased white matter integrity in half of the EG patients' unaffected hemisphere, and in all but 2 CG patients' affected hemisphere. Individual patient analysis suggested that lesion location was relevant since functional and structural lateralisations occurred towards different hemispheres depending on stroke site.Significance. This study shows that a BCI intervention can elicit more pronounced neuroplasticity-related lateralisations than a sham-BCI therapy. These findings could serve as future biomarkers, helping to better select patients and increasing the impact that a BCI intervention can achieve. Clinical trial: NCT04724824.

Inflammation and platelet hyperresponsiveness in coronary artery disease and the influence of Talin-1/αIIbβ3-mediated bidirectional signaling pathway

Background

While platelet hyperreactivity constitutes an independent risk factor for major adverse cardiovascular events (MACEs) in coronary artery disease, its molecular underpinnings remain poorly characterized. Recent advances in transcriptomic profiling have revealed potential associations with specific RNA signatures. Through systematic bioinformatics analysis of differential gene expression patterns and pathway activation in CHD patients, this study aims to elucidate key molecular regulators of platelet hyperactivity, establishing a theoretical framework for developing precision therapeutic strategies to mitigate post-CHD complications.

Methods

This randomized controlled study included 16 CHD patients and 16 healthy controls. Inflammation markers, platelet aggregation function, and CD62p levels were assessed using flow cytometry. Mitochondrial morphology and organelles were observed using scanning electron microscopy and transmission electron microscopy. Genes related to symptom alteration between CHD patients and healthy controls were identified using the criteria of p < 0.05. The molecular correlations of these genes were analyzed using a comprehensive perspective that included Gene Ontology (GO) biological process and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses. Western blot and correlation analyses were also conducted to validate the expression and diagnostic value of the DEGs.

Results

CHD patients exhibited alterations in platelet organelles ultrastructure, heightened platelet activation and aggregation, and disturbance of the inflammatory equilibrium. RNA sequencing demonstrated distinct changes in the gene expression profiles of circulating platelets from CHD patients. The increase in platelet activation and aggregation could be partially associated with the upregulation of the Talin-1 and αIIbβ3 proteins expression.

Conclusion

Abnormal transcription and platelet activation occur after CHD onset, and upregulation of the Talin-1/αIIbβ3-mediated bidirectional signaling pathway are the primary pathological features.

Clinical Trial Registration

https://www.chictr.org.cn/, identifier ChiCTR2100041998.

Cold and hot fibrosis define clinically distinct cardiac pathologies

Fibrosis remains a major unmet medical need. Simplifying principles are needed to better understand fibrosis and to yield new therapeutic approaches. Fibrosis is driven by myofibroblasts that interact with macrophages. A mathematical cell-circuit model predicts two types of fibrosis: hot fibrosis driven by macrophages and myofibroblasts and cold fibrosis driven by myofibroblasts alone. Testing these concepts in cardiac fibrosis resulting from myocardial infarction (MI) and heart failure (HF), we revealed that acute MI leads to cold fibrosis whereas chronic injury (HF) leads to hot fibrosis. MI-driven cold fibrosis is conserved in pigs and humans. We computationally identified a vulnerability of cold fibrosis: the myofibroblast autocrine growth factor loop. Inhibiting this loop by targeting TIMP1 with neutralizing antibodies reduced myofibroblast proliferation and fibrosis post-MI in mice. Our study demonstrates the utility of the concepts of hot and cold fibrosis and the feasibility of a circuit-to-target approach to pinpoint a treatment strategy that reduces fibrosis. A record of this paper's transparent peer review process is included in the supplemental information.

T Cell-Targeting Nanotherapies for Atherosclerosis

Cardiovascular diseases remain the leading cause of mortality worldwide. Specifically, atherosclerosis is a primary cause of acute cardiac events. However, current therapies mainly focus on lipid-lowering versus addressing the underlying inflammatory response that leads to its development and progression. Nanoparticle-mediated drug delivery offers a promising approach for targeting and regulating these inflammatory responses. In atherosclerotic lesions, inflammatory cascades result in increased T helper (Th) 1 and Th17 activity and reduced T regulatory activation. The regulation of T cell responses is critical in preventing the inflammatory imbalance in atherosclerosis, making them a key therapeutic target for nanotherapy to achieve precise atherosclerosis treatment. By functionalizing nanoparticles with targeting modalities, therapeutic agents can be delivered specifically to immune cells in atherosclerotic lesions. In this Review, we outline the role of T cells in atherosclerosis, examine current nanotherapeutic strategies for targeting T cells and modulating their differentiation, and provide perspectives for the development of nanoparticles specifically tailored to target T cells for the treatment of atherosclerosis.

Modulating biomechanical and integrating biochemical cues to foster adaptive remodeling of tissue engineered matrices for cardiovascular implants

Cardiovascular disease remains one of the leading causes of mortality in the Western world. Congenital heart disease affects nearly 1 % of newborns, with approximately one-fourth requiring reconstructive surgery during their lifetime. Current cardiovascular replacement options have significant limitations. Their inability to grow poses particular challenges for pediatric patients. Tissue Engineered Matrix (TEM)-based in situ constructs, with their self-repair and growth potential, offer a promising solution to overcome the limitations of current clinically used replacement options. Various functionalization strategies, involving the integration of biomechanical or biochemical components to enhance biocompatibility, have been developed for Tissue Engineered Vascular Grafts (TEVG) and Tissue Engineered Heart Valves (TEHV) to foster their capacity for in vivo remodeling. In this review, we present the current state of clinical translation for TEVG and TEHV, and provide a comprehensive overview of biomechanical and biochemical functionalization strategies for TEVG and TEHV. We discuss the rationale for functionalization, the implementation of functionalization cues in TEM-based TEVG and TEHV, and the interrelatedness of biomechanical and biochemical cues in the in vivo response. Finally, we address the challenges associated with functionalization and discuss how interdisciplinary research, especially when combined with in silico models, could enhance the translation of these strategies into clinical applications. STATEMENT OF SIGNIFICANCE: Cardiovascular disease remains one of the leading causes of mortality, with current replacements being unable to grow and regenerate. In this review, we present the current state of clinical translation for tissue engineered vascular grafts (TEVG) and heart valves (TEHV). Particularly, we discuss the rationale and implementation for functionalization cues in tissue engineered matrix-based TEVGs and TEHVs, and for the first time we introduce the interrelatedness of biomechanical and biochemical cues in the in-vivo response. These insights pave the way for next-generation cardiovascular implants that promise better durability, biocompatibility, and growth potential. Finally, we address the challenges associated with functionalization and discuss how interdisciplinary research, especially when combined with in silico models, could enhance the translation of these strategies into clinical applications .

Reduced Risk of Cardiovascular Diseases After Bariatric Surgery Based on the New Predicting Risk of Cardiovascular Disease EVENTs Equations

BACKGROUND

We applied the novel Predicting Risk of Cardiovascular Disease EVENTs equations to evaluate cardiovascular-kidney-metabolic (CKM) health and estimated cardiovascular disease (CVD) risk after bariatric surgery.

METHODS

Among 7804 patients (aged 20-79 years) undergoing bariatric surgery at Vanderbilt University Medical Center during 1999 to 2022, CVD risk factors from before surgery to 2 years after surgery were extracted from electronic health records. The 10- and 30-year risks of total CVD, atherosclerotic CVD, coronary heart disease, stroke, and heart failure (HF) were estimated for patients without CVD history at each time point (n=124-2910), using the social deprivation index-enhanced Predicting Risk of Cardiovascular Disease EVENTs equations. Paired t tests or McNemar tests were used to compare pre- with postsurgery CKM health and CVD risk. Two-sample t tests were used to compare CVD risk reduction between patient subgroups.

RESULTS

CKM health was significantly improved after surgery with lower systolic blood pressure, non-high-density lipoprotein cholesterol, and diabetes prevalence, and higher high-density lipoprotein and estimated glomerular filtration rate. The 10-year risks of total CVD and its subtypes decreased by 21.7% to 56.3% at 1 year after surgery and by 14.6% to 46.5% at 2 years after surgery, with the largest reduction observed for HF. Younger age, White race, >30% weight loss, and diabetes history were associated with greater HF risk reductions. Similar results were found for the 30-year CVD risk estimates.

CONCLUSIONS

Bariatric surgery significantly improves CKM health and reduces estimated CVD risk, particularly HF, by 47% to 56% within 1 to 2 years after surgery. HF risk reduction may vary by patient's demographics, weight loss, and disease history, which warrants further research.

Do CRP gene variants and smoking elevate recurrent stroke risk in minor ischemic stroke patients?

BACKGROUND

Minor ischemic strokes, despite their initial mild symptoms, pose a significant risk of recurrence, potentially leading to severe disability. The role of C-reactive protein (CRP) gene variants in predicting the recurrent minor stroke, particularly their interaction with lifestyle factors such as smoking, remains unclear. We aimed to investigate the relationship of single-nucleotide polymorphisms (SNPs) in CRP gene with minor stroke recurrence, focusing on gene-environment interactions.

METHODS

A retrospective cohort study was conducted using data from the stroke registry at Linfen People's Hospital, including 2032 first-time minor stroke patients (NIHSS score ≤ 5) admitted within 7 days of symptom onset from January 2019 to December 2022. Follow-up assessments were conducted every 3 months for one year. Based on recurrence during follow-up, participants were classified into Recurrence and Non-recurrence group. Genomic DNA was extracted for genotyping four CRP gene SNPs: rs1130864, rs1800947, rs2808632, and rs3093059. Genetic associations with the stroke recurrence were analyzed using additive, dominant, recessive genetic and allelic models. Generalized Multifactor Dimensionality Reduction (GMDR) was employed to explore the complex interaction of these SNPs with smoking status. Multivariate logistic regression was used to estimate the strength of these associations.

RESULTS

Our study recruited 261 participants who experienced recurrent minor strokes and 264 age- and sex-matched controls without recurrence. The A allele of rs2808632 (P = 0.002) and C allele of rs3093059 (P = 0.001) were significantly associated with an increased risk of stroke recurrence. Participants with the combined genotypes rs2808632 CA + AA and rs3093059 TC + CC had a 1.325-fold higher risk of recurrence when compared to those with the genotypes rs2808632 CC and rs3093059 TT (P = 0.003). Additionally, among smokers, the rs3093059 TC + CC genotypes were associated with a 2.467-fold increased risk of recurrence compared to non-smokers with TT genotype (P < 0.001).

CONCLUSION

The rs2808632 and rs3093059 polymorphisms independently and interactively contribute to an increased risk of recurrent minor stroke. Furthermore, the interaction between rs3093059 SNP and smoking status significantly influenced stroke recurrence, highlighting the importance of considering both genetic and environmental factors in predicting the risk of minor stroke recurrence.

Cardiac preservation using ex vivo organ perfusion: new therapies for the treatment of heart failure by harnessing the power of growth factors using BMP mimetics like THR-184

As heart transplantation continues to be the gold standard therapy for end-stage heart failure, the imbalance between the supply of hearts, and the demand for them, continues to get worse. In the US alone, with less than 4,000 hearts suitable for transplant and over 100,000 potential recipients, this therapy is only available to a very few. The use of hearts Donated after Circulatory Death (DCD) and Donation after Brain Death (DBD) using ex vivo machine perfusion (EVMP) is a promising approach that has already increased the availability of suitable organs for heart transplantation. EVMP offers the promise of enabling the expansion of the overall number of heart transplants and lower rates of early graft dysfunction. These are realized through (1) safe extension of the time between procurement and transplantation and (2) ex vivo assessment of preserved hearts. Notably, ex vivo perfusion has facilitated the donation of DCD hearts and improved the success of transplantation. Nevertheless, DCD hearts suffer from serious preharvest ischemia/reperfusion injury (IRI). Despite these developments, only 40% of hearts offered for transplantation can be utilized. These devices do offer an opportunity to evaluate donor hearts for transplantation, resuscitate organs previously deemed unsuitable for transplantation, and provide a platform for the development of novel therapeutics to limit cardiac injury. Bone Morphogenetic Protein (BMP) signaling is a new target which holds the potential for ameliorating myocardial IRI. Recent studies have demonstrated that BMP signaling has a significant role in blocking the deleterious effects of injury to the heart. We have designed novel small peptide BMP mimetics that act via activin receptor-like kinase (ALK3), a type I BMP receptor. They are capable of (1) inhibiting inflammation and apoptosis, (2) blocking/reversing the epithelial-mesenchymal transition (EMT) and fibrosis, and (3) promoting tissue regeneration. In this review, we explore the promise that novel therapeutics, including these BMP mimetics, offer for the protection of hearts against myocardial injury during ex vivo transportation for cardiac transplantation. This protection represents a significant advance and a promising ex vivo therapeutic approach to expanding the donor pool by increasing the number of transplantable hearts.

Mental Health Factors and Lifestyle Adherence After Myocardial Infarction: An Integrative Review

BACKGROUND

Engaging in healthy lifestyle behaviors following myocardial infarction can improve clinical health outcomes and lower cardiovascular risk factors among patients. However, adhering to a healthy lifestyle after having a myocardial infarction can be challenging, especially for those experiencing poor mental health.

OBJECTIVE

Based on a conceptual model derived from Lazarus and Folkman's Theory of Stress and Coping and the Health Belief Model, this integrative review focuses on mental health factors associated with adherence to healthy lifestyle behaviors post-myocardial infarction.

METHODS

Whittemore and Knafl's integrative review method was used to search and select relevant literature from the EMBASE, PubMed, CINAHL, Scopus, and PsycINFO databases between 2013 and 2023.

RESULTS

A total of 35 articles were included in the review. Based on the Johns Hopkins Nursing Evidence-Based Practice Model criteria, 34 studies were of good quality (B). Mental health factors related to healthy lifestyle behaviors after myocardial infarction included the following: (1) personality factors and coping (eg, neuroticism, agreeableness, and optimism); (2) psychological symptoms (i.e., depression, anxiety, and fear); (3) appraisal (ie, illness perception); (4) health beliefs (ie, susceptibility, severity, benefits, barriers, cues to action, and self-efficacy); and (5) motivation. Social support and demographic characteristics were also related to adherence to healthy lifestyle behaviors.

CONCLUSIONS

This review highlights the role of mental health factors in adhering to healthy lifestyle behaviors among persons with myocardial infarction. Comprehensive theoretically based approaches are needed to develop future interventions for promoting healthy lifestyle behaviors in individuals post-myocardial infarction.

Gestational Blood Pressure Trajectories and 5-Year Postpartum Hypertension Risk in the MADRES Study

BACKGROUND

Blood pressure (BP) changes during pregnancy, but less is known about heterogeneous changing patterns within a population and long-term hypertension risk.

OBJECTIVES

The purpose of this study was to identify distinct gestational systolic blood pressure (SBP) trajectories and examine their association with postpartum hypertension risk.

METHODS

The MADRES (Maternal and Developmental Risks from Environmental and Social Stressors) (2015-present) cohort followed 854 pregnant individuals from early pregnancy to 5 years postpartum and collected information on demographics, lifestyle, and medical records, including BP at each prenatal visit. Latent class growth modeling was used to identify gestational SBP trajectories. Incident postpartum hypertension was identified from interviews and BP measurements. Cox modeling was used to assess the association of trajectory groups with the risk of hypertension at 2 to 5 years postpartum.

RESULTS

We identified 3 distinct gestational SBP trajectory groups. The majority (n = 685, 80.2%) had a "consistently low" trajectory over pregnancy. A "consistently elevated" trajectory group (n = 106, 12.4%) was characterized by modestly elevated SBP within a clinically normal range but lacked a midpregnancy dip. A "high-drop-high" trajectory group (n = 63, 7.4%) consisted of most cases of gestational hypertension or pre-eclampsia. Risk of hypertension in 5 years postpartum was 4.91 (95% CI: 2.01-12.0) fold higher in the "consistently elevated" group and 5.44 (95% CI: 1.89-15.7) fold higher in the "high-drop-high" group than the "consistently low" group, after adjusting for covariates.

CONCLUSIONS

Pregnant individuals with consistently elevated SBP yet within the subclinical range face longer-term risk of hypertension but may not be captured by standard prenatal clinical guidelines.

Neural repair mechanisms after ischemic stroke

Ischemic stroke triggers inflammation that promotes neuronal injury, leading to disruption of neural circuits and exacerbated neurological deficits in patients. Immune cells contribute to not only the acute inflammatory responses but also the chronic neural repair. During the post-stroke recovery, reparative immune cells support the neural circuit reorganization that occurs around the infarct region to connect broad brain areas. This review highlights the time-dependent changes of neuro-immune interactions and reorganization of neural circuits after ischemic brain injury. Understanding the molecular mechanisms involving immune cells in acute inflammation, subsequent neural repair, and neuronal circuit reorganization that compensate for the lost brain function is indispensable to establish treatment strategies for stroke patients.

Beyond Cholesterol: Unraveling Residual Lipidomic Risk in Cardiovascular Health

PURPOSE OF REVIEW

This paper reviews the existing literature on lipidomics as a tool for improved cardiovascular risk estimation in both primary and secondary prevention populations.

RECENT FINDINGS

Detailed lipidomic signatures identified by mass spectrometry have been shown to enhance risk estimation for clinical CAD and the presence of subclinical CAD on CTCA in multiple large cohort populations. In patients with established atherosclerotic disease, ceramide and phospholipid-based risk scores improve prediction for recurrent cardiovascular events and cardiovascular death. Lipidomic profiles and lipidomic-enhanced risk scores have been shown to improve prediction of incident cardiovascular disease, recurrent cardiovascular events and cardiovascular death independent of traditional risk factors. Simplified risk scores utilizing the ratios of several ceramide species improve clinical utility, however resources and infrastructure limit widespread implementation. There are currently no therapeutics to address lipidomic risk aside from traditional risk factor modification.

Advancement of the implementation of evidence-based therapies for cardiovascular-kidney-metabolic conditions: A multi-stakeholder perspective

Cardiovascular disease remains the leading cause of mortality and healthcare expenditures in the United States. It is also a major contributor to premature mortality, years lived with disability, and rising healthcare costs around the world. Despite the availability of proven therapies and interventions that could vastly decrease the burden of cardiovascular disease and cardiometabolic conditions, their implementation is poor, with generally less than half of patients being treated with the most effective therapies. Implementation science offers promise in bridging this gap and mitigating disparities. However, even though small studies have shown that there are effective methods to improve the implementation of evidence-based therapies, these methods have not been scaled to make an impact at the level of health systems or nationally. A coordinated, multi-stakeholder approach is essential to identify barriers to implementation on a broad scale and, more critically, to develop and deploy practical solutions. The Duke Clinical Research Institute conducted an Implementation Summit entitled "Scalability, Spread, and Sustainability" to explore strategies for advancing the uptake of evidence-based interventions for cardiometabolic diseases in healthcare in the United States. This manuscript presents the participants' multi-stakeholder perspective on the steps necessary to improve the implementation of evidence-based therapies in cardiometabolic disease. Key recommendations include focused efforts on evidence generation around broad implementation strategies, dissemination of the evidence generated, uptake of evidence into usual care settings, and investment in training the current and next generations of leaders in implementation.

Nonlinear association between hemoglobin glycation index and mortality in ischemic stroke Patients: Insights from the MIMIC-IV database

AIMS

Hemoglobin glycation index (HGI) is closely associated with adverse outcomes in several diseases. However, few studies have investigated the correlation between HGI and prognosis in patients with critical ischemic stroke.

METHODS

A cohort of patients was established from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Kaplan-Meier analysis, multivariate regression models, and restricted cubic splines (RCS) were used to investigate the associations between HGI and different outcomes. Mediation models were constructed to determine the mediating role of white blood cell (WBC) counts.

RESULTS

This study included 2,332 participants. In-hospital mortality differs significantly across HGI groups (24.43 %, 11.82 %, and 10.14 %, P < 0.001). Multivariate regression analyses found that lower HGI was significantly associated with greater mortality risk. Nonlinear analyses revealed an L-shaped association between HGI and short-term mortality (30-day and in-hospital), while a reverse J-shaped relationship emerged for long-term (365-day) mortality. Mediation analysis revealed that WBC counts mediated the association with proportions (%) of 33.73, 19.65, and 30.00, respectively.

CONCLUSION

Lower HGI is consistently related to poorer outcomes in patients with critical ischemic stroke. Higher HGI could be a protective factor in the short term but might increase mortality risk in the long term. WBC counts significantly mediate the association.

Metabolite profiling of Shenhua compound in rats and pharmacokinetics study of four bioactive compounds with liquid chromatography combined with electrospray ionization tandem mass spectrometry

Shenhua compound, composed of ginseng, hawthorn and sophora flower, has been shown to improve hyperlipidemia. However, the main ingredients, their metabolic pathways in vivo, and pharmacokinetic characteristics. In this study, ultra-high-performance liquid chromatography coupled with electrospray ionization quadruple time-of-flight mass spectrometry (UHPLC-Q-TOF) was used to qualitatively analyze the main ingredients in ethanol extract of Shenhua compound and to investigate the metabolites in serum, bile, feces, and urine of rats following oral administration. The pharmacokinetics of ginsenoside Rg1, ginsenoside Re, ginsenoside Ro and rutin in rats were analyzed using triple-quadrupole liquid chromatography combined with electrospray ionization mass spectrometry (QQQ-LC/MS). The results indicated that 48 compounds were present in Shenhua compound, including saponins, flavonoids and organic acids. Metabolites were comprehensively analyzed after oral administration of Shenhua compound, and 24 prototype ingredients and 92 metabolite ingredients were identified or characterized. By analyzing the pharmacokinetic parameters of ginsenoside Rg1, ginsenoside Re, ginsenoside Ro and rutin from 0 to 72 h after oral administration of various dose of Shenhua compound, it was observed that the concentration of ginsenosides in blood remained below 2 ng∙mL1, but the metabolic excretion time was prolonged. Meanwhile, the blood concentration of rutin was significantly higher than ginsenosides and showed a double absorption peak. In conclusion, this study provides valuable insights into compound ingredients metabolism regularities in vivo and pharmacokinetics after oral administration of Shenhua compound.

Hospitalizations during the 30-day period preceding admissions with ST-elevation myocardial infarction: Insights from the Nationwide Readmission Database (NRD)

INTRODUCTION

The extent and associated reasons or characteristics related to patients presenting to hospital prior with ST-elevation myocardial infarction (STEMI) are unknown.

METHODS

This retrospective cohort study analyzed the Nationwide Readmission Database from 2018 to 2020 to evaluate hospitalizations within 30 days preceding a hospitalization with the diagnosis of STEMI in order to determine how often this occurs and what are the causes and factors associated with the recent admission.

RESULTS

There were 1,355,765 hospital admissions with a diagnosis of STEMI and 54,545 (4.0 %) were hospitalized within 30-days prior to STEMI event. The most common causes of preceding hospitalization were sepsis, chronic ischemic heart disease, hypertensive disease with chronic kidney disease, complications of cardiac or vascular prosthetic devices, and implants/grafts, hypertensive heart disease with heart failure, and cerebral infarction. Independent factors associated with hospitalization within 30-days preceding STEMI, were cancer (OR 3.44 95 %CI 3.23-3.67, p < 0.001), elective admission (OR 2.76 95 %CI 2.59-2.95, p < 0.001), chronic kidney disease (OR 1.93 95 %CI 1.84-2.02, p < 0.001), chronic lung disease (OR 1.65 95 %CI 1.58-1.73, p < 0.001), previous stroke (OR 1.46 95 %CI 1.38-1.73, p < 0.001), and previous myocardial infarction (OR 1.45 95 %CI 1.37-1.53, p < 0.001).

CONCLUSIONS

Among the 4.0 % of patients were admitted to hospital within 30-days prior to a later admission for STEMI, predictors of such admissions were sepsis, chronic ischemic heart disease and hypertension and cancer. This raises potential opportunities to prevent future admissions with STEMI once such patients are hospitalized.

Intratracheal Delivery of a Phospholamban Decoy Peptide Attenuates Cardiac Damage Following Myocardial Infarction

Heart failure (HF) remains a major cause of mortality worldwide. While novel approaches, including gene and cell therapies, show promise, efficient delivery methods for such biologics to the heart are critically needed. One emerging strategy is lung-to-heart delivery using nanoparticle (NP)-encapsulated biologics. This study examines the efficiency of delivering a therapeutic peptide conjugated to a cell-penetrating peptide (CPP) to the heart via the lung-to-heart route through intratracheal (IT) injection in mice. The CPP, a tandem repeat of NP2 (dNP2) derived from the human novel LZAP-binding protein (NLBP), facilitates intracellular delivery of the therapeutic payload. The therapeutic peptide, SE, is a decoy peptide designed to inhibit protein phosphatase 1 (PP1)-mediated dephosphorylation of phospholamban (PLN). Our results demonstrated that IT injection of dNP2-SE facilitated efficient delivery to the heart, with peak accumulation at 3 h post-injection. The administration of dNP2-SE significantly ameliorated morphological and functional deterioration of the heart under myocardial infarction. At the molecular level, dNP2-SE effectively prevented PLN dephosphorylation in the heart. Immunoprecipitation experiments further revealed that dNP2-SE binds strongly to PP1 and disrupts its interaction with PLN. Collectively, our findings suggest that lung-to-heart delivery of a CPP-conjugated therapeutic peptide, dNP2-SE, represents a promising approach for the treatment of HF.

Sex Hormones and Heart Failure Risk

Heart failure (HF) is a significant cause of morbidity and mortality. Although there are inconsistencies, epidemiological studies have implicated sex hormones (SHs) in pathways that are linked to HF. The age-related decline in SH levels causes physiological changes that differentially impact HF risk in both sexes. Conversely, SHs are tightly regulated by complex feedback loops that become disrupted in chronic HF to create a vicious cycle that further worsens the HF syndrome. By altering the androgenic balance, SHs exert variable effects that could impact HF risk in men and women. Further studies are needed to clarify whether measurement of SH levels can identify future HF patients for early intervention, as well as HF patients who may benefit from more intensive treatments.

Trends in cardiac arrest care and mortality in United States emergency departments over eight years

INTRODUCTION

Cardiac arrest in the emergency department (ED) is a rare event. Prior studies have used dedicated cardiac arrest registries, but few have leveraged "big data" from electronic healthcare vendors to analyze trends in the care of patients excluded from registries.

METHODS

This was a retrospective cohort study of adult patients in the ED with cardiac arrest from Epic Cosmos, a database with 277 million patients. Patients with ICD-10 codes corresponding to cardiac arrest in the ED were included. Outcomes included the incidence of cardiac arrest, mortality, code length, and extracorporeal membrane oxygenation (ECMO). Data were compared using odds ratio with 95 % confidence intervals (CI).

RESULTS

Among 196,834,283 ED visits from 1/1/2016 to 12/31/2023, there were 429,917 (0.22 %) cardiac arrests and 197,233 (45.88 %) patients who died in the ED. The incidence of cardiac arrest (0.26 %) and death in the ED (55.70 %) peaked in 2020. Cardiac arrest was more common in male and older patients, between 00:00-05:59, on weekends, and in the South (p < 0.001). The median code length was 10-20 min. Only 0.29 % of cardiac arrest patients received ECMO. Compared to 2016, the odds of a code length > 90 min and ECMO in 2023 were 1.43 (95 % CI 1.32-1.54) and 3.58 (95 % CI 2.41-5.31) times greater, respectively.

CONCLUSION

Although cardiac arrest in the ED is a rare event, almost half of patients die in the ED. The use of ECMO after cardiac arrest is increasing but remains low. Further research is needed to mitigate these differences in care.

Role of coronary artery calcification detection in tailoring patient care, personalized risk assessment, and prevention of future cardiac events

PURPOSE OF REVIEW

We review the utility of coronary artery calcium (CAC) scoring in personalized risk assessment and initiation of cardiovascular disease risk modifying therapy.

RECENT FINDINGS

Many populations - including South Asians, patients with cancer, patients with human immunodeficiency virus (HIV), younger patients, and elderly patients - were not included during the conception of the current risk stratification tools. CAC scoring may allow clinicians to risk-stratify these individuals and help initiate preventive therapy in higher risk populations. Furthermore, CAC scoring may be able to be integrated into current imaging practices to allow for more ubiquitous and equitable screening practices.

SUMMARY

CAC scoring is an additional, objective metric that may allow for nuanced and personalized risk assessment of future atherosclerotic cardiovascular disease (ASCVD) events.

Prevention and Management of Thromboembolism in Patients with Paroxysmal Nocturnal Hemoglobinuria in Asia: A Narrative Review

Thromboembolism (TE) is a major cause of morbidity and mortality in patients with paroxysmal nocturnal hemoglobinuria (PNH). This narrative review summarizes available evidence on TE in Asian patients with PNH and discusses practical considerations and challenges for preventing and managing PNH-associated TE in Asian populations. Evidence suggests that, compared with non-Asians, fewer Asian patients have a history of TE (3.6% vs. 8.9%, p < 0.01), receive anticoagulants (8.5% vs. 16.2%, p = 0.002), or die from TE (6.9% vs. 43.7%, p = 0.000). Independent predictors of TE include lactate dehydrogenase ≥ 1.5 × upper limit of normal, pain, and male sex. Clone size alone does not appear to be a reliable estimate of TE risk. D-dimer levels are a useful marker of hemostatic activation, although they are not specific to PNH. Complement inhibition reduces the incidence of TE, although it does not wholly eliminate TE risk. Eligibility criteria and access to complement inhibitors vary across Asia, with limited availability in some countries. Anticoagulation is required to treat acute TE events and for primary or secondary prophylaxis in selected patients. Physicians and patients must stay alert to the signs and symptoms of TE to ensure prompt and appropriate treatment.