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

Prognostic value of the Naples Prognostic Score in adult chronic obstructive pulmonary disease: NHANES 2005-2018

Background

Previous studies have demonstrated that the Naples Prognostic Score (NPS) provides strategic direction in the prognosis of malignant illness. Nevertheless, its relationship with chronic obstructive pulmonary disease (COPD) remains underexplored. Therefore, additional research specifically focusing on the relationship between the Naples Prognostic Score and COPD is necessary to determine its widespread applicability.

Objectives

The objective was to explore the relationship between the NPS and the susceptibility to developing COPD.

Methods

A total of 15,184 participants were included in our research, and statistical analyses were performed after weighting. We used weighted logistic regression to assess whether the NPS and COPD had a relationship, as well as its association with lung function. Subgroup analysis was used to detect the interaction. In addition, Kaplan-Meier survival curves were generated, and adjusted hazard ratios of different causes of death were calculated using Cox regression.

Results

Our investigation examined 15,184 participants' data and then revealed a significant positive link between the NPS and COPD risk, while smoking has an interactive effect on it. A trend toward a decreasing prevalence of lung function indicators such as FEV1 [OR (95%CI), -339.70 (-456.53, -222.87)], FVC [OR (95%CI), -296.70 (-435.34, -158.06)], FEV1/FVC [OR (95%CI), -0.03 (-0.04, -0.02)], predicted FEV1 [OR (95%CI), -0.09 (-0.14, -0.04)], and predicted FVC [OR (95%CI), -0.08 (-0.15, -0.01)] was observed with increased NPS levels. Survival curves were drawn, and Cox regression analysis was conducted by dividing participants into group 0, group 1, and group 2 with NPS values of 0, 1-2, and 3-4, respectively. After assigning participants to groups 0, 1, and 2, with NPS values of 0, 1-2, and 3-4, respectively, the survival curves were created, and the Cox regression analysis was carried out. All-cause mortality [HR (95%CI), 1.68 (1.39-2.85)] and hypertension-related mortality [HR (95%CI), 67.64 (8.88-515.07)] of group 2 were significantly elevated.

Conclusion

The findings of this study suggested that the NPS serves as a robust prognostic indicator of COPD.

Agreement Between Office-Based and Laboratory-Based Globorisk Models and their Prediction of Cardiovascular Diseases in Turkish Population: A Nationwide Cohort Study

Globorisk is a country-specific risk prediction model that estimates 10-year cardiovascular disease (CVD) risk. This study aims to evaluate the agreement between different versions of Globorisk and their ability to predict CVD in a nationwide Turkish cohort. Baseline data from 5449 participants aged 40-74 were obtained from Türkiye Chronic Diseases and Risk Factors Survey 2011. Office- and laboratory-based Globorisk risk scores were calculated using age, gender, systolic blood pressure (SBP), current smoking status, body mass index (BMI), diabetes, and total cholesterol levels. Correlation and Bland-Altman analysis were employed to assess the agreement between 10-year risk scores. Multivariable logistic regression models were estimated with Globorisk variables to predict the presence of CVD over a 6-year follow-up period. Model calibration was performed. The study identified 515 incident CVD cases during the 6-year follow-up period. There was a strong positive correlation between 10-year Globorisk versions (r = 0.89). The limit of the agreement was narrower in males (- 6.11 to 6.89%) compared to females (- 7.01 to 7.73%). Age and systolic blood pressure were associated with 6-year CVD in both office- and laboratory-based models. The models showed similar discriminative performance (AUC: 0.68) and predictive accuracy (mean absolute error: 0.009) for 6-year CVD. Both Globorisk models were strongly correlated, had similar discrimination power and predictive accuracy. The office-based Globorisk can be used instead of the laboratory-based model, especially where resources are limited.

The effects of high-intensity interval training and moderate-intensity continuous training on patients underwent Coronary Artery Bypass Graft surgery; a systematic review

OBJECTIVES

To our knowledge, there is no clear consensus on a definitive cardiac rehabilitation method for patients undergoing Coronary Artery Bypass Graft (CABG). We conducted this systematic review to compare and evaluate the effects of two of the most frequent cardiac rehabilitation modalities, high-intensity interval training (HIIT) and moderate-intensity continuous training (MICT), on cardiopulmonary variables.

METHODS

We carried out a systematic search of the databases PubMed, Web of Science, Embase, Scopus, and Google Scholar. Following the removal of duplicate results, the original search yielded 385 citations. We identified four randomized clinical trials after reviewing titles, abstracts, and potential full-text studies. We utilized the Cochrane Risk of Bias Tool (RoB2) to assess the risk of bias.

RESULTS

We included four randomized clinical trials involving 143 people. All trials included individuals who had CABG and completed HIIT or MICT sessions for at least four weeks. The findings indicated that HIIT programs may improve functional capacity, heart rate variability indices, and blood pressure management while lowering brain natriuretic peptide (BNP1-32) and N-terminal pro-b-type natriuretic peptide (NT-proBNP1-76) levels.

CONCLUSION

Given the findings, it appeared that supervised high-intensity exercise regimens could be more useful to patients. Following the surgery, HIIT therapy improves exercise capacity, the autonomic nervous system, volume overload, and blood pressure regulation.

Evaluation of clonal hematopoiesis and mosaic loss of Y chromosome in cardiovascular risk: An analysis in prospective studies

Background

Clonal hematopoiesis of indeterminate potential (CHIP) was initially linked to a twofold increase in atherothrombotic events. However, recent investigations have revealed a more nuanced picture, suggesting that CHIP may confer only a modest rise in myocardial infarction (MI) risk. This observed lower risk might be influenced by yet unidentified factors that modulate the pathological effects of CHIP. Mosaic loss of the Y chromosome (mLOY), a common marker of clonal hematopoiesis in men, has emerged as a potential candidate for modulating cardiovascular risk associated with CHIP. In this study, we aimed to ascertain the risk linked to each somatic mutation or mLOY and explore whether mLOY could exert an influence on the cardiovascular risk associated with CHIP.

Methods

We conducted an examination for the presence of CHIP and mLOY using targeted high-throughput sequencing and digital PCR in a cohort of 446 individuals. Among them, 149 patients from the CHAth study had experienced a first MI at the time of inclusion (MI(+) subjects), while 297 individuals from the Three-City cohort had no history of cardiovascular events (CVE) at the time of inclusion (MI(-) subjects). All subjects underwent thorough cardiovascular phenotyping, including a direct assessment of atherosclerotic burden. Our investigation aimed to determine whether mLOY could modulate inflammation, atherosclerosis burden, and atherothrombotic risk associated with CHIP.

Results

CHIP and mLOY were detected with a substantial prevalence (45.1% and 37.7%, respectively), and their occurrence was similar between MI(+) and MI(-) subjects. Notably, nearly 40% of CHIP(+) male subjects also exhibited mLOY. Interestingly, neither CHIP nor mLOY independently resulted in significant increases in plasma hs-CRP levels, atherosclerotic burden, or MI incidence. Moreover, mLOY did not amplify or diminish inflammation, atherosclerosis, or MI incidence among CHIP(+) male subjects. Conversely, in MI(-) male subjects, CHIP heightened the risk of MI over a 5 y period, particularly in those lacking mLOY.

Conclusions

Our study highlights the high prevalence of CHIP and mLOY in elderly individuals. Importantly, our results demonstrate that neither CHIP nor mLOY in isolation substantially contributes to inflammation, atherosclerosis, or MI incidence. Furthermore, we find that mLOY does not exert a significant influence on the modulation of inflammation, atherosclerosis burden, or atherothrombotic risk associated with CHIP. However, CHIP may accelerate the occurrence of MI, especially when unaccompanied by mLOY. These findings underscore the complexity of the interplay between CHIP, mLOY, and cardiovascular risk, suggesting that large-scale studies with thousands more patients may be necessary to elucidate subtle correlations.

Funding

This study was supported by the Fondation Cœur & Recherche (the Société Française de Cardiologie), the Fédération Française de Cardiologie, ERA-CVD (« CHEMICAL » consortium, JTC 2019) and the Fondation Université de Bordeaux. The laboratory of Hematology of the University Hospital of Bordeaux benefitted of a convention with the Nouvelle Aquitaine Region (2018-1R30113-8473520) for the acquisition of the Nextseq 550Dx sequencer used in this study.

Clinical trial number

NCT04581057.

Ferroptosis in Cardiovascular Diseases and Ferroptosis-Related Intervention Approaches

OBJECTIVE

Cardiovascular diseases (CVDs) are major public health problems that threaten the lives and health of individuals. The article has reviewed recent progresses about ferroptosis and ferroptosis-related intervention approaches for the treatment of CVDs and provided more references and strategies for targeting ferroptosis to prevent and treat CVDs.

METHODS

A comprehensive review was conducted using the literature researches.

RESULTS AND DISCUSSION

Many ferroptosis-targeted compounds and ferroptosis-related genes may be prospective targets for treating CVDs and our review provides a solid foundation for further studies about the detailed pathological mechanisms of CVDs.

CONCLUSION

There are challenges and limitations about the translation of ferroptosis-targeted potential therapies from experimental research to clinical practice. It warrants further exploration to pursure safer and more effective ferroptosis-targeted thereapeutic approaches for CVDs.

Association of Lactate with Risk of Cardiovascular Diseases: A Two-Sample Mendelian Randomization Study

Purpose

Studies consistently show abnormally high levels of lactate acid in cardiovascular disease patients, suggested that targeting lactate production may serve as potential strategies for the treatment in the future. However, observational results may be subject to residual confounding and bias.

Methods

This study used the dataset from GWAS database to examine confounding in epidemiologic associations between lactate and cardiovascular diseases. A genome-wide genetic association study using Mendelian randomization (MR) was performed from December 02, 2023 to January 15, 2024 to reduce confounding and enhance causal inference. Primary analysis was conducted using inverse-variance-weighted MR. All studies included patients predominantly of European ancestry.

Results

The association between lactate and cardiovascular diseases, including 60801 cases from coronary heart disease, 7018 cases from myocardial infarction, 14334 cases from coronary atherosclerosis, 60620 cases from atrial fibrillation, 54358 cases from hypertension, 71 cases from hypertrophic cardiomyopathy, 47309 cases from heart failure, 7055 cases from stroke, 7193 cases from cardioembolic ischemic stroke, 4373 cases from ischemic stroke caused by large vascular atherosclerosis, 2118 cases from pulmonary embolism, 1230 cases from peripheral artery disease, and 4620 cases from venous thromboembolism. Genetically predicted coronary atherosclerosis was associated with a higher risk of lactate level (OR = 1.950; 95% CI (0.087, 1.249); P = 0.024); this association was also evident for peripheral artery disease (OR = 1.003; 95% CI (0.000, 0.005); P = 0.021). No genetically predicted associations were noted for the other cardiovascular diseases.

Conclusion

The findings of this study provide genetic evidence supporting a higher risk of lactate level only in coronary atherosclerosis and peripheral artery disease. However, no genetic association between lactate level and the other cardiovascular diseases.

Additive interaction of family medical history of cardiovascular diseases with hypertension and diabetes on the diagnosis of cardiovascular diseases among older adults in India

Introduction

The present study aimed to examine the additive interaction of family medical history of cardiovascular disease (CVD) and self-reported hypertension and diabetes on the diagnosis of CVD among older adults aged 45 years and above in India. A family medical history of CVD in individuals with hypertension and diabetes could identify a subpopulation with a higher risk of CVD.

Methods

The study used the data from the Longitudinal Ageing Study in India (LASI) Wave 1 (2017-2018). The total sample size for the study was 58,734 older adults aged 45 years and above. An additive model was applied to determine the additive interaction effect of the family medical history of CVD with hypertension and diabetes on the diagnosis of CVD by calculating three different measures of additive interaction: the relative excess risk due to interaction (RERI), attribution proportion due to interaction (AP), and synergy index (S).

Results

The prevalence of CVD was higher among hypertensive individuals with a family medical history of CVD (18.6%) than individuals without the coexistence of family medical history of CVD and hypertension (4.7%), and hypertensive individuals without family medical history of CVD (11.3%). On the other hand, the prevalence of CVD was higher among individuals with diabetes and family history of CVD (20.5%) than individuals without the coexistence of family history of CVD and diabetes (5.0%). Individuals with parental and sibling medical history had two times higher odds of having chronic heart diseases and strokes, respectively than those without parental and sibling history. In the adjusted model, RERI, AP, and S for CVD were 2.30 (95% CI: 0.87-3.74), 35% (0.35; 95% CI: 0.20-0.51), and 1.71 (95% CI: 1.27-2.28) respectively, demonstrating significant positive interaction between family medical history and hypertension on the diagnosis of cardiovascular diseases.

Conclusions

The present study revealed that in the additive model, the interaction effects of family medical history and hypertension were significantly positive on cardiovascular diseases even after adjustment with potential confounding factors. Therefore, it is crucial to consider the presence of family medical history of CVD among individuals with hypertension and diabetes measured in research and clinical practice.

Cardiologists vs Endocrinologists in Glycemic Control for Coronary Artery Disease Patients with Type 2 Diabetes: A Cross-Sectional Study

Background

The comorbidity of coronary artery disease (CAD) and type 2 diabetes mellitus (T2DM) presents significant challenges in clinical management, particularly regarding glycemic control. The clinical management of CAD complicated by T2DM requires coordinated glycemic control, as poor management can exacerbate cardiovascular risks and increase morbidity and mortality. While endocrinologists traditionally manage diabetes, cardiologists are increasingly involved due to the cardiovascular risks associated with poor glycemic control. This study explores the current practices of glycemic management by cardiologists and endocrinologists in patients with CAD and T2DM, focusing on treatment intensification in a Chinese hospital setting.

Methods

This cross-sectional study included 1,074 hospitalized patients with both CAD and T2DM, admitted to the Cardiology Department of Ruijin Hospital between January 2021 and December 2023. Data were retrospectively collected from electronic medical records, including demographic information, clinical characteristics, and treatment interventions. Patients were stratified by year, and differences in treatment strategies between cardiologists and endocrinologists were analyzed. Glycemic control was assessed using HbA1c levels, with treatment intensification defined by any adjustment in antidiabetic therapy and consideration for comprehensive cardiovascular risk factors.

Results

Endocrinologists were significantly more likely to initiate treatment intensification, especially in cases of severe hyperglycemia (HbA1c ≥9.0%), while cardiologists' role in glycemic management was limited, with a preference for outpatient endocrinology referrals over in-hospital adjustments. Despite improvements in glycemic control, the percentage of patients achieving comprehensive cardiovascular risk management targets remained low.

Conclusion

This study underscored the distinct yet complementary roles of cardiologists and endocrinologists in managing glycemic control among patients with CAD and T2DM, noting endocrinologists' more active involvement in treatment intensification. Future integrated care models should harness the unique expertise of both specialties to optimize patient outcomes, better address glycemic control needs, and enhance overall cardiovascular risk management in this high-risk patient population.

Highlights of Cardiovascular Disease Prevention Studies Presented at the 2024 European Society of Cardiology Congress

PURPOSE OF REVIEW

To summarize selected late-breaking science on cardiovascular disease (CVD) prevention presented at the 2024 European Society of Cardiology (ESC) Congress.

RECENT FINDINGS

Key studies from the 2024 ESC Congress highlight advances in (CVD) management. Apolipoprotein A-1 infusions reduced risk in acute myocardial infarction patients with high LDL cholesterol. Plozasiran cut triglycerides and apolipoprotein C-III levels, lowering pancreatitis risk. A 14-year study linked smoking among youth to cardiac abnormalities. Baseline hsCRP, LDL-C, and Lp(a) were strong predictors of 30-year outcomes in women. Alternative LDL-lowering strategies matched high-intensity statins in effectiveness of LDL-C lowering and reduced diabetes risk. Early combination lipid lowering therapy improved outcomes post-myocardial infarction. Nordic and Mediterranean diets were linked to lower atherosclerotic CVD risk. The findings from the 2024 ESC Congress highlight significant advancements in CVD prevention, including novel lipid-lowering therapies, biomarker-based risk prediction, and lifestyle interventions. These studies underscore the importance of early and personalized treatment strategies to mitigate long-term cardiovascular risk.

Cholesterol, Triglyceride, and Glucose Levels Across Birth Cohorts in the US

Importance

Population mean levels of total cholesterol and fasting triglycerides have decreased substantially in the US in recent decades, but improvements in cardiometabolic health may have slowed among younger cohorts. Conversely, prevalence of diabetes (types 1 and 2) and obesity has increased, especially among adults younger than 65 years. It is unclear how trends in cholesterol, triglyceride, and glucose levels have changed across different birth cohorts and whether adverse trends in obesity are associated with these patterns.

Objective

To quantify national trends in total cholesterol, fasting triglyceride, and fasting glucose levels among cohorts born between 1920 and 1999 and examine the potential association of these patterns with body mass index (BMI).

Design, Setting, and Participants

This serial cross-sectional study used National Health and Nutrition Examination Survey (NHANES) data from the 1999-2000 to 2017-2020 cycles. Data were analyzed between November 1, 2023, and July 31, 2024. Participants included nonpregnant and noninstitutionalized US adults 18 years or older, born between 1920 and 1999, who had data collected from 1999 to 2020.

Exposure

Eight 10-year birth cohorts (from 1920 to 1999).

Main Outcomes and Measures

Total cholesterol, fasting triglyceride, and fasting glucose levels and BMI. Quantile regression models reported average marginal effects to quantify mean change in cardiometabolic outcome measures per decade of birth years. Parametric regression models estimated the association of birth cohort with outcomes, assessing BMI as the mediator.

Results

Of 52 006 participants weighted to represent 264 664 915 US adults, weighted median age was 46 (IQR, 33-60) years and 50.6% were women. For the 50th percentile of measures, mean difference per 1-decade younger birth cohort was -7.1 (95% CI, -8.2 to -6.1) mg/dL for total cholesterol level, -13.1 (95% CI, -15.1 to -11.1) mg/dL for fasting triglyceride level, and 2.7 (95% CI, 2.3-3.1) mg/dL for fasting glucose level. BMI appeared to attenuate the associations between birth cohort and lipid levels and enhanced the associations between birth cohort and fasting glucose levels. However, up to 80% of the associations between birth cohorts and cardiometabolic outcomes were not mediated through BMI.

Conclusions and Relevance

In this cross-sectional study of 52 006 participants representing 264 664 915 US adults, population-level improvements in total cholesterol and triglyceride levels decelerated and adverse trends in glucose levels accelerated in more recent birth cohorts, which was partially mediated by concurrent increases in BMI. Public health initiatives that target antecedent health behaviors are needed to improve cardiometabolic health across generations.

Impact of ketogenic diet on cardiovascular disease

OBJECTIVES

A comprehensive review of the current literature was conducted to summarize the potential therapeutic and management roles of ketogenic diet (KD) for cardiovascular disease (CVD).

BACKGROUND

Consensus has not been reached on the optimal diet for individuals with cardiovascular risk factors. KDs are characterized by high-fat, low-carbohydrate, and appropriate protein content, and have gained popularity in recent years in the management of various conditions, including cardiovascular and metabolic diseases.

METHODS

Original research, systematic reviews, and meta-analyses available in the PubMed, Web of Science, and Google Scholar databases were reviewed.

RESULTS

The current body of preclinical and clinical evidence on the efficacy of KD in the management of CVD remains limited. Specific applications of KD seem to suggest a positive impact on management of CVD. However, conflicting results and a lack of precise molecular and biochemical mechanisms of action provide ample opportunity for future investigation.

CONCLUSION

More multidisciplinary studies are needed to determine the true clinical benefit of KD in the management of CVD and so justify its expanded clinical use.

Cardiovascular disease and stroke following cancer and cancer treatment in older adults

BACKGROUND

Cancer survivors can be at risk of cardiovascular disease (CVD) because of either their malignancy or its treatment. Although studies linking cancer and CVD exist, few examine risk in older adults, the impact of cancer treatment, or the effect of aspirin on reducing risk in this cohort.

METHODS

The authors conducted a secondary analysis of the Aspirin in Reducing Events in the Elderly (ASPREE) trial to investigate the impact of cancer and cancer treatment on a composite CVD end point comprising hospitalization for heart failure (HHF), myocardial infarction (MI), and stroke.

RESULTS

Of 15,454 Australian and US ASPREE participants, 1392 had an incident cancer diagnosis. Rates of CVD were greater in the cancer risk-set compared to the cancer-free risk-set (20.8 vs. 10.3 events per 1000 person-years; incidence rate ratio, 2.03; 95% confidence interval, 1.51-2.66), with increased incidence seen across MI, HHF, overall stroke, and ischemic stroke. Increased incidence remained after adjustment for clinically significant risk factors for CVD. Incidence was greatest in metastatic, hematological, and lung cancer. Chemotherapy was associated with increased risk of CVD. Similar rates of CVD were seen across aspirin and placebo groups.

CONCLUSIONS

Incidence of CVD, including MI, HHF, and ischemic stroke, was increased in older adults with cancer. Aspirin did not impact CVD incidence. Risk may be higher in those with metastatic, hematological, and lung cancer, and following chemotherapy.

Female-specific risk factors for cardiovascular disease: an update

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide. While it was previously believed that men have greater susceptibility to CVD, recent research suggests that women face an increased risk of CVD after the onset of menopause, primarily due to the loss of the protective effects of estrogens. Premature ovarian insufficiency (POI), polycystic ovarian syndrome (PCOS), and gestational factors, such as gestational diabetes mellitus (GDM), recurrent pregnancy loss, preterm delivery, and preeclampsia, are specific reproductive disorders that may contribute to an elevated risk of CVD at earlier ages, i.e., before the onset of menopause. This suggests that women with these conditions should be closely monitored for CVD risk factors even before reaching menopause. Such early intervention may help reduce the incidence of CVD and improve overall cardiovascular health in this population. The precise pathophysiological mechanism underlying the development of CVD in women with menopause, premature POI, PCOS, and gestational factors remains elusive. This review article seeks to elucidate the latest research on the relationship between these conditions and CVD in women, aiming to explore the underlying pathogenic mechanisms contributing to this association.

2024 Guideline for the Primary Prevention of Stroke: A Guideline From the American Heart Association/American Stroke Association

AIM

The "2024 Guideline for the Primary Prevention of Stroke" replaces the 2014 "Guidelines for the Primary Prevention of Stroke." This updated guideline is intended to be a resource for clinicians to use to guide various prevention strategies for individuals with no history of stroke.

METHODS

A comprehensive search for literature published since the 2014 guideline; derived from research involving human participants published in English; and indexed in MEDLINE, PubMed, Cochrane Library, and other selected and relevant databases was conducted between May and November 2023. Other documents on related subject matter previously published by the American Heart Association were also reviewed.

STRUCTURE

Ischemic and hemorrhagic strokes lead to significant disability but, most important, are preventable. The 2024 primary prevention of stroke guideline provides recommendations based on current evidence for strategies to prevent stroke throughout the life span. These recommendations align with the American Heart Association's Life's Essential 8 for optimizing cardiovascular and brain health, in addition to preventing incident stroke. We also have added sex-specific recommendations for screening and prevention of stroke, which are new compared with the 2014 guideline. Many recommendations for similar risk factor prevention were updated, new topics were reviewed, and recommendations were created when supported by sufficient-quality published data.

Tofacitinib Safety and Effectiveness in Canadian Patients with Rheumatoid Arthritis by Cardiovascular Risk Enrichment: Subanalysis of the CANTORAL Study

INTRODUCTION

ORAL Surveillance, a post-authorisation safety study of patients with rheumatoid arthritis (RA) enriched for cardiovascular (CV) risk, demonstrated increased risk of major adverse CV events (MACE) and malignancies (excluding non-melanoma skin cancer [NMSC]) for tofacitinib versus tumour necrosis factor inhibitors (TNFi). This analysis of a real-world Canadian observational study evaluated tofacitinib safety/effectiveness in patients meeting or not meeting CV risk criteria.

METHODS

CANTORAL included patients with moderate-to-severe RA initiating tofacitinib (10/2017-07/2020; N = 504). Interim data (data-cut: 07/2021) were stratified as CV risk-enriched (CV+ ; patients ≥ 50 years with ≥ 1 additional CV risk factor) or not CV risk-enriched (CV-; ≥ 50 years without additional CV risk factors and 18-49 years with/without CV risk factors). Safety and persistence were evaluated to month (M) 36. Effectiveness outcomes to M18 included Clinical Disease Activity Index (CDAI)-defined low disease activity (LDA)/remission (CANTORAL co-primary endpoints) and Disease Activity Score in 28 joints, C-reactive protein (DAS28-4[CRP]) < 3.2/ < 2.6.

RESULTS

Overall, 272/232 patients were included in CV+ /CV- cohorts (full analysis set) (435/356 patient-years [safety analysis set]). Incidence rates (events/100 patient-years) in CV+ /CV- cohorts were 138.5/112.5 for treatment-emergent adverse events (AEs); 17.0/5.6 for serious AEs; 1.2/0.3 for deaths; 5.5/1.7 for serious infections; 1.4/1.1 for herpes zoster; 1.6/0.0 for MACE; 2.1/0.3 for malignancies (excluding NMSC); 0.7/0.6 for NMSC; 0.5/0.0 for venous thromboembolic events. Persistence was generally comparable between cohorts. In CV+ /CV- cohorts, at M6, CDAI LDA and remission rates were 51.5%/54.6% and 12.0%/19.6%; DAS28-4(CRP) < 3.2/ < 2.6 rates were 44.0%/39.3% and 31.5%/28.8%, respectively; effectiveness was generally maintained to M18.

CONCLUSIONS

In concordance with studies of background risk, AEs were more common in patients with CV risk enrichment, particularly those aged ≥ 65 years. Tofacitinib effectiveness/persistence were generally similar regardless of CV risk enrichment. These findings support individualised treatment benefit-risk assessment, including CV assessment/management, to optimise RA outcomes.

Evidence-based simulation: Fostering competency through structured and multisource feedback

ABSTRACT

Preclinical simulation is an evidence-based method for nurse practitioner (NP) students to improve clinical communication and disease management competency. During simulation, students may receive feedback from multiple sources, including standardized patients (SPs), faculty, peers, and themselves. Although evidence supports simulation with multisource feedback, its impact on clinical knowledge and communication has yet to be evaluated among NP students. We designed, implemented, and evaluated a preclinical simulation program with structured multisource feedback integrated into a disease management course within a Doctor of Nursing Practice curriculum. Differences in communication self-efficacy and disease management knowledge before and after participation, as well as perceptions of learning and importance of varying feedback sources, were evaluated using a single group pre-post mixed-methods design. On average, clinical communication self-efficacy was significantly higher, and disease management knowledge scores were significantly higher after participation. Learners rated feedback sources as important or very important and described varying feedback sources as complementary. Feedback from SPs, peers, learners themselves, and faculty was complementary and important to learning. This preclinical simulation program with purposeful integration of multisource feedback provides an evidence-based foundation for scaffolding multidomain competency development into curriculums to meet updated standards of advanced nursing education.

Implication of knowledge, lifestyle and self-efficacy in the prevention of cardiovascular diseases' risk factors among the urban elderly

Background: Cardiovascular disease (CVD) is preventable by effectively managing its risk factors. Such risk factors (smoking, unhealthy eating habits, sedentary lifestyles, etc.) are judged to reflect an individual's self-efficacy, lifestyle modification, and CVD knowledge. Objectives: To evaluate the relationship between lifestyle practices, self-efficacy, and knowledge of CVDs risk factors among the elderly. Methods: A descriptive cross-sectional study was conducted on 424 randomly individuals whose age is ≥60 years. A questionnaire-based survey was administered on the self-efficacy rate, lifestyle practices, and respondents' knowledge of CVDs risk factors. Respondents with a score of ≤50%, 51%-74.99%, and ≥75% were classified as having low, medium, or high self-efficacy. Similarly, the same score was used to classify poor, fair, or good lifestyle; and low, average, or high knowledge. Data were analysed using Statistical Package for Social Sciences, while association among variables was determined using chi-square. Results: Few respondents were involved in physical exercise (1.7%), cigarette smoking (4.5%), regular soft drinks (18.2%), and alcohol consumption (13.2%). Many respondents used excess salt during cooking (92.7%) or ate outside their homes (64.6%). 58.5%, 30.0%, and 11.6% of the respondents had fair, good, and poor lifestyle practices. 11.3%, 58.7%, and 30.0% had low, medium, and high self-efficacy scores. A total of 45.3%, 35.4%, and 19.3% had low, average, and high knowledge. Knowledge and self-efficacy scores were significantly different (P  =  0.001). Conclusion: High self-efficacy and its significant relationship with knowledge could mean that CVD risk factors can be checked if the elderly have a proper lifestyle, positive attitudes, and nutrition education.

Glomerular Hematuria as a Predictor of Renal Prognosis in Malignant Hypertension Patients with Thrombotic Microangiopathy: A Propensity Score-Matched Analysis of a Biopsy-Based Cohort Study

Introduction

Malignant hypertension (mHTN) is a hypertensive emergency. Thrombotic microangiopathy (TMA) is a widespread complication of mHTN. Few studies have evaluated whether glomerular hematuria provides prognostic information for renal dysfunction in patients with mHTN-associated TMA.

Methods

This observational cohort study included 292 patients with mHTN-associated TMA based on renal biopsy. Propensity-score matching (PSM) analysis was conducted to adjust for clinical characteristics in a comparison between with and without glomerular hematuria. Cox regression was employed to identify risk factors for renal prognosis.

Results

A total of 70 patients with glomerular hematuria were compared to 222 patients with non-glomerular hematuria. After PSM, 67 pairs of patients with mHTN-associated TMA were matched. Patients with glomerular hematuria exhibited lower serum albumin levels, higher 24-h proteinuria, and a higher prevalence of glomerular sclerosis than those with non-glomerular hematuria. Glomerular hematuria was independently associated with deteriorated renal function compared with non-glomerular hematuria (HR: 0.51; 95% CI: 0.29-0.89, p = 0.019). This association remained significant after PSM (HR: 0.51; 95% CI: 0.28-0.91, p = 0.022). Additionally, glomerular hematuria was independently associated with renal replacement therapy (RRT) (HR: 3.14; 95% CI: 2.06-5.66, p < 0.001). This difference remained significant after PSM comparison (HR: 2.41; 95% CI: 1.34-4.33, p = 0.003). Furthermore, despite intensive blood pressure control, patients with glomerular hematuria experienced a higher incidence of RRT and a poorer recovery in renal function, specifically a 25% reduction of creatinine levels, compared to patients with non-glomerular hematuria.

Conclusion

Glomerular hematuria is significantly associated with an increased risk of adverse renal outcomes in patients with mHTN-associated TMA.

Prognostic importance of extensive coronary calcium on lung cancer screening chest computed tomography

BACKGROUND

Low-dose chest computed tomography (CT) is used for lung cancer screening, but can also detect coronary artery disease as coronary artery calcium. We sought to determine the prevalence and prognostic utility of coronary artery calcium in a population at high risk of cancer.

METHODS

We reviewed CT scans from consecutive participants screened for lung cancer between March 2017 and November 2018 as part of the Ontario Health Lung Cancer Screening Pilot for People at High Risk. We quantified coronary artery calcium using an estimated Agatston score. We identified the composite primary outcome of all-cause death and cardiovascular events using linked electronic medical record data from The Ottawa Hospital to December 2023.

RESULTS

Among 1486 people who underwent screening CT, coronary artery calcium was detected in 1232 (82.9%) and was extensive in 439 (29.5%). On multivariable analysis, extensive coronary artery calcium was associated with the composite primary outcome (hazard ratio [HR] 2.13, 95% confidence interval [CI] 1.35-3.38), all-cause death (HR 2.39, 95% CI 1.34-4.27), and cardiovascular events (HR 2.06, 95% CI 1.13-3.77). Extensive coronary artery calcium remained predictive of cardiovascular events after we adjusted for noncardiovascular death as a competing risk (HR 2.05, 95% CI 1.09-3.85).

INTERPRETATION

Among people undergoing low-dose chest CT for lung cancer screening, extensive coronary artery calcium was an independent predictor of all-cause death and cardiovascular events, even after adjustment for noncardiovascular death. The opportunity to identify and reduce risks from coronary artery disease may represent an additional benefit of lung cancer screening.

Plaque Stabilization and Regression, from Mechanisms to Surveillance and Clinical Strategies

With advances in therapies to reduce cardiovascular events and improvements in coronary imaging, an increasing number of clinical trials have demonstrated that treatments to reduce cardiovascular events in coronary artery disease are associated with favorable effects on atherosclerotic plaque size and characteristics. It has been observed that various drugs may induce plaque regression and enhance plaque stability after plaque formation. Numerous clinical trials have been conducted to verify the occurrence of plaque stabilization and regression and their beneficial effects on cardiovascular events. Using invasive imaging techniques such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT), researchers have been able to gather evidence supporting the existence of coronary plaque stabilization and regression. In this review, we explore the possible mechanisms of plaque stabilization and regression, summarize the imaging features of plaque stabilization and regression, and assemble the evidence from clinical studies that have used different features as observational endpoints.

Deprescribing Cardiovascular Medications in Older Adults Living with Frailty

Certain medications have shown significant effectiveness in reducing the incidence of cardiovascular events and mortality, leading them to be among those that are prescribed most commonly for Canadian seniors. However, polypharmacy, which disproportionately affects older adults, is particularly concerning for frail individuals who are at higher risk for adverse medication-related events. The deprescribing process is the discontinuation, either immediate or gradual, of inappropriate medications, to address polypharmacy and improve outcomes. Nonetheless, the incorporation of deprescribing principles into clinical practice present challenges, including the limited amount of data available on the clinical benefits of deprescription, and a lack of consensus on how to deprescribe. The current narrative review explores frailty as a basis for deciding to deprescribe medication. The evidence regarding the benefits of use of medications prescribed for common cardiovascular conditions (including acetylsalicylic acid, statins, and antihypertensives) in older adults with frailty is reviewed. The review also examines the issue of who should initiate the deprescribing process, and the associated psychological implications. Although no one-size-fits-all approach to deprescription is available, patient goals should be prioritized. For older adults with frailty, healthcare professionals must consider carefully whether the benefits of use of a cardiovascular medication outweighs the potential harms. Ideally, the deprescribing process should involve shared decision-making among physicians, other health professionals, and patients and/or their substitute decision-makers, with the common goal of improving patient outcomes.

Is 'Cardiopulmonary' the New 'Cardiometabolic'? Making a Case for Systems Change in COPD

Chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) have a syndemic relationship with shared risk factors and complex interplay between genetic, environmental, socioeconomic, and pathophysiological mechanisms. CVD is among the most common comorbidities in patients with COPD and vice versa. Patients with COPD, irrespective of their disease severity, are at increased risk of CVD morbidity and mortality, driven in part by COPD exacerbations. Despite these known interrelationships, CVD is underestimated and undertreated in patients with COPD. Similarly, COPD is an independent risk-enhancing factor for adverse cardiovascular (CV) events, yet it is not incorporated into current CV risk assessment tools, leading to under-recognition and undertreatment. There is a pressing need for systems change in COPD management to move beyond symptom control towards a comprehensive cardiopulmonary disease paradigm with proactive prevention of exacerbations and adverse cardiopulmonary outcomes and mortality. However, there is a dearth of evidence defining optimal cardiopulmonary care pathways. Fortunately, there is a precedent to support systems-level change in the field of diabetes, which evolved from glycemic control to comprehensive multi-organ risk assessment and management. Key elements included integrated multidisciplinary care, intensive risk factor management, coordination between primary and specialist care, care pathways and protocols, education and self management, and disease-modifying therapies. This commentary article draws parallels between the cardiometabolic and cardiopulmonary paradigms and makes a case for systems change towards multidisciplinary, integrated cardiopulmonary care, using the evolution in diabetes care as a potential framework.

Prevalence of obesity and cardiovascular disease in adults with type 2 diabetes and use of diabetes medication in Germany: A claims data study

AIMS

To identify the prevalence of cardiovascular disease (CVD) and obesity in patients with type 2 diabetes (T2D) in Germany and to evaluate if antidiabetic treatment patterns varied by comorbidity status.

MATERIALS AND METHODS

Patients with T2D (aged ≥18 years) were identified during the study period (2014-2020) from medical claims of 4.5 million publicly insured German residents and divided into different cohorts based on CVD and/or obesity diagnosis. Annual prevalence and incidence were estimated for each study year, while characteristics and treatments were assessed in 2020. Data were extrapolated to the German population by age and sex.

RESULTS

The prevalence of T2D in 2020 was 11.4%. Among patients with T2D, 53.0% had CVD, 39.3% had obesity, and 20.9% had CVD and obesity. Since 2014, CVD increased by 1.4%, obesity by 4.5%, and CVD with obesity by 2.7% in patients with T2D. The incidence of T2D in 2020 was 1.0% (42.9% had CVD, 37.9% had obesity, and 15.8% had CVD and obesity). Among the prevalent T2D population in 2020, 4.9% received glucagon-like peptide-1 receptor agonists (GLP-1RAs), 9.7% received sodium-glucose cotransporter-2 (SGLT2) inhibitors, and 13.0% received GLP-1 RAs and/or SGLT2 inhibitors. Of those with CVD, 12.9% received GLP-1 RAs and/or SGLT2 inhibitors (without CVD, 13.2%). Of those with obesity, 19.4% received GLP-1RAs and/or SGLT2 inhibitors (without obesity, 9.0%).

CONCLUSIONS

In this retrospective claims database study, more than two thirds of patients with T2D also had CVD, obesity, or both CVD and obesity. GLP-1 RA and SGLT2 inhibitor use remained low.

Comparing Carotid Artery Velocities with Current ASCVD Risk Stratification: A Novel Approach to Simpler Risk Assessment

PURPOSE

To explore the potential of a novel approach to simplify risk assessment by comparing carotid artery velocities with current atherosclerotic cardiovascular disease (ASCVD) risk stratification method using nonlinear measurements.

METHODS

In this prospective study conducted at a medical center in southern Taiwan from January 1, 2020, to December 31, 2021, 1636 participants aged 40-75 years without prior ASCVD events were enrolled. Carotid flow velocity was obtained through duplex ultrasonography. ASCVD risk was categorized into two groups according to the 2022 USPSTF guidelines for primary prevention. We analyzed associations between flow indices and ASCVD risk using logistic regression and generalized additive models (GAMs).

RESULTS

The end diastolic velocity (EDV) of common carotid artery (CCA) and the peak systolic velocity (PSV) of internal carotid artery (ICA) were inversely and nonlinearly associated with cardiovascular event risk. Multivariate logistic regression analysis with ROC curves revealed that the optimal speed for the EDV of CCA was approximately 23.75 cm/s, and the optimal PSV and EDV of ICA were approximately 81.75 cm/s and 26.75 cm/s, respectively. The GAMs showed U-shaped relationships between elevated ASCVD risk and blood flow velocity in the carotid arteries, with inflection points of approximately 82 cm/s in the PSV of ICA and near 25 cm/s in the EDV of CCA. Both methods revealed similar results.

CONCLUSIONS

The EDVs and PSVs of the CCA and ICA are associated with the development of cardiovascular events. Optimal velocity ranges were identified; however, further hemodynamic investigations are warranted.

National Trends in Aspirin Use and Expenditures in the United States: Analysis of The Medical Expenditure Panel Survey 2000-2021

INTRODUCTION

Since its invention in 1897, aspirin (ASA) has been the most widely used and cost-effective antiplatelet agent to prevent and treat atherosclerotic cardiovascular disease (ASCVD). We aimed to study the trends and expenditures associated with ASA use in the USA.

METHODS

We conducted a serial cross-sectional analysis using the Medical Expenditure Panel Survey data from January 2000 to December 2021, focusing on adults aged ≥ 40 years. Total and out-of-pocket expenditures associated with ASA were estimated to 2021 US dollars (USD). Trends, demographics, and predictors of ASA use among patients with and without ASCVD were also evaluated.

RESULTS

A total of 53 million adults were identified during the study period. The number of ASA users increased from 2.9 million to 6.6 million with increased female (36.7%-49.7%; p trend = 0.02) and African American (13%-18.9%; p trend = 0.03) representation amongst all ASA users during the survey period. The use of low-dose ASA increased, while high-dose ASA declined significantly. Only 50% of all ASA users had known ASCVD. The most prevalent ASA users among patients with ASCVD were those aged ≥ 70 years, while patients without ASCVD, it was the 50-69 age group. The total annual expenditure on ASA averaged approximately 60 million USD, with 27.3 million USD out-of-pocket.

CONCLUSION

Total and low-dose (81 mg) ASA use has increased, while high-dose (325 mg) ASA has declined. ASA use for primary prevention has risen among adults aged 50-69 years, and patients ≥ 70 years continue to use ASA without known ASCVD. Further studies are needed to understand the implications of increased ASA use, especially among those without ASCVD.

Association of High-Sensitivity C-Reactive Protein (hs-CRP) with Weight Loss After Sleeve Gastrectomy and Roux-en-Y Gastric Bypass at 10 Years: A Secondary Analysis of the SLEEVEPASS Randomized Clinical Trial

BACKGROUND

Severe obesity is associated with a low-grade chronic inflammation, and high-sensitivity C-reactive protein (hs-CRP) is a marker that can be used to evaluate chronic inflammation status. Metabolic bariatric surgery (MBS) is shown to decrease hs-CRP level, but long-term results are scarce, and association with weight loss outcomes is undetermined. This study aims to evaluate chronic inflammation in patients with obesity using hs-CRP, and its association with long-term weight loss outcomes after laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB).

METHODS

The long-term follow-up data of SLEEVEPASS (ClinicalTrials.gov NCT00793143) randomized clinical trial (RCT) was used. Hs-CRP was measured at baseline, and at 6 months, 1, 3, 5, 7, and 10 years after surgery, and the association with weight and weight loss outcomes were analyzed.

RESULTS

Hs-CRP at baseline was available for 59 out of 240 (24.6%) patients. In the whole study population, the nadir hs-CRP (mean estimate 1.14 mg/ml, 95% CI 0.87-1.49) was achieved at 3 years after surgery with a statistically significant difference to baseline (p = 0.003). No statistically significant difference was seen between LSG and LRYGB in hs-CRP change over time (operation*time interaction p = 0.540). Higher hs-CRP correlated with higher BMI at baseline (Spearman correlation 0.282, p = 0.030) and at 10 years (Spearman correlation 0.490, p = 0.001). At 10 years, a greater percentage total weight loss (%TWL) correlated with lower hs-CRP level (Spearman correlation - 0.558, p < 0.001). Baseline hs-CRP (Spearman correlation - 0.152, p = 0.299) and hs-CRP change in first 6 months postoperatively (Spearman correlation 0.167, p = 0.254) did not correlate statistically significantly with %TWL at 10 years.

CONCLUSIONS

MBS decreases hs-CRP also at long-term follow-up with weight loss as the driving force. Neither baseline hs-CRP nor hs-CRP change at 6 months were feasible as a predictive marker for long-term outcomes.

Assessing the Accuracy of Cardiovascular Disease Prediction Using Female-Specific Risk Factors in Women Aged 45 to 69 Years in the UK Biobank Study

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of mortality in women. We aimed to assess whether adding female-specific risk factors to traditional factors could improve CVD risk prediction.

METHODS

We used a cohort of women from the UK Biobank Study aged 45 to 69 years, free of CVD at baseline (2006-2010) followed until the end of 2019. We developed Cox proportional hazards models using the risk factors included in 3 contemporary CVD risk calculators: Pooled Cohort Equation - Atherosclerotic Cardiovascular Disease, Qrisk2, and PREDICT. We added each of the following female-specific risk factors, individually and all together, to determine if these improved measures of discrimination and calibration for predicting CVD: early menarche (<11 years), endometriosis, excessive, frequent or irregular menstruation, miscarriage, number of miscarriages, number of stillbirths, infertility, preeclampsia or eclampsia, gestational diabetes (without subsequent type 2 diabetes), premature menopause (<40 years), early menopause (<45 years), and natural or surgical early menopause (menopause <45 years or timing of menopause reported as unknown and oophorectomy reported at age <45).

RESULTS

In the model of 135 142 women (mean age, 57.5 years; SD, 6.8) using risk factors from Pooled Cohort Equation - Atherosclerotic Cardiovascular Disease, CVD incidence was 5.3 per 1000 person-years. The c-indices for the Pooled Cohort Equation - Atherosclerotic Cardiovascular Disease, Qrisk2, and PREDICT models were 0.710, 0.713, and 0.718, respectively. Adding each of the female-specific risk factors did not improve the c-index, the net reclassification index, the integrated discrimination index, the slope of the regression line for predicted versus observed events, and the Brier score or plots of calibration. Adding all female-specific risk factors simultaneously increased the c-index for the Pooled Cohort Equation - Atherosclerotic Cardiovascular Disease, Qrisk2, and PREDICT models to 0.712, 0.715, and 0.720, respectively.

CONCLUSIONS

Although several female-specific factors have been shown to be early indicators of CVD risk, these factors should not be used to reclassify risk in women aged 45 to 69 years when considering whether to commence a blood pressure or lipid-lowering medication.

SREBP1 induction mediates long-term statins therapy related myocardial lipid peroxidation and lipid deposition in TIIDM mice

Statins therapy is efficacious in diminishing the risk of major cardiovascular events in diabetic patients. However, our research has uncovered a correlation between the prolonged administration of statins and an elevated risk of myocardial dysfunction in patients with type II diabetes mellitus (TIIDM). Here, we report the induction of sterol regulatory element-binding protein 1 (SREBP1) activation, associated lipid peroxidation, and the consequent diabetic myocardial dysfunction after statin treatment and explored the underlying mechanisms. In db/db mice, we observed that 40 weeks atorvastatin (5 and 10 mg/kg) and rosuvastatin (20 mg/kg) administration exacerbated diabetic myocardial dysfunction by echocardiography and cardiomyocyte contractility assay, increased myocardial inflammation and fibrosis as shown by CD68, IL-1β, Masson's staining and Collagen1A1 immunohistochemistry (IHC) staining, increased respiratory exchange ratio (RER) by metabolic cage system assessment, exacerbated mitochondrial structural pathological changes by transmission electron microscopy (TEM) examination, increased deposition of lipid and glycogen by TEM, Oil-red and periodic acid-schiff stain (PAS) staining, which were corresponded with augmented levels of myocardial SREBP1 protein and lipid peroxidation marked by 4-hydroxynonenal (4-HNE) staining. Comparable myocardial fibrosis was also observed in KK-ay and low-dose streptozotocin (STZ)-induced TIIDM mice. Elevated SREBP1 levels were observed in the heart tissues from diabetic patients, which was positively correlated with their myocardial dysfunction. To elucidate the role of statin induced SREBP1 in lipid peroxidation and lipid deposition and related mechanism, we cultured neonatal mouse primary cardiomyocytes (NMPCs) and treated them with atorvastatin (10 μM, 24 h), tracing with [U-13C]-glucose and evaluating for SREBP1 expression and localization. We found that statin treatment elevated de novo lipogenesis (DNL) and the levels of SREBP1 cleavage-activating protein (SCAP), reduced the interaction of SCAP with insulin-induced gene 1 (Insig1), and enhance SCAP/SREBP1 translocation to the Golgi, which facilitate SREBP1 cleavage leading to its nuclear trans-localization and activation in NMPCs. Ultimately, SREBP1 knockdown or l-carnitine mitigated long-term statins therapy induced lipid peroxidation and myocardial fibrosis in low-dose STZ treated SREBP1+/- mice and l-carnitine treated db/db mice. In conclusion, we demonstrated that statin therapy may augment DNL by activating SREBP1, resulting in myocardial lipid peroxidation and lipid deposition.

Low-Intensity Statin Plus Ezetimibe Versus Moderate-Intensity Statin for Primary Prevention: A Population-Based Retrospective Cohort Study in Asian Population

BACKGROUND

While moderate-intensity statin therapy is recommended for primary prevention, statins may not be utilized at a recommended intensity due to dose-dependent adverse events, especially in an Asian population. However, evidence supporting the use of low-intensity statins in primary prevention is limited.

OBJECTIVE

We sought to compare clinical outcomes between a low-intensity statin plus ezetimibe and a moderate-intensity statin for primary prevention.

METHODS

This population-based retrospective cohort study used the Korean nationwide claims database (2002-2019). We included adults without atherosclerotic cardiovascular diseases who received moderate-intensity statins or low-intensity statins plus ezetimibe. The primary outcome was a composite of all-cause mortality, myocardial infarction, and ischemic stroke. The safety outcomes were liver and muscle injuries and new-onset diabetes mellitus (DM). We used standardized inverse probability of treatment weighting (sIPTW) and propensity score matching (PSM).

RESULTS

In the sIPTW model, 1717 and 36 683 patients used a low-intensity statin plus ezetimibe and a moderate-intensity statin, respectively. In the PSM model, each group included 1687 patients. Compared with moderate-intensity statin use, low-intensity statin plus ezetimibe use showed similar risks of the primary outcome (hazard ratio [HR] = 0.92, 95% CI = 0.81-1.12 in sIPTW and HR = 1.16, 95% CI = 0.87-1.56 in PSM model). Low-intensity statin plus ezetimibe use was associated with decreased risks of liver and muscle injuries (subHR [sHR] = 0.84, 95% CI = 0.74-0.96 and sHR = 0.87, 95% CI = 0.77-0.97 in sIPTW; sHR = 0.84, 95% CI = 0.72, 0.96 and sHR = 0.82, 95% CI = 0.72-0.94 in PSM model, respectively). For new-onset DM and hospitalization of liver and muscle injuries, no difference was observed.

CONCLUSION AND RELEVANCE

Low-intensity statin plus ezetimibe may be an alternative to moderate-intensity statin for primary prevention. Our findings provide evidence on safety and efficacy of statin therapy in Asian population.

Low LDL-C: Is It all Good News?

PURPOSE OF REVIEW

This review presents the risks and benefits of very low LDL cholesterol and the safety of using lipid-lowering therapy to achieve these levels.

RECENT FINDINGS

A growing body of literature suggests that lower LDL cholesterol levels are associated with a reduced risk of cardiovascular disease. Further, achieving these levels with pharmaceuticals is remarkably safe. Although statins may slightly increase the risk of diabetes mellitus and hemorrhagic stroke, the benefits outweigh the risks. While recommendations from professional societies are increasingly aggressive, additional risk reduction could be achieved by setting more even ambitious LDL cholesterol goals.

Long-Term Pentoxifylline Therapy Is Associated with a Reduced Risk of Atherosclerotic Cardiovascular Disease by Inhibiting Oxidative Stress and Cell Apoptosis in Diabetic Kidney Disease Patients

There is limited understanding of the optimal duration and dosage of pentoxifylline (PTX) therapy required to achieve significant reductions in atherosclerotic cardiovascular disease (ASCVD) risk, particularly in patients with diabetic kidney disease (DKD). This study aimed to evaluate the impact of long-term PTX therapy on the risk of ASCVD in patients with DKD who do not have pre-existing cardiovascular disease, while also exploring potential vascular protective mechanisms. This retrospective cohort study included data from Taiwan's Ministry of Health and Welfare's Health and Welfare Data Science Center. In 2008-2019, we identified and analyzed a specific sample of 129,764 patients with DKD without established cardiovascular disease. Participants were categorized according to their PTX treatment regimen. Short-term PTX users (<763 days) had a greater risk of developing ASCVD than non-PTX users. However, those who used PTX for >763 days (long-term PTX treatment) had a significantly lower risk of ASCVD, with a 47% lower cumulative incidence. A dose-dependent reduction in apoptosis was observed via Klotho treatment in cultured human aortic endothelial cells following PTX treatment. Long-term PTX treatment (24 h) caused a higher reduction in H2O2-induced reactive oxygen species production and cell apoptosis than short-term PTX treatment (2 h). In the DKD mice model experiments, PTX reduced the ASCVD risk by increasing the Klotho levels to inhibit endothelial cell damage. These findings suggest that the cardiovascular and renoprotective benefits of PTX may be extended to primary prevention strategies for people with DKD.

Inclisiran for the treatment of hypercholesterolaemia

Inclisiran is a synthetic small interfering RNA (siRNA) that inhibits the production of proprotein convertase subtilisin/kexin 9 (PCSK9) in hepatocytes by silencing the translation of PCSK9 mRNA. The result of this mechanism is a decrease in PCSK9 synthesis resulting in decreased degradation of the LDL receptor, leading to more LDL receptors being available to clear LDL cholesterol (LDL-C) from the circulation. Inclisiran received FDA approval in 2021 and EMA approval in 2020. The indication for inclisiran use is as an adjunct to diet and statin therapy for the treatment of adults with primary hyperlipidaemia, including those with heterozygous familial hypercholesterolaemia to reduce LDL-C. Inclisiran has demonstrated consistent LDL-C lowering in the range of 44-54%. Furthermore, inclisiran has been demonstrated to be a safe medication with indications of significant or serious adverse events when compared to placebo. Inclisiran is given as an initial subcutaneous dose followed by a repeat dose at 3 months and every 6 months thereafter. The 2022 American College of Cardiology Expert Consensus Decision Pathway includes inclisiran as an option for non-statin therapy in addition to maximally tolerated statin therapy in those at very high risk of atherosclerotic cardiovascular disease or those with LDL-C >190 mg/dL. The ORION-4, VICTORION-1 PREVENT and VICTORION-2 PREVENT trials are ongoing and designed to evaluate the ability of inclisiran to reduce major cardiovascular events in addition to LDL-C lowering but will not be completed for a few years.

Sex modifies association between dietary sodium intake and cardiovascular disease mortality among US adult with hypertension: a national population-based cohort

Objectives

The objective of this study was to examine the relationship between dietary sodium intake and cardiovascular disease (CVD) mortality in hypertensive American adults.

Methods

A prospective cohort study was conducted to examine the association between dietary sodium intake, as estimated by a single 24-h dietary recall from the National Health and Nutrition Examination Survey (2003-2012), and mortality data obtained from the National Death Index.

Results

This study included 12,236 adults with hypertension, with 837 CVD-related deaths identified over a median follow-up period of 10.3 years. A nonlinear association between dietary sodium intake and CVD mortality was observed. The inflection point of the curve occurred at a sodium intake level of 2.07 g/day. Below this threshold, higher sodium intake was associated with a reduced risk of CVD mortality, though the association was not statistically significant after full adjustment (aHR: 0.78, 95% CI: 0.58-1.05). In contrast, sodium intake above 2.07 g/day was significantly associated with an increased risk of CVD mortality (aHR: 1.12, 95% CI: 1.02-1.23). The log-likelihood ratio test yielded a P-value of 0.04. This J-shaped association was observed exclusively in females, not males. Among females, the adjusted hazard ratios (95% CI) were 0.65 (0.42, 0.99) below and 1.29 (1.11, 1.53) above the inflection point (P for log-likelihood ratio test = 0.009).

Conclusions

In American adults with hypertension, dietary sodium intake exceeding 2.07 g/day was significantly associated with an increased risk of CVD mortality, while intake below this threshold was not significantly linked to mortality risk. Additionally, a sex-specific effect of dietary sodium intake on CVD mortality was observed, showing a J-shaped relationship exclusively in females, with no such association found in males.

The Implication of NT-proBNP in the Assessment of the Clinical Phenotype of Patients with Type 2 Diabetes Mellitus, Without Established Cardiovascular Disease

Background: Natriuretic peptide (NP) levels have been proposed for characterization and risk stratification of heart failure (HF) among patients with cardiovascular disease (CVD). However, their role in patients with diabetes mellitus type 2 (T2DM) has not been well studied and understood. The aim of this study was to assess phenotypical, functional characteristics and imaging parameters in relation to N-terminal pro b-type natriuretic peptide (NT-proBNP) values in T2DM patients without known CVD that may predispose to overt HF. Methods: This was a cross-sectional study of 100 consecutive T2DM patients (mean overall age of 67 ± 9 years, 40% women and 60% men) who were enrolled from the outpatient diabetic clinic. Patients underwent a cardiopulmonary exercise test (CPET), and echocardiographic and cardiac magnetic resonance imaging (CMR); serum NT-proBNP was also measured. Results: The mean (standard deviation) NT-proBNP was 149 (±186) pg/mL. Patients in the highest tertile of NT-proBNP values (>107 pg/mL) had lower values of predicted maximum oxygen consumption compared to the lowest quartile (<55 pg/mL) (84% vs. 92%, p = 0.018) in the CPET and higher ratio of early diastolic mitral inflow velocity to early diastolic mitral annulus velocity (E/e') (9.0 vs. 7.2, p = 0.05) in echocardiography. Finally, there was a negative correlation between right ventricle end diastolic volume in CMR and predicted maximum oxygen consumption (b = -0.225 ± 0.11, p = 0.046). Conclusions: NT-proBNP levels seemed to be a useful marker in people with T2DM, as elevated levels reflected ongoing appearance of HF with preserved ejection fraction and were related to CPET and echocardiographic indices of impaired left ventricular diastolic and right ventricular systolic function.

PCSK9 Inhibitors: Focus on Evolocumab and Its Impact on Atherosclerosis Progression

This paper investigates the therapeutic use of PCSK9 inhibitors, particularly Evolocumab, as monoclonal antibodies for the treatment of atherosclerosis based on recent literature reviews. PCSK9 is an outstanding example of a breakthrough in medical science, with advancements in understanding its biological function driving substantial progress in atherosclerosis treatment. Atherosclerotic cardiovascular disease (ASCVD) is a leading global cause of mortality, imposing substantial financial burdens on healthcare systems. Elevated low-density lipoprotein cholesterol (LDL-C), a modifiable risk factor, plays a pivotal role in the development of ASCVD. Emerging treatments such as PCSK9 inhibitors are now being introduced to combat this issue, with the goal of reducing ASCVD risk by directly targeting LDL-C levels. This discovery highlighted the potential of monoclonal antibodies to inhibit PCSK9, thereby enhancing LDL-C receptor activity. This breakthrough led to the development of Alirocumab and Evolocumab inhibitors, which typically reduce LDL-C levels by approximately 50%. This research underscores the importance of PCSK9 inhibitors in treating ASCVD, drawing on evidence from various randomized controlled trials such as FOURIER, ODYSSEY OUTCOMES, and VESALIUS-CV. These trials have also shown that PCSK9 inhibitors are effective and safe for the treatment of several cardiovascular disorders. PCSK9 inhibitors are therefore useful in patients who do not reach their target LDL-C levels when on the highest doses of statins or patients with very high cardiovascular risk who cannot tolerate statins at all.

Healthcare dashboard technologies and data visualization for lipid management: A scoping review

BACKGROUND

Lipid disorders significantly increase cardiovascular disease (CVD) risk, the leading cause of mortality worldwide. Effective lipid management is critical for improving health outcomes. Traditional screening methods face challenges due to data complexity and the need for timely decision-making. Data visualization and dashboard technologies offer clear, actionable insights and supporting informed decision-making. This study investigates the use of these technologies in lipid management and their impacts on the quadruple aim of healthcare.

METHODS

This scoping review followed the Joanna Briggs Institute (JBI) approach, focusing on studies involving dashboard technologies or data visualization in lipid management. A comprehensive search across multiple databases (Embase, Web of Science, PubMed, Scopus, CINAHL) and gray literature was conducted, including English-language publications from 2014 to 2024. Data were analyzed using quantitative descriptive and qualitative content analysis to evaluate the key features, clinical applications, and outcomes.

RESULTS

Twenty-seven studies met the inclusion criteria, primarily focusing on dashboard utilization by physicians for managing diabetes and CVD, utilizing electronic medical records and clinical guidelines. Key analysis methods included comparing key performance indicators (KPIs) (85.2%) and trend analysis (74.1%). Lipid management workflows emphasized prevention (88.9%) and treatment planning (77.8%). Interventions included care packages (comprehensive sets of interventions for patient care), decision support systems, web-based tools, and mobile health solutions. Regarding Quadruple Aim outcomes: 12 studies focused on improving population health (8 positive, 4 no change), 9 on clinical outcomes (5 positive, 4 no change), 6 on provider work life (5 positive), 5 on patient experience (positive changes in education and time management), and 2 on cost reduction (1 positive, 1 negative).

CONCLUSIONS

Dashboards are important tools in managing lipid disorders in managing lipid disorders, integrating with educational tools, collaborative care models, and decision support systems. Although they are effective in enhancing population health and clinical experiences, their impact on patient outcomes and cost reduction requires further exploration. Future research should focus on detailed evaluations of dashboard impacts on patient outcomes and cost-effectiveness, emphasizing precision prevention of chronic diseases.

Precision Medicine for Cardiovascular Prevention and Population Health: A Bridge Too Far?

Precision medicine aims to provide personalized clinical care guided by tools that reflect underlying pathophysiology. The need for such an approach has never been greater in cardiovascular medicine, given the large number of guideline-directed medical therapies available. However, progress has been modest to date with few precision tools available for clinicians. Arguably, cardiovascular prevention and population health are poised for innovation to guide evaluation and management, as these areas are already informed by risk-assessment, but limited by the use of crude assessment tools with marginal performance. Risk assessment in prevention and population health may be improved with the use of genetics, circulating biomarkers, and imaging, leading to outcome-specific risk-prediction and enhanced phenotyping. Personalized management matching therapy to risk profile can be then implemented for either individuals or groups, improving cost-effectiveness and risk-benefit. Here, we explore this precision-like approach, including available tools, potential applications, and future perspectives for cardiovascular prevention and population health management.

Effect of an 18-month meditation training on cardiovascular risk in older adults: a secondary analysis of the Age-Well randomized controlled trial

BACKGROUND

Cardiovascular risk factors represent an important health issue in older adults. Previous findings suggest that meditation training could have a positive impact on these risk factors. The objective of this study was to investigate the effects of an 18-month meditation-based intervention on cardiovascular health.

METHODS

Age-Well was a randomized, controlled superiority trial with blinded end point assessment, including community-dwelling cognitively unimpaired adults 65 years and older enrolled between November 24, 2016, and March 5, 2018, in France. One hundred and thirty-four participants were included in this secondary analysis. Participants were randomly affected to an intervention group that received an 18-month meditation-based program or to comparison groups (active control group i.e. non-native language training or passive control group i.e. no intervention). The main outcome was change in the Framingham Risk Score (FRS); other outcomes were changes in cardiovascular and metabolic risk factors.

RESULTS

There was no difference in FRS change after 18 months between trial arms (p = .38). When assessing individual cardiovascular or metabolic risk factors, meditation training was associated with a greater reduction in diastolic blood pressure than the comparison group in participants with intermediate to high cardiovascular risk (FRS > 10%) at baseline (p = .03).

CONCLUSION

An 18-month meditation training was not effective to increase overall cardiovascular health in older adults, but improved diastolic blood pressure in a subgroup analysis including at-risk participants. These results suggest a potential benefit of a long-term meditation intervention in older adults at-risk of cardiovascular diseases, and highlights the need for future research in more targeted populations.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02977819.

Cardiac organ chip: advances in construction and application

Cardiovascular diseases are a leading cause of death worldwide, and effective treatment for cardiac disease has been a research focal point. Although the development of new drugs and strategies has never ceased, the existing drug development process relies primarily on rodent models such as mice, which have significant shortcomings in predicting human responses. Therefore, human-based in vitro cardiac tissue models are considered to simulate physiological and functional characteristics more effectively, advancing disease treatment and drug development. The microfluidic device simulates the physiological functions and pathological states of the human heart by culture, thereby reducing the need for animal experimentation and enhancing the efficiency and accuracy of the research. The basic framework of cardiac chips typically includes multiple functional units, effectively simulating different parts of the heart and allowing the observation of cardiac cell growth and responses under various drug treatments and disease conditions. To date, cardiac chips have demonstrated significant application value in drug development, toxicology testing, and the construction of cardiac disease models; they not only accelerate drug screening but also provide a new research platform for understanding cardiac diseases. In the future, with advancements in functionality, integration, and personalised medicine, cardiac chips will further simulate multiorgan systems, becoming vital tools for disease modelling and precision medicine. Here, we emphasised the development history of cardiac organ chips, highlighted the material selection and construction strategy of cardiac organ chip electrodes and hydrogels, introduced the current application scenarios of cardiac organ chips, and discussed the development opportunities and prospects for their of biomedical applications.

Effectiveness of treat-to-target cholesterol-lowering interventions on cardiovascular disease and all-cause mortality risk in the community-dwelling population: a target trial emulation

Little is known about the long-term effectiveness of risk-based treat-to-target cholesterol-lowering interventions on cardiovascular risk. Here, we show the emulated effectiveness of guideline-recommended low-density and non-high-density lipoprotein cholesterol-lowering interventions using the absolute risk reduction (ARR) and the restricted mean event-free time-based number needed to treat (NNT). With 5,375 participants, the 29-year risks for cardiovascular disease (CVD), all-cause mortality, and atherosclerotic CVD were 18.6%, 25.6%, and 17.7%, respectively. Long-term treat-to-target interventions showed significant reductions in CVD (ARR -2.3%, 95%CI -3.4% to -0.8%; NNT 115), all-cause mortality (-3.0%, -4.3% to -1.8%; 95), and atherosclerotic CVD (-2.6%, -3.5% to -1.2%; 104). Such effects appear more pronounced in women, smokers, and those with body mass index < 24 kg/m² or higher adherence rates.

Primary prevention of cardiovascular diseases among women in a South Asian population: a descriptive study of modifiable risk factors

OBJECTIVE

The aim of this study was the assessment of modifiable risk factors of cardiovascular diseases (CVD) among women versus men at a newly developed preventive cardiology clinic of a large tertiary care cardiac centre in Pakistan.

DESIGN

Observational study.

SETTING

Tertiary care cardiac hospital in Karachi, Pakistan.

PARTICIPANTS

Data for this study were obtained retrospectively from a prospectively collected ongoing registry. We have included all female and male individuals who have presented or were referred to our clinic for primary prevention. All the participants had no history of ischaemic heart disease.

OUTCOME MEASURE

In this study, we evaluated the CVD risk factors, estimated risk of CVD, and glycaemic and cholesterol control at baseline and at subsequent follow-ups for high-risk patients.

RESULTS

A total of 535 patients, 314 females, were included with a mean age of 48.3±12.5 years. At baseline, 57.9% (128) of men versus 73.2% (230) of women (p<0.001) were known cases of hypertension (HTN); 18.1% (40) vs 26.8% (84) (p=0.019) were diabetic; 40.5% (89) vs 9.2% (29) (p<0.001) were tobacco users; 26.0% (56) vs 3.2% (10) (p<0.001) were smokers; and 26.9% (57) vs 50.5% (153) had BMI ≥30 kg/m2, respectively.Baseline atherosclerotic cardiovascular disease (ASCVD) risk score was available for 348 (65%), 61.5% (136) of men versus 67.5% (212) of women. The median ASCVD risk score was 6.8% (2.8%-16.1%) vs 2.25% (1%-5.1%) (p<0.001 for men and women, respectively). The ASCVD risk score was ≥20% (high risk) for 22.1% (30) vs 1.9% (4), while the ASCVD risk score was <5% (low risk) for 40.4% (55) vs 74.1% (157) of men and women, respectively.A repeat ASCVD assessment at a median follow-up of 49.5 (7.0-231) days was available for 259 (48.4%) patients, 26.2% (58) of men vs 64% (201) of women, respectively. The median follow-up ASCVD score was 6.55% (2.8%-15.4%) vs 2.1% (0.9%-4.8%) (p<0.001 with ≥20% (high risk) in 19% (11) vs 2% (4) and <5% (low risk) in 34.5% (20) vs 77.1% (155) of men and women, respectively).

CONCLUSIONS

There is a high prevalence of modifiable risk factors for atherosclerotic CVD such as HTN, diabetes and obesity in women as compared with men, but interestingly, ASCVD risk score at the baseline as well as at the follow-up is high in men versus women. Some other non-modifiable risk factors like age, gender and blood lipid profile may also contribute to this difference between the high prevalence of risk factors and low ASCVD risk score in women. With appropriate follow-up and proper counselling, the looming CVD can be better prevented in this population. A dedicated preventive cardiology clinic for the identification of high-risk women and systematic follow-up is needed to predict their actual CVD risk.

TRIAL REGISTRATION

NCT06503341.

Do Statins Affect Cognitive Health? A Narrative Review and Critical Analysis of the Evidence

PURPOSE OF REVIEW

Statins are the first-line treatment for hypercholesterolemia and play a key role in the prevention of cardiovascular disease (CVD). Current studies report mixed effects of statins on cognitive health, including harmful, neutral, and protective outcomes. However, these ongoing controversies about the potential cognitive adverse effects of statins may compromise their use in CVD prevention. Several factors may influence how statins affect cognition, including the unique cholesterol homeostasis in the brain, the limited permeability of the blood-brain barrier to lipoproteins, and the varying lipophilicity of different statins. This review examines the evidence linking statins to cognitive function and considers the effect of different dosages and treatment durations.

RECENT FINDINGS

Earlier studies suggested cognitive disturbances with statins, but recent evidence does not strongly support a link between statins and cognitive impairment. In fact, observational studies suggest potential neuroprotective benefits, though biases like selection bias, confounding and reverse causation limit definitive conclusions. Two large randomized controlled trials, STAREE and PREVENTABLE, are underway, and their results are expected to address some of these gaps in the literature. Due to insufficient evidence in the current literature, well-designed randomized controlled trials are needed for a better understanding of statins' effects on cognition. More data is needed regarding statin type, dose intensity, and treatment duration, which may affect cognitive outcomes. Future studies are also needed to examine how statins may affect cognition in specific high-risk groups, such as individuals with mild cognitive impairment, diabetes, cardiovascular disease, or chronic kidney disease.

Association between the aromatase (CYP19A1) gene variant rs10046 and cardiovascular risk in postmenopausal women

Objective

To assess the genotypic and allelic distribution of the rs10046 polymorphism in the CYP19A1 gene and evaluate whether this aromatase gene variant is associated with cardiovascular risk in postmenopausal women.

Materials and methods

This cross-sectional study analyzed repository-stored samples from 370 postmenopausal women aged 44-72 years. Clinical, metabolic, and hormonal data were collected. The patients' estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk was calculated using the ASCVD Risk Estimator Plus, as recommended by the American College of Cardiology/American Heart Association. Genotyping of the rs10046 polymorphism of the CYP19A1 gene was carried out using real-time polymerase chain reaction with allelic discrimination assays.

Results

The participants had a mean age of 56.07 ± 5.58 years and a mean body mass index (BMI) of 27.73 ± 5.41 kg/m². The 10-year ASCVD risk was estimated to be low, borderline, intermediate, and high in 64.7%, 12.8%, 19.8%, and 2.7% of the participants, respectively. The CC genotype of the rs10046 polymorphism was associated with low estradiol levels (p = 0.003) and high ASCVD scores (p = 0.014). In a multivariate model, age (p < 0.001) and CC genotype (p = 0.021) were independently associated with higher ASCVD risk.

Conclusion

The present study found that the CC genotype of the rs10046 polymorphism in the CYP19A1 gene is associated with low estradiol levels and an increased ASCVD risk. Additionally, the results indicated that, among postmenopausal women, age and the CC genotype of rs10046 were associated with a high prevalence of ASCVD risk, independent of BMI.

Osteocalcin and Chinese visceral adiposity index are associated with the risk of ASCVD and arterial stiffness in patients with T2DM

This study aims to discover the association between serum osteocalcin, the Chinese visceral adiposity index (CVAI), and atherosclerotic cardiovascular disease (ASCVD) risk, and their impact on arterial stiffness in T2DM patients. We included 639 T2DM patients aged 30 and older who received the assessment of ASCVD risk using the China-PAR equation, Osteocalcin and arterial stiffness in this cross-sectional study. We found that osteocalcin and CVAI as independent risk factors for both medium-high-risk ASCVD (osteocalcin: men, OR,0.96, 95% CI 0.92, 1.00; women, OR, 0.93, 95% CI 0.8, 1.08, respectively)(CVAI: men, OR,1.01,95% CI 1.00,1.02; women: OR, 1.08, 95% CI 1.02,1.14, respectively) and arterial stiffness (osteocalcin: men, OR, 0.98, 95% CI 0.94,1.01; women, OR, 0.98, 95% CI 0.90,1.06, respectively)(CVAI: men, OR,1.0, 95% CI 0.99,1.01; women, OR, 1.02, 95% CI 1.00,1.04, respectively) in both men and women patients with T2DM. Combining osteocalcin levels and CVAI improved the prediction accuracy of arterial stiffness in men patients with T2DM (difference of AUC(Model 4 vs. Model 1):1.5%, NRI: 0.06 [0.0,0.4]). All P-values were < 0.05. The results suggested that osteocalcin levels and CVAI are independent risk factors for ASCVD risk and arterial stiffness in T2DM. Combining osteocalcin and CVAI can enhance the early detection of atherosclerosis through male patients with T2DM.

Chronic low-grade inflammation in patients with systemic sclerosis is associated with increased risk for arteriosclerotic cardiovascular disease

Background

Vasculopathy is a hallmark of systemic sclerosis (SSc) putting patients at an increased risk of cardiovascular disease. Approximately 20-25% of all SSc patients show prolonged elevated C-reactive protein (CRP) levels and thus signs of chronic low-grade inflammation. While CRP-positivity is an independent predictor of cardiovascular disease in non-SSc populations, the relationship between CRP-positivity and cardiovascular health/atherosclerosis in SSc patients is only incompletely understood. Here, we aimed to assess (1) which general, SSc disease-specific and cardiovascular parameters are associated with CRP-positivity in a cohort of SSc patients with prolonged CRP elevations (CRP+ SSc group) relative to SSc patients without CRP elevations (CRP- SSc group). In addition (2), we aimed to investigate whether prolonged CRP-positivity in SSc patients is associated with a higher cardiovascular risk and an increased atherosclerotic burden. We also aimed to (3) identify via random forest classification modeling which combined cardiovascular and/or SSc-specific parameters could differentiate best between SSc patients with elevated CRP levels (the so-called "inflammatory SSc subtype") and SSc patients without increased CRP levels.

Methods

Sixty-five SSc patients were recruited and assigned to the CRP+ SSc group (n = 20) if their CRP levels were > 5 mg/L in at least three half-yearly visits within 2 years before enrolment or to the CRP- SSc group (n = 45), respectively. All patients underwent an anamnesis, physical examination, blood draw, and bilateral carotid ultrasound in order to assess arteriosclerotic burden including the presence, number and height of plaques, and carotid intima-media thickness (CIMT) as well as lipid profiles. 10-year ASCVD risk was estimated via the ASCVD risk estimator plus. Statistical evaluation included Spearman's correlations, logistic regression and random forest modeling under 5-fold cross-validation, and permutation testing to determine combinations of cardiovascular variables highly discriminatory for CRP-positivity.

Results

SSc groups showed comparable mean age, height, and extent of SSc organ involvement. Regarding cardiovascular health, CRP+ SSc patients exhibited a significantly altered HDL-, LDL-, and triglyceride profile (0.001 ≤ p ≤ 0.017) and a significantly higher 10-year ASCVD risk (p = 0.047), relative to CRP- SSc patients. Additionally, within the subgroup of CRP+ SSc patients, positive correlations between CRP levels and CIMT right (ρ = 0.657, p = 0.002) and mean CIMT left and right (ρ = 0.497, p = 0.026) were seen. Combined ROC models identified the four lipid components (HDL, LDL, total cholesterol, and triglycerides) or the SSc duration and ASCVD category to differentiate with high cross-validated ROC-AUCs (AUC: 0.83 ± 0.15, and AUC: 0.86 ± 0.09, p < 0.001) for prolonged CRP-positivity among SSc patients.

Conclusion

Our data indicate that persistent CRP-positivity and thus chronic low-grade inflammation in SSc patients enhance the risk for arteriosclerotic-cardiovascular disease significantly beyond the ASCVD risk observed for our SSc patients without CRP elevations. It seems to be along with a disrupted lipid profile the hallmark of a distinct "inflammatory" subgroup of SSc patients. However, large population-based studies and clinical trials in patients with SSc are needed to validate our findings in a prospective or interventional setting.

Smoking Cessation and Incident Cardiovascular Disease

Importance

The association between smoking cessation and cardiovascular disease (CVD) risk in relation to cumulative smoking exposure remains poorly understood.

Objective

To evaluate the associations among smoking cessation, lifetime smoking burden, and CVD risk according to the number of years elapsed after smoking cessation.

Design, Setting, and Participants

This retrospective cohort study of the Korean National Health Insurance Service database investigated smoking duration and intensity between January 2006 and December 2008. Participants were categorized by self-reported smoking habits as current, ex-, or never-smokers. Smoking records were updated every 2 years until December 2019, with participants whose smoking status changed or whose smoking status was unclear excluded. Data analysis was performed between June and December 2022.

Exposures

Time-updated self-reported smoking status, years since quitting, and cumulative smoking amount (pack-years [PY]).

Main Outcomes and Measures

The primary outcome was incidence and hazard ratio of CVD (composite of cardiovascular death, myocardial infarction, stroke, and heart failure).

Results

Overall, 5 391 231 participants (39.9% male; mean [SD] age, 45.8 [14.7] years; 853 756 [15.8%] current smokers, 104 604 [1.9%] ex-smokers, and 4 432 871 [82.2%] never smokers) were followed up for a mean (SD) of 4.2 (4.4) years. The median (IQR) baseline cumulative smoking amounts were 14.0 (7.5-20.0) PY in current smokers and 10.5 (5.3-20.0) PY in ex-smokers. The median (IQR) duration of smoking cessation was 4 (2-8) years for ex-smokers. Regardless of continued smoking, a dose-dependent association was evident between smoking and incident CVD. Compared with current smokers, ex-smokers with a lifetime smoking burden of less than 8 PY (light ex-smokers) experienced a significant reduction in CVD risk within 10 years of cessation, with a CVD risk similar to that of never-smokers. Conversely, ex-smokers with at least 8 PY (heavy ex-smokers) exhibited a slower decline in CVD risk than light ex-smokers, requiring more than 25 years for the residual CVD risk to disappear.

Conclusions and Relevance

In this cohort study, smoking and CVD risk exhibited a dose-dependent association, with light ex-smokers having a CVD risk similar to that of never-smokers relatively soon after smoking cessation. For heavy ex-smokers, greater than 25 years might be required for the residual CVD risk to align with that of never-smokers.

Space Travel: The Radiation and Microgravity Effects on the Cardiovascular System

Space flight modulates the functions of the cardiovascular system. The exposure to space conditions can alter the cerebral blood flow, as well as the venous return. Anemia, cardiac output changes, and increased activity of the sympathetic nervous system can also be seen. Understanding cardiac changes prepares astronauts for both better in-flight adaptations and long-term protection against cardiovascular diseases. The heart could undergo radio-degenerative effects when exposed to space radiation, increasing the risk of cardiovascular diseases in the long run. A high frequency of arrhythmias, such as ventricular/atrial premature complexes, have been reported during the Gemini and Apollo missions. Additionally, microgravity can lead to progressive degeneration of the myocytes and muscle atrophy with altered gene expression and calcium handling, along with impaired contractility. This review summarizes the potential cardiovascular effects of spaceflight and prevention measures.