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

Discharge Disposition in Veterans with Heart Failure: Impact of Dementia and Severe Mental Illness

OBJECTIVES

Post-acute heart failure (HF) care presents significant management challenges, particularly among veterans with cognitive and behavioral impairments due to Alzheimer disease and related dementias (AD/ADRD) or severe mental illness (SMI). We hypothesized that comorbid AD/ADRD and SMI would reduce the likelihood of discharge home following HF hospitalization. In addition, we explored how AD/ADRD and SMI influence discharge to Veterans Affairs (VA) Community Living Centers (CLCs) compared with Medicare Skilled Nursing Facilities (SNFs).

DESIGN

Retrospective cohort study spanning January 1, 2011, to September 30, 2019.

SETTING AND PARTICIPANTS

Veterans hospitalized with acute HF at VA hospitals (n = 291,117).

METHODS

We examined VA administrative data from HF hospitalizations to assess how AD/ADRD and SMI impact post-hospital discharge location. Using diagnostic codes from the prior year, we stratified participants by the presence of AD/ADRD and/or SMI, then employed logistic regression models to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for discharge location, adjusted for demographics, comorbidities, and health care utilization.

RESULTS

Participants were predominantly older (mean age: 78.1 ± 11.1 years), male (97.5%), and self-identified as white (72.7%). Those with AD/ADRD alone (n = 16,212) or SMI alone (n = 33,194) outnumbered those with both conditions (n = 3612). Compared with neither condition, the presence of AD/ADRD alone [adjusted OR (aOR), 0.523; 95% CI, 0.505-0.542], SMI alone (aOR, 0.869; 95% CI, 0.843-0.896), and both conditions (aOR, 0.505; 95% CI, 0.47-0.542) all reduced likelihood of discharge home. Participants with AD/ADRD and SMI were more likely to be discharged to a CLC than a SNF (aOR, 1.225; 95% CI, 1.064-1.411).

CONCLUSIONS AND IMPLICATIONS

Our findings indicate that AD/ADRD and SMI are major barriers to discharge home for patients with HF, suggesting a need for enhanced supervision during health care transitions. This study calls for further research into how discharge location affects short- and long-term clinical outcomes in patients with cognitive and behavioral impairment.

Cardiac Repair and Regeneration via Advanced Technology: Narrative Literature Review

BACKGROUND

Cardiovascular diseases (CVDs) are the leading cause of death globally, and almost one-half of all adults in the United States have at least one form of heart disease. This review focused on advanced technologies, genetic variables in CVD, and biomaterials used for organ-independent cardiovascular repair systems.

OBJECTIVE

A variety of implantable and wearable devices, including biosensor-equipped cardiovascular stents and biocompatible cardiac patches, have been developed and evaluated. The incorporation of those strategies will hold a bright future in the management of CVD in advanced clinical practice.

METHODS

This study employed widely used academic search systems, such as Google Scholar, PubMed, and Web of Science. Recent progress in diagnostic and treatment methods against CVD, as described in the content, are extensively examined. The innovative bioengineering, gene delivery, cell biology, and artificial intelligence-based technologies that will continuously revolutionize biomedical devices for cardiovascular repair and regeneration are also discussed. The novel, balanced, contemporary, query-based method adapted in this manuscript defined the extent to which an updated literature review could efficiently provide research on the evidence-based, comprehensive applicability of cardiovascular devices for clinical treatment against CVD.

RESULTS

Advanced technologies along with artificial intelligence-based telehealth will be essential to create efficient implantable biomedical devices, including cardiovascular stents. The proper statistical approaches along with results from clinical studies including model-based risk probability prediction from genetic and physiological variables are integral for monitoring and treatment of CVD risk.

CONCLUSIONS

To overcome the current obstacles in cardiac repair and regeneration and achieve successful therapeutic applications, future interdisciplinary collaborative work is essential. Novel cardiovascular devices and their targeted treatments will accomplish enhanced health care delivery and improved therapeutic efficacy against CVD. As the review articles contain comprehensive sources for state-of-the-art evidence for clinicians, these high-quality reviews will serve as a first outline of the updated progress on cardiovascular devices before undertaking clinical studies.

Recent Progress in Developing Extracellular Vesicles as Nanovehicles to Deliver Carbohydrate-Based Therapeutics and Vaccines

Cell-derived, nanoscale extracellular vesicles (EVs) have emerged as promising tools in diagnostic, therapeutic, and vaccine applications. Their unique properties including the capability to encapsulate diverse molecular cargo as well as the versatility in surface functionalization make them ideal candidates for safe and effective vehicles to deliver a range of biomolecules including gene editing cassettes, therapeutic proteins, glycans, and glycoconjugate vaccines. In this review, we discuss recent advances in the development of EVs derived from mammalian and bacterial cells for use in a delivery of carbohydrate-based protein therapeutics and vaccines. We highlight key innovations in EVs' molecular design, characterization, and deployment for treating diseases including Alzheimer's disease, infectious diseases, and cancers. We discuss challenges for their clinical translation and provide perspectives for future development of EVs within biopharmaceutical research and the clinical translation landscape.

Temporal Transcriptomic Differences in Stroke Between Diabetic and Non-Diabetic Mice

Diabetes is a key risk factor for ischemic stroke and negatively impacts long-term outcomes post-stroke. However, genomic studies on diabetic stroke remain insufficient. This study aims to investigate the interaction between diabetes and stroke from the acute phase to the early recovery phase by establishing a diabetic stroke animal model and comparing transcriptome sequencing results with those of non-diabetic stroke models. The study identified a greater number of downregulated genes in the diabetic stroke group compared to the non-diabetic group at different stages post-stroke. Functional enrichment analysis revealed an enhanced immune response and a relatively lower neurodegeneration potential in the diabetic group. Post-stroke, a higher presence of CD4 + T cells, eosinophils, and M1 macrophages was observed in the diabetic group. Additionally, time-series analysis identified a set of genes with time-specific expression patterns following diabetic stroke. This study underscores the role of inflammation and immune responses as potential factors exacerbating ischemic stroke in diabetes while also identifying gene regulatory networks at different stages post-stroke. These findings provide new insights into the role of diabetes in stroke and suggest potential therapeutic targets for improving outcomes in diabetic patients.

Catestatin in Cardiovascular Diseases

Cardiovascular diseases are one of the leading causes of mortality and morbidity worldwide. The pathogenesis of this group of disorders is highly complex and involves interactions between various cell types and substances, among others, catestatin (CTS). In recent years, numerous researchers have expanded our knowledge about CTS's role in development and its potential for the treatment of a variety of diseases. In this review, the authors discuss CTS's importance in the pathogenesis of arterial hypertension, coronary artery disease, and heart failure. Moreover, we present CTS's influence on heart and vessel function.

Autoimmune cardiac channelopathies and heart rhythm disorders: A contemporary review

Cardiac arrhythmias still represent a major health problem worldwide, at least in part because the fundamental pathogenic mechanisms are not fully understood, thus affecting the efficacy of therapeutic measures. In fact, whereas cardiac arrhythmias are in most cases due to structural heart diseases, the underlying cause remains elusive in a significant number of patients despite intensive investigations even including postmortem examination and molecular autopsy. A large body of data progressively accumulated during the last decade provides strong evidence that autoimmune mechanisms may be involved in a significant number of such unexplained or poorly explained cardiac arrhythmias. Several proarrhythmic anti-cardiac ion channel autoantibodies have been discovered, in all cases able to directly interfere with the electrophysiologic properties of the heart but leading to different arrhythmic phenotypes, including long QT syndrome, short QT syndrome, and atrioventricular block. These autoantibodies, which may develop independent of a history of autoimmune diseases, could help explain a percentage of arrhythmic events of unknown origin, thereby opening new frontiers for diagnosis and treatment of heart rhythm disorders. Based on this evidence, the novel term autoimmune cardiac channelopathies was coined in 2017. Since then, the interest in the field of cardioimmunology has shown a tumultuous growth, so much so that the number of arrhythmogenic anti-ion channel autoantibodies reported has significantly increased, also in association with not previously described arrhythmic phenotypes, such as atrial fibrillation, Brugada syndrome, and ventricular fibrillation/cardiac arrest. Thus, an updated reassessment of this topic, also highlighting perspectives and unmet needs, has become necessary and represents the main objective of this review.

Air pollution is associated with increased risk of venous thromboembolism: the Multi-Ethnic Study of Atherosclerosis

ABSTRACT

Air pollution exposure may induce procoagulant effects, and chronic exposure may be linked to greater risk of venous thromboembolism (VTE). We tested the hypothesis that air pollution is associated with increased VTE risk in the prospective Multi-Ethnic Study of Atherosclerosis, which has well-characterized air pollution measures and information on potential confounding factors. We included 6651 participants recruited in 2000 to 2002 (baseline age range, 45-84 years; 53% female). Air pollution was assessed with a validated spatiotemporal model that incorporates cohort-specific monitoring. Four indexes of air pollution updated each fortnight over follow-up were averaged to estimate participant-level chronic exposure: fine particulate matter ≤2.5 micrometers in aerodynamic diameter (PM2.5), oxides of nitrogen (NOx), nitrogen dioxide (NO2), and ozone (O3). Mean±SD PM2.5 was 13.5±3.0 μg/m3, NO2 17.9±8.2 parts per billion (ppb), NOx 36.1±19.6 ppb, and O3 22.2±3.7 ppb. Incident VTE was identified using hospitalization discharge codes through 2018. A total of 248 VTE events accrued over a median follow-up of 16.7 years. After adjustment for baseline demographics, health behaviors, and body mass index, the hazard ratio (95% confidence interval) for incident VTE associated per 3.6 μg/m3 higher PM2.5 was 1.39 (1.04-1.86); per 13.3 ppb higher NO2 concentration was 2.74 (1.57-4.77); and per 30 ppb higher NOx was 2.21 (1.42-3.44). O3 was not related. In this prospective community-based cohort with individual-level estimation of chronic air pollution exposure, higher average ambient concentrations of PM2.5, NO2, and NOX were associated with greater risk of developing VTE. Findings add to accumulating evidence of adverse health effects attributed to air pollution exposure.

Overcoming Financial Barriers to Optimal Guideline-Directed Medical Therapy for Patients With Heart Failure

Optimizing guideline-directed medical therapy in patients with heart failure with reduced ejection fraction is paramount. The cost of the newer medications can be a financial barrier for many patients. There are numerous resources available for patients to help overcome financial barriers using team-based care. Here, we discuss a case of a 79-year-old woman with heart failure with reduced ejection fraction who gained access to all 4 pillars of guideline-directed medical therapy by utilizing patient assistance resources through a medication optimization clinic.

Indoleacetylglutamine Pathway Is a Potential Biomarker for Cardiovascular Diseases

Cardiovascular diseases (CVDs) remain a leading cause of global morbidity and mortality. Metabolomics allows for the identification of important biomarkers for CVDs, essential for early detection and risk assessment. This cross-sectional study aimed to identify novel metabolic biomarkers associated with CVDs using non-targeted metabolomics. We compared the metabolic profiles of 112 patients with confirmed CVDs diagnosis and 112 gender- and age-matched healthy controls from the Qatar Biobank database. Orthogonal partial least square discriminate analysis and linear models were used to analyze differences in the level of metabolites between the two groups. We report here a significant association between the indoleacetylglutamine pathway and cardiovascular diseases, expanding the repertoire of gut microbiota metabolites linked to CVDs. Our findings suggest that alterations in gut microbiota metabolism, potentially resulting in increased production of indoleacetate, indoleacetylglutamine, and related compounds at the expense of the cardioprotective indolepropionate, may contribute to this association. Our findings may pave the way for novel approaches in CVD risk assessment and potential therapeutic interventions targeting the gut-heart axis.

A spectral machine learning approach to derive central aortic pressure waveforms from a brachial cuff

Analyzing cardiac pulse waveforms offers valuable insights into heart health and cardiovascular disease risk, although obtaining the more informative measurements from the central aorta remains challenging due to their invasive nature and limited noninvasive options. To address this, we employed a laboratory-developed cuff device for high-resolution pulse waveform acquisition and constructed a spectral machine learning model to nonlinearly map the brachial wave components to the aortic site. Simultaneous invasive aortic catheter and brachial cuff waveforms were acquired in 115 subjects to evaluate the clinical performance of the developed wave-based approach. Magnitude, shape, and pulse waveform analysis on the measured and reconstructed aortic waveforms were correlated on a beat-to-beat basis. The proposed cuff-based method reconstructed aortic waveform contours with high fidelity (mean normalized-RMS error = 11.3%). Furthermore, continuous signal reconstruction captured dynamic aortic systolic blood pressure (BP) oscillations (r = 0.76, P < 0.05). Method-derived central pressures showed strong correlation with the independent invasive measurement for systolic BP (R2 = 0.83; B [LOA] = -0.3 [-17.0, 16.4] mmHg) and diastolic BP (R2 = 0.58; B [LOA] = -0.7 [-13.1, 11.6] mmHg). Shape-based features are effectively captured by the spectral machine learning method, showing strong correlations and no systemic bias for systolic pressure-time integral (r = 0.91, P < 0.05), diastolic pressure-time integral (r = 0.95, P < 0.05), and subendocardial viability ratio (r = 0.86, P < 0.05). These results suggest that the nonlinear transformation of wave components from the distal to the central site predicts the morphological waveform changes resulting from complex wave propagation and reflection within the cardiovascular network. The proposed wave-based approach holds promise for future applications of noninvasive devices in clinical cardiology.

Burden of Hyperlipidemia, Cardiovascular Mortality, and COVID-19: A Retrospective-Cohort Analysis of US Data

BACKGROUND

Hyperlipidemia is a major cardiovascular disease (CVD) risk factor, but there are limited data on its mortality trends in CVD over time. We assessed annual hyperlipidemia-related CVD mortality trends in the United States, including the COVID-19 pandemic's impact.

METHODS AND RESULTS

Mortality data were obtained from the Centers for Disease Control and Prevention repository between 1999 and 2020 among patients ≥15 years old, using International Classification of Diseases, Tenth Revision (ICD-10) codes for hyperlipidemia (E78.0-E78.5) and CVD (I00-I99). Age-adjusted mortality rates (AAMRs) per 1 000 000 population were standardized to the 2000 US population. Log-linear regression models were used to evaluate mortality shifts. Average annual percentage change from 1999 to 2019 was used to project 2020 AAMRs, estimating pandemic-attributed excess deaths. From 1999 to 2020, 483 155 hyperlipidemia-related CVD deaths occurred. Despite a general CVD mortality decline, hyperlipidemia-related CVD AAMRs rose from 36.33 in 1999 to 99.77 in 2019. Ischemic heart diseases (AAMR 49.39) were the leading cause, whereas hypertension had the highest mortality increase (average annual percentage change +10.23%). Mortality rates were higher in men (AAMR 104.87) and non-Hispanic (AAMR 82.49), and rural populations (AAMR 89.98). Highest mortality was observed in Black populations (AAMR 84.35), those ≥75 years old (AAMR 646.45), and Western US regions (AAMR 96.88). During the first pandemic year, deaths exceeded projections by 10.55%, with notable increases among ages 35 to 75 (14.23%), Hispanic (17.96%), Black (14.82%), and urban (11.68%) groups.

CONCLUSIONS

Hyperlipidemia-related CVD mortality has risen over the past 2 decades, further heightened by the COVID-19 pandemic, with higher impact on men, Black Americans, the older population, and rural residents. Further study is needed to understand contributing factors and mitigate disparities.

Association Between Stroke and Traumatic Brain Injury: A Systematic Review and Meta-Analysis

BACKGROUND

Stroke and traumatic brain injury (TBI) represent two major health concerns worldwide. There is growing evidence suggesting a potential association between TBI and stroke. In this systematic review and meta-analysis, we aim to explore the association between TBI and stroke risk, with a specific focus on overall stroke risk and subgroup variations based on stroke type, severity, and the post-TBI time period.

METHODS

PubMed, Web of Science (WOS), Scopus, and Cochrane Library were systematically searched for studies exploring the link between stroke and TBI. The pooled hazard ratios (HRs) with a 95% confidence interval (CI) were calculated. The Comprehensive Meta-Analysis (CMA) software was used for the analysis. Subgroup analyses were conducted based on stroke type, TBI severity, and post-TBI phase. The Newcastle-Ottawa Scale (NOS) was utilized for the quality assessment.

RESULTS

We included a total of 13 observational studies, with data from 8 studies used for quantitative analysis. A history of TBI was associated with a significantly higher odds of stroke compared to controls (HR = 2.3, 95% CI (1.79 to 2.958), p < 0.001). The risk was greater for hemorrhagic stroke (HR = 4.8, 95% CI (3.336 to 6.942), p < 0.001) than for ischemic stroke (HR = 1.56, 95% CI (1.28 to 1.9), p < 0.001). Both moderate-to-severe TBI (HR = 3.64, 95% CI (2.158 to 6.142), p < 0.001) and mild TBI (HR = 1.81, 95% CI (1.17 to 2.8), p = 0.007) were associated with a significantly higher risk of stroke. The risk was also higher in the early post-TBI phase (1-30 days) (HR = 4.155, 95% CI (2.25 to 7.67), p < 0.001) compared to later phases (HR = 1.68, 95% CI (1.089 to 2.59), p = 0.019) from 30 days to 1 year and (HR = 1.87, 95% CI (1.375 to 2.544), p < 0.001) after 1 year.

CONCLUSIONS

This systematic review confirms a significant association between TBI and an increased risk of stroke, regardless of TBI severity, type, or timing of stroke. The findings highlight the need for early monitoring and advocating preventive strategies for stroke in patients with a history of TBI.

Menopause-related changes in vascular signaling by sex hormones

Cardiovascular disease (CVD), such as hypertension and coronary artery disease, involves pathological changes in vascular signaling, function, and structure. Vascular signaling is regulated by multiple intrinsic and extrinsic factors that influence endothelial cells, vascular smooth muscle, and extracellular matrix. Vascular function is also influenced by environmental factors including diet, exercise, and stress, as well as genetic background, sex differences, and age. CVD is more common in adult men and postmenopausal women than in premenopausal women. Specifically, women during menopausal transition, with declining ovarian function and production of estrogen (E2) and progesterone, show marked increase in the incidence of CVD and associated vascular dysfunction. Mechanistic research suggests that E2 and E2 receptor signaling have beneficial effects on vascular function including vasodilation, decreased blood pressure, and cardiovascular protection. Also, the tangible benefits of E2 supplementation in improving menopausal symptoms have prompted clinical trials of menopausal hormone therapy (MHT) in CVD, but the results have been inconsistent. The inadequate benefits of MHT in CVD could be attributed to the E2 type, dose, formulation, route, timing, and duration as well as menopausal changes in E2/E2 receptor vascular signaling. Other factors that could affect the responsiveness to MHT are the integrated hormonal milieu including gonadotropins, progesterone, and testosterone, vascular health status, preexisting cardiovascular conditions, and menopause-related dysfunction in the renal, gastrointestinal, endocrine, immune, and nervous systems. Further analysis of these factors should enhance our understanding of menopause-related changes in vascular signaling by sex hormones and provide better guidance for management of CVD in postmenopausal women. SIGNIFICANCE STATEMENT: Cardiovascular disease is more common in adult men and postmenopausal women than premenopausal women. Earlier observations of vascular benefits of menopausal hormone therapy did not materialize in randomized clinical trials. Further examination of the cardiovascular effects of sex hormones in different formulations and regimens, and the menopausal changes in vascular signaling would help to adjust the menopausal hormone therapy protocols in order to enhance their effectiveness in reducing the risk and the management of cardiovascular disease in postmenopausal women.

Sex-Related Differences in the Prognostic Role of Acetylcholine Provocation Testing

BACKGROUND

Intracoronary provocation testing with acetylcholine (ACh) is helpful to diagnose and risk-stratify patients with ischemia with nonobstructed coronary arteries (NOCA) and myocardial infarction with NOCA. This study explored potential sex-related disparities on the prognostic significance of ACh provocative testing.

METHODS

Consecutive patients with ischemia with NOCA and those with myocardial infarction with NOCA who underwent ACh provocation testing were enrolled. The primary end point was the incidence of major adverse cardiovascular and cerebrovascular events at follow-up. Co-primary end points were angina recurrence and quality of life assessed by 12-month Seattle Angina Questionnaire (SAQ) summary score.

RESULTS

A total of 519 patients (mean age, 61.4±12.1 years; 275 [53.0%] women and 244 [47%] men) were enrolled: 346 (66.7%) with ischemia with NOCA and 173 (33.3%) with myocardial infarction with NOCA. A positive ACh test was observed in 274 (52.8%) patients, with a lower prevalence of epicardial spasm (82 [56.2%] versus 106 [82.8%]) and a higher prevalence of microvascular spasm (64 [43.8%] versus 22 [17.2%]) in women compared with men (P>0.001). After a median 22-month follow-up, major adverse cardiovascular and cerebrovascular events occurred in 53 (10.2%) patients, without significant sex differences (P>0.05). Men with a positive ACh test had a significantly higher rate of major adverse cardiovascular and cerebrovascular events (22 [17.2%] versus 5 [4.3%], P=0.002) compared with those with a negative test; no difference was observed in women (P>0.05) (P for interaction=0.003). Women with a positive test experienced a higher rate of angina recurrence (61 [41.8%] versus 32 [24.8%], P=0.005) and a lower SAQ summary score (82 [interquartile range, 72-90] versus 86 [interquartile range, 78-100], P<0.001) compared with those with a negative result; no difference was observed in men (P>0.05).

CONCLUSIONS

This study revealed the importance of recognizing sex-specific differences in the prognostic value of ACh testing for proper management of coronary vasomotor disorders.

Depression, Anxiety, and Quality of Life in a Cardiac Rehabilitation Program Without Dedicated Mental Health Resources Post-Myocardial Infarction

Anxiety and depression are common after a myocardial infarction (MI), so psychological and psychiatric mental health (MH) interventions are recommended during Cardiac Rehabilitation Programs (CRP). We aim to evaluate anxiety and depression symptoms and quality of life in MI sufferers followed in a CRP without dedicated MH resources. We prospectively included 164 MI patients in our CRP without dedicated MH resources. Patient Health Questionnaire 2-item (PHQ-2) and Generalized Anxiety Disorder 2-item (GAD-2) questionnaires for depression and anxiety screening (altered if ≥3 points) and the 36-Item Short Form Survey Instrument (SF-36) to analyze four MH components and Mental Component Summary (MCS) were assessed at the beginning and after CRP. The mean age was 61.35 ± 10.76 years, and most patients were male (86.6%). A significant improvement in SF-36 mental components (from +5.94 ± 27.98 to +8.31 ± 25 points, p < 0.001) and SF-36-MCS (+1.85 ± 10.23 points, p = 0.02) was noted, as well as a reduction in depression and anxiety symptoms in PHQ-2 and GAD-2 (p < 0.001). However, 33 (20.1%) patients showed a positive screening for depression and/or anxiety at the end of the program. These patients were younger (56.6 ± 8.05 vs. 62.55 ± 11.05 years, p = 0.004) and showed significantly worse initial scores of SF-36 mental components, PHQ-2, and GAD-2 (p < 0.001). We conclude that a Phase 2 CRP without dedicated MH resources can achieve significant improvements in MH well-being after MI. However, one-fifth of the population had substantial depression and/or anxiety symptoms at the end of the program. This subset, characterized by worse initial MH scores, may benefit from specific MH interventions during CRP.

A Virtual Cardiometabolic Health Program Among African Immigrants in the US: A Pilot Cluster-Randomized Clinical Trial

Importance

Black persons, including immigrants, in the US disparately experience poor cardiometabolic health (CMH). Limited research on the effect of lifestyle interventions that improve CMH among African immigrant populations is available.

Objective

To test the effectiveness of a culturally adapted, virtual lifestyle intervention on control of blood pressure (BP) and hemoglobin A1c (HbA1c) levels among African immigrants with CMH risk factors.

Design, Setting, and Participants

Afro-DPP (Diabetes Prevention Program), a pilot cluster-randomized clinical trial, evaluated the effectiveness of a multicomponent CMH intervention. The study took place in 2 churches with predominantly African immigrant congregations in the Baltimore-Washington, DC, metropolitan area from January 1, 2022, to July 31, 2023. Participants were adults aged 25 to 75 years with at least 2 CMH risk factors who self-identified as African immigrants and belonged to the participating churches. Analyses followed the intention-to-treat principle.

Intervention

Participants received a 6-month culturally adapted lifestyle intervention based on the National DPP curriculum, delivered via virtual group sessions by a lifestyle coach of African origin. The delayed intervention began 6 months later with a follow-up time of 6 months. The intervention also included remote BP and weight monitoring.

Main Outcome and Measures

Primary outcomes were changes in systolic and diastolic BP and HbA1c levels from baseline to 6 months. Secondary outcomes included reduced body weight and body mass index (BMI; calculated as weight in kilograms divided by height in meters squared).

Results

The analytic population included 60 participants (mean [SD] age, 50.6 [11.9] years; 40 [66.7%] women). In the first intervention group (n = 30), systolic BP decreased by 9.2 (95% CI, 2.5-15.9) mm Hg, diastolic BP by 6.1 (95% CI, 2.1-10.0) mm Hg, body weight by 4.9 (95% CI, 1.0-8.7) kg, and BMI by 1.1 (95% CI, 0.4-1.7) at 6 months. In the delayed intervention group (n = 30), systolic BP decreased by 11.4 (95% CI, 2.4-20.5) mm Hg, diastolic BP by 10.3 (95% CI, 5.4-15.2) mm Hg, and body weight by 3.3 (95% CI, 0.01-6.5) kg, while BMI increased by 0.3 (95% CI, -1.5 to 2.0).

Conclusions and Relevance

Trial findings indicate that interventions incorporating cultural adaptation and virtual components could help address CMH disparities in this population.

Trial Registration

ClincalTrials.gov Identifier NCT05144737.

Usefulness of body and visceral fat determined by bioimpedancemetry versus body mass index and waist circumference in the identification of elevated values of different atherogenesis risk scales

INTRODUCTION

Obesity and atherogenesis are two highly prevalent pathological processes worldwide that also share several pathophysiological mechanisms.

OBJECTIVES

Descriptive and cross-sectional study in 8,590 Spanish workers (4,104 men and 4,486 women) with an average age of 41.5years, in which the usefulness of four scales of overweight and obesity such as body mass index (BMI), waist circumference and percentages of body and visceral fat determined by bioimpedance measurement to identify high levels of atherogenic risk determined by atherogenic dyslipidemia (AD), lipid triad (LT) and several atherogenic indices is assessed.

RESULTS

All the overweight and obesity scales show a predictive value between moderate and good, determined by the AUC of the ROC curves, with values ranging from 0.727 to 0.886 in women and 0.676 to 0.885 in men. Of all of them, the one with the highest AUC is visceral fat with values exceeding 0.800 and the lowest are for BMI. In all cases, the AUC is higher in women.

CONCLUSIONS

The overweight and obesity scales analysed (BMI, waist circumference and percentage of body and visceral fat) show AUCs for predicting atherogenic risk between moderate and high, with visceral fat being the most useful of all.

Does the alternating timing of rTMS combined with soft-hand rehabilitation robot affect the recovery of hand function in patients after stroke? A study protocol for a multicentre randomised controlled trial

INTRODUCTION

Combining repetitive transcranial magnetic stimulation (rTMS) with robotic training could result in more significant improvements in motor function than either treatment alone. The efficacy of this combination may depend on the sequencing of the interventions. However, few studies have explored the possibility of interleaving or alternating between the two treatment modalities within a single session or over a shorter time frame. The objective of this study is to evaluate the efficacy of alternating rTMS and soft-hand rehabilitation robot therapy to enhance upper limb and hand function in patients with ischaemic stroke.

METHODS AND ANALYSIS

This multicentre study will be conducted as a single-blind, controlled, randomised trial, enrolling 132 post-stroke patients with a disease duration ranging from 1 week to 3 months. The study participants will be randomly assigned to group A (n=44), group B (n=44) and group C (n=44). All participants will undergo a 4-week neurological rehabilitation programme, which includes standardised physical and occupational therapy administered by experienced therapists. Group A will receive 10 Hz high-frequency rTMS (HF-rTMS) over the ipsilesional primary motor cortex (iM1) for 20 min, followed by 20 min of soft-hand rehabilitation robot training. Group B will receive 5 min of 10 Hz HF-rTMS over the iM1 followed by 5 min of soft-hand rehabilitation robot training, repeated four times. Group C will receive sham rTMS with other parameters identical to those of group A. The above treatments will be administered once daily, 5 days a week, for 4 weeks. The primary outcome measurement is the Fugl-Meyer assessment of upper extremity (FMA-UE). The secondary outcome measurements include the Hong Kong edition of Functional Test for the Hemiplegic Upper Extremity (FTHUE-HK), the Modified Ashworth Scale (MAS), and the International Classification of Functioning, Disability and Health upper extremity entries (ICF-Upper Extremity Entries). Assessments will be conducted at baseline and after 4 weeks of treatment.

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Committee of the First Affiliated Hospital of Nanjing Medical University (2024-SR-515). The findings of this study will be spread through networks of scientists, professionals and the general public, as well as peer-reviewed scientific papers and presentations at pertinent conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2400089583.

Face Recognition-Driven Video Game for Dysphagia Rehabilitation in Stroke Patients: A Pilot Randomized Controlled Trial

OBJECTIVE

To explore the feasibility and effectiveness of face recognition-driven video game (FR-VG) swallowing training for stroke patients with dysphagia.

DESIGN

A single-blind pilot randomized controlled trial.

SETTING

A rehabilitation center.

PARTICIPANTS

Stroke patients with dysphagia (N=26).

INTERVENTIONS

Participants in the intervention group were trained using FR-VG, while the control group used the conventional method (ie, lip exercise, tongue exercise, and lower jaw exercise). The training was conducted 5 days a week over 4 weeks.

OUTCOME MEASURES

The swallowing function and swallowing-related quality of life between the 2 groups were observed before and after the intervention. The acceptance of FR-VG in the intervention group and the adherence of the patients in the 2 groups after the intervention were analyzed.

RESULTS

A total of 26 stroke patients with dysphagia were included. The results showed that after the intervention, both groups exhibited significant improvements in swallowing function and swallowing-related quality of life compared to the pre-intervention (P<.05). Patients in the intervention group demonstrated better swallowing function than the control group on the Gugging Swallowing Screen (P=.015) and Functional Oral Intake Scale (P=.004). The intervention group had a high acceptance of the FR-VG training and had significantly better adherence compared to the control group (P=.032).

CONCLUSIONS

FR-VG rehabilitation training can help improve swallowing function, swallowing-related quality of life, and training adherence in stroke patients with dysphagia. Patients have a high acceptance of FR-VG rehabilitation training, which can be used as an adjunctive method to conventional rehabilitation.

Patient Interpretations of Heart Failure Symptom Recognition and Self-Management Using Vignettes: A Pilot Study

BACKGROUND

Heart failure is a condition with significant symptom burden and high hospitalization rates. Effective self-management, including recognizing symptoms and making behavior changes, is crucial but often inadequately addressed by current educational methods. To improve this, heart failure self-care vignettes were developed to measure knowledge of managing physical and psychological symptoms. However, the vignettes' face validity and reliability have not been thoroughly evaluated.

OBJECTIVE

To ensure the understandability of a novel instrument to measure knowledge of heart failure symptom recognition and self-management and to examine its inter-rater reliability with individuals diagnosed with heart failure.

METHODS

Cognitive interviews were conducted with heart failure patients admitted to an academic hospital in the Midwest U.S. Vignette segments and interview questions were analyzed, totaling 74 items. Five patients aged 65 and older, participated without cognitive, visual, or hearing impairments. The interviews were coded by two independent raters using a cognitive interview coding book. Vignettes were evaluated qualitatively with a 3-point Likert scale (1 = misunderstanding, 2 = partial understanding, and 3 = full understanding). Inter-rater reliability was assessed using percent agreement and Cohen's kappa.

RESULTS

Patients understood an average of 76% of the psychological and 83% of the physical vignette items, indicating acceptable preliminary understandability. Inter-rater reliability was moderate, with Cohen's kappa values of 0.39 (psychological) and 0.43 (physical).

CONCLUSIONS

This pilot study suggests that vignettes could be a useful tool for assessing knowledge of symptom recognition and self-management. Cognitive interviewing helped evaluate how vignette segments were interpreted before using them in future data collection.

Early Versus Delayed Invasive Management of Female Patients With Non-ST-Elevation Acute Coronary Syndrome: An Individual Patient Data Meta-Analysis

BACKGROUND

Female patients are at greater risk of adverse events following non-ST-elevation acute coronary syndrome but less frequently receive guideline-recommended coronary angiography and revascularization. Routine invasive management benefits high-risk patients, but evidence informing the optimal timing of angiography specifically in female patients is lacking.

METHODS

Medline, Web of Science, and Scopus were searched up to November 2023. Randomized controlled trials investigating early versus delayed timing of coronary angiography in patients with non-ST-elevation acute coronary syndrome were included. Individual patient data from female patients were extracted. The primary end point was a composite of all-cause mortality or myocardial infarction at 6 months. We performed a 1-stage individual patient data meta-analysis using random-effects Cox models.

RESULTS

Six trials contributed individual patient data from 2257 female patients. Median time to coronary angiography was 5 hours in the early invasive group (n=1141) and 49 hours in the delayed invasive group (n=1116). Overall, there was no significant reduction in the risk of the primary end point in the early invasive group compared with the delayed group (hazard ratio, 0.79 [95% CI, 0.60-1.06]; P=0.12). Early invasive management was associated with a reduction in recurrent ischemia (hazard ratio, 0.60 [95% CI, 0.39-0.94]; P=0.025). In the prespecified subgroup analysis, high-risk female patients with Global Registry of Acute Coronary Events score >140 receiving early invasive management experienced a significantly reduced hazard for all-cause mortality or myocardial infarction at 6 months (hazard ratio, 0.65 [95% CI, 0.45-0.94]; P=0.021; Pinteraction=0.035). Similar benefits were observed for female patients with elevated cardiac biomarkers.

CONCLUSIONS

Early invasive management in female patients with non-ST-elevation acute coronary syndrome, compared with delayed invasive management, was not associated with a significant reduction in the hazard for the primary end point. In prespecified subgroup analysis, high-risk female patients as assessed with Global Registry of Acute Coronary Events score >140 or elevated cardiac biomarkers experienced significant reductions in all-cause mortality or myocardial infarction at 6 months following early invasive management.

REGISTRATION

URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42023468604.

Modified bFGF targeting connective tissue growth factor in the injured microenvironment improved cardiac repair after chronic myocardial ischemia

Myocardial infarction (MI) was a cardiovascular emergency that led to heart failure, arrhythmia, and sudden death. Basic fibroblast growth factor (bFGF) was revealed to promote angiogenesis and protect cardiomyocytes against ischemic injury. But conventional delivery of bFGF in an uncontrolled manner was inefficient and diffusive, limiting its application in MI therapy. Currently, stimuli-responsive drug delivery is emphasized in tissue regeneration. The present study constructed a CFBP-bFGF recombinant protein, which could specifically target upregulated connective tissue growth factor (CTGF) and release bFGF in ischemic myocardium. In a rat model with MI, intravenous administration of CFBP-bFGF significantly accumulated in ischemic myocardium by targeting with CTGF. The responsive release of CFBP-bFGF effectively enhanced blood vessel regeneration, decreased cardiomyocyte apoptosis, and improved cardiac function recovery. In addition, the molecular mechanism was further explored by RNA sequencing and transcriptome analysis. Besides activating the pathways and genes related to angiogenesis and cardiac protection, CFBP-bFGF also decreased the expression of fibrosis-related pathways and genes, such as TGF-β. These results demonstrated that the CTGF-responsive CFBP-bFGF was effective for targeting release that promoted the functional recovery of MI.

Racial and ethnic disparities in post-acute care service utilization after stroke

Evidence examining disparities in post-acute care (PAC) utilization among various racial and ethnic groups after stroke and the influence of social determinants of health (SDOH) in these decisions is lacking. Thus, we searched the literature from January 2000 to November 2023 regarding PAC among individuals after stroke through: 1) Pubmed, 2) Scopus, 3) Web of Science, 4) Embase, and 5) CINAHL. We found 14 studies. Black individuals were more likely than White individuals to be discharged home with home health (HH) and skilled nursing facilities (SNF). Hispanic individuals were more likely than White individuals to be discharged home with HH, but less likely to be discharged to institutions. Lower socioeconomic status, Medicaid insurance, urban residence, area PAC supply and hospital characteristics were associated with increased institutional discharges among racial and ethnic minority individuals. Future policy should improve access to appropriate PAC commensurate with an individual's medical/social complexity.

Acute dentate nucleus deep brain stimulation modulates corticomotor excitability in chronic stroke survivors

BACKGROUND

Deep brain stimulation of the dentate nucleus (DN-DBS) is an emerging therapy to improve upper extremity (UE) motor function after stroke. This study sought to investigate the physiologic mechanisms of acute DN-DBS in chronic stroke survivors enrolled in a phase I trial for DN-DBS.

METHODS

Twelve chronic stroke participants with moderate-to-severe UE impairment received (acute) single sessions (≥45 min) of active DBS and sham DBS in a sham-controlled, double-blind, cross-over experiment (order randomized). Transcranial magnetic stimulation (TMS) was used to evaluate corticomotor physiology. We also characterized the relationship between acute DBS effects on physiology and baseline clinical and neuroimaging measures, and chronic DBS effects on motor function.

RESULTS

Acute active DBS led to an increase in ipsilesional corticomotor excitability evident as a 5.2 % maximal stimulator output (MSO) reduction in active motor threshold (p = 0.017, d = 0.28), but there was no effect of acute sham DBS. Increases in corticomotor excitability observed with acute DBS were associated with higher microstructural integrity of ipsilesional corticospinal tract (r > 0.70, p < 0.017) and dentato-thalamo-cortical pathways (ρ > 0.69, p < 0.022). Gains in corticomotor excitability with acute DBS were associated with higher dexterity gains made with chronic DBS plus rehabilitation (r > 0.65, p < 0.028).

CONCLUSIONS

Acute DN-DBS leads to heightened ipsilesional corticomotor excitability in moderate-to-severe chronic stroke survivors. Effects of acute DN-DBS on physiology are contingent upon structural preservation of key white matter tracts and associated with motor gains made with chronic DN-DBS. Findings provide mechanistic support of DN-DBS as a potential therapy for post-stroke motor recovery and potential of TMS to monitor responses.

Research Advances in Myocardial Infarction Repair and Cardiac Regenerative Medicine via the Notch Signaling Pathway

Acute myocardial infarction is myocardial necrosis caused by acute and persistent ischemia and hypoxia in the coronary artery and severely affects public health. Recently, stem cell research has presented transformational developments in treating myocardial infarction. The Notch signaling pathway plays a crucial role in the post-myocardial infarction repair process and cardiac regenerative medicine. Additionally, the Notch signaling pathway can be involved in regulating the inflammatory response, myocardial fibrosis, oxidative stress, cardiomyocyte apoptosis, and cardiomyocyte regeneration after myocardial infarction. Moreover, the Notch signaling pathway is applied in cardiac tissue engineering. This review mainly elaborates on the research on the Notch signaling pathway in repairing myocardial infarction and cardiac regenerative medicine, aiming to provide a reference for treating acute myocardial infarction.

Serum Homocysteine and Atrial Fibrillation Recurrence after Catheter Ablation: A Meta-Analysis of 11 Cohort Studies Involving 2147 Patients

The relationship between serum homocysteine (Hcy) levels and atrial fibrillation (AF) recurrence following catheter ablation remains unclear. This meta-analysis aims to investigate this association. Comprehensive searches in PubMed, Web of Science, Embase, Wanfang, and China National Knowledge Infrastructure (CNKI) databases identified relevant studies published up to May 25, 2024. Cohort studies that measured pre-ablation serum Hcy levels and reported AF recurrence post-ablation were included. Data were analyzed using random-effects models by incorporating the potential influence of heterogeneity, with odds ratios (ORs) and 95% confidence intervals (CIs) calculated for the association between serum Hcy levels and AF recurrence. Eleven retrospective cohort studies involving 2147 patients with AF who underwent catheter ablation were analyzed. Higher pre-ablation serum Hcy levels were associated with an increased risk of AF recurrence (OR for per 1 μmol/l increment of Hcy: 1.22, 95% CI: 1.17 to 1.28, p<0.001; I²=0%). Additionally, studies that categorized Hcy levels also found a higher risk of AF recurrence in patients with elevated Hcy (OR for patients with a high versus a low serum Hcy: 2.75, 95% CI: 2.02 to 3.75, p <0.001; I²=0%). Funnel plots and Egger's regression test indicated low risks of publication bias. In conclusions, elevated pre-ablation serum Hcy levels are significantly associated with an increased risk of AF recurrence post-catheter ablation. These findings suggest that Hcy could be a valuable biomarker for predicting AF recurrence and may inform pre-ablation risk stratification. Further prospective studies are warranted to confirm these results.

Unhealthy alcohol use and risk of coronary heart disease among young and middle-aged adults

Objective

To examine the associations between unhealthy alcohol use and risk of coronary heart disease (CHD) among women and men aged 18-65 years.

Methods

An observational study in an integrated healthcare system with systematic alcohol screening. We identified 432,265 primary care patients aged 18-65 years who, in 2014-2015, reported weekly alcohol intake levels. Weekly alcohol intake, categorized into below (≤14/week men; ≤7/week women) and above limits (≥15/week men; ≥ 8/week women) per U.S. guidelines, and heavy episodic drinking (HED, ≥5/≥4 drinks any day in past 3 months for men/women, respectively). Main outcome was CHD during 4-year follow-up, based on inpatient ICD diagnoses of myocardial infarction and CHD. Cox proportional hazards models adjusted for age, sex, race/ethnicity, body mass index, physical activity, smoking, hypertension, diabetes, and hyperlipidemia.

Results

The cohort comprised 44 % women, mean age (standard deviation) of 43.5 years (±13.1). Weekly alcohol intake above limits was associated with higher prevalence of cardiovascular risk factors, and a 26 %, 19 % and 43 % higher risk on the overall, men- and women-specific risk of CHD after adjusting for these risk factors (hazard ratio [95 % confidence interval] = 1.26[1.13 -1.40], 1.19[1.04-1.35] and 1.43[1.20-1.71], respectively).

Conclusions

In a large, real-world, diverse population with a systematic alcohol screening program, having weekly alcohol intake above limits was associated with increased risk of CHD among young and middle-aged men and women. Increased CHD risk due to alcohol intake above limits warrants particular awareness and interventions.

The Relationship Between Perceived Discrimination and Blood Pressure in Black Adults: A Narrative Review

BACKGROUND

Cardiovascular disease is the leading cause of death in the United States, with disproportionately higher morbidity and mortality rates among Black people. Experiences of discrimination and racism constitute a public health crisis. Given the significant race- and ethnicity-related disparities in cardiovascular health, it's essential to understand the mechanisms by which these disparities occur.

PURPOSE

The purpose of this review was to identify and synthesize the current literature on the relationship between perceived discrimination and its impact on blood pressure among Black adults.

METHODS

A literature search was conducted to locate relevant research. To be included, articles had to report on quantitative studies that were conducted in the United States among Black adults, used discrimination as an independent variable, and used blood pressure or hypertension as an outcome variable. These articles also had to have been peer-reviewed and published in English between 2010 and 2021. Discrimination was categorized as everyday, lifetime, or both.

RESULTS

Eleven studies met all criteria and were included for analysis. Eight of these studies reported an association between increased racial discrimination and higher blood pressure; moreover, of the eight studies that reported this finding, seven specified lifetime discrimination.

CONCLUSIONS

This narrative review found significant evidence supporting a positive association between perceived lifetime discrimination and blood pressure in Black adults. But the relationship isn't clearly understood, and future research should explore the underlying mechanisms and potential confounders. Priorities include more rigorous assessment of Black individuals' experiences with both lifetime and everyday discrimination and how these interact with confounders (such as stress), so that blood pressure control can be better achieved in this population. Specific areas for investigation include considering how we measure discrimination, the impact of provider bias and discrimination, and the impact of discrimination on medication adherence. This work is essential to developing the urgently needed, evidence-based interventions that will help to prevent racial and ethnic discrimination and mitigate its effects.

Controversies related to the cardiac origin of preeclampsia - Does a mother's heart know?

A potential role of cardiac output has been proposed in the development of preeclampsia. Given that cardiac output may contribute to hypertensive states in the general population, a contribution from cardiac output to preeclampsia is plausible. However, the interplay between the heart and the periphery is complex, and some responses in cardiac output during pregnancy are surprising even when pregnancy progresses without complications. Therefore, this review focuses on recent evidence that has provided new insight into cardiac output in healthy humans including pregnancy, and offers some suggestions about future studies in preeclamptic patients.

Caregiver Tasks and Life Changes Among Family Caregivers of Stroke Survivors

PURPOSE

Stroke family caregivers often struggle to provide care. The purpose of the current study was to determine: (a) ease or difficulty with caregiving tasks; (b) life changes because of providing care; and (c) relationship between caregiving tasks and life changes.

METHOD

A descriptive correlational design was used. Telephone interviews were conducted with 74 stroke caregivers. Tasks were measured using the Oberst Caregiving Burden Scale; life changes with the Bakas Caregiving Outcomes Scale.

RESULTS

The most difficult tasks were managing survivor behaviors and the most negative life changes were lack of time for social activities. The easiest tasks were medical or nursing treatments, whereas the most positive life change was an improved relationship with the survivor. Tasks and life changes were different for each caregiver. Caregiver tasks and life changes were moderately correlated (r = 0.33, p < 0.01).

CONCLUSION

Caregiver tasks and life changes are important for designing strategies to support stroke caregivers. [Journal of Gerontological Nursing, 51(3), 13-18.].

Gender disparities in the association between atherogenic index of plasma and chronic kidney disease

OBJECTIVE

This study investigates the relationship between the atherogenic index of plasma (AIP) and chronic kidney disease (CKD) occurrence in the general population, with a focus on potential gender disparities.

METHODS

The study included 22,952 adults from the National Health and Nutrition Examination Survey (NHANES). Various statistical models were employed to evaluate the association between AIP and CKD occurrence and explore gender-specific differences.

RESULTS

Adjusted for confounding factors, higher AIP levels showed a mild association with increased CKD risk in the general population. Specifically, individuals in the highest AIP quartile had a slightly elevated odds ratio (OR) for CKD compared to the lowest quartile (OR: 1.24, 95% CI: 1.02-1.52, P for trend = 0.023). Gender-stratified analysis revealed significant differences. Among males, higher AIP levels were significantly associated with CKD risk (OR: 1.49, 95% CI: 1.15-1.94, P for trend < 0.001), whereas in females, the association was weaker and statistically non-significant (P for trend = 0.055). U-shaped relationships between AIP and CKD were observed. Mediation analysis provided insights into potential pathways underlying this association. Among males, changes in uric acid accounted for 44.50% of CKD prevalence related to AIP, while glomerular filtration rate (eGFR), BMI, and bicarbonate levels contributed 44.09%, 17.55%, and 15.36%, respectively. Among females, uric acid changes accounted for 45.53%, while eGFR, bicarbonate, C-reactive protein (CRP), sodium, and potassium levels contributed 37.96%, 12.43%, 6.37%, 5.58%, and 3.14%, respectively.

CONCLUSION

Our findings suggest that elevated AIP levels may increase CKD risk, particularly among males in the general U.S.

POPULATION

Cardiovascular Complications, Kidney Failure, and Mortality in Young-Onset Type 1 and Type 2 Diabetes: Data From the Korean National Health Insurance Service

OBJECTIVE

To explore all-cause mortality and the incidence of cardiovascular and renal complications among patients with young-onset diabetes in South Korea using a nationwide registry database.

RESEARCH DESIGN AND METHODS

Data were collected from the Korean National Health Insurance Service-National Sample Cohort database from 2006 to 2019 for patients aged ≤30 years with type 1 diabetes (T1D) or type 2 diabetes (T2D). The incidence rates of cardiovascular complications (myocardial infarction [MI] and stroke) and kidney failure, as well as all-cause mortality, were compared with those in the general population.

RESULTS

This study included 513,633 participants, comprising 413 with T1D, 1,250 with T2D, and 511,970 control individuals. After adjusting for sex, age, family income, hypertension, and dyslipidemia, the hazard ratio (HR) for MI was 6.76 (95% CI 2.44-18.72) and 5.07 (95% CI 2.48-10.36) for T1D and T2D, respectively. The HR for stroke was 4.65 (95% CI 1.70-12.71) and 3.30 (95% CI 1.67-6.53) for T1D and T2D, respectively. The HR for kidney failure was 20.92 (95% CI 11.40-38.39) and 2.78 (95% CI 1.37-5.64) for T1D and T2D, respectively. The mortality risk was significantly higher in patients with T1D (3.69; 95% CI 1.95-6.98) and T2D (3.06; 95% CI 2.02-4.63) than in the control group. The mortality risk was highest in the T2D subgroup of participants aged <20 years at enrollment (10.70; 95% CI 4.41-25.94).

CONCLUSIONS

In South Korea, patients with young-onset diabetes are at high risk of cardiovascular complications, kidney failure, and death.

Hypertensive pregnancy disorder, an under-recognized women specific risk factor for heart failure?

During pregnancy, the maternal cardiovascular (CV) system undergoes major haemodynamic alterations ensuring adequate placental perfusion and a healthy pregnancy course. Hypertensive disorders of pregnancy (HDP) occur in almost 10% of gestations and preeclampsia, a more severe form, in 3-4%. Women with HDP demonstrated impaired myocardial function, biventricular chamber dysfunction and adverse biventricular remodelling. Shortly after delivery, women who experienced HDP express increased risk of classic CV risk factors such as hypertension, renal disease, abnormal lipid profile, and diabetes. Within the first two decades following a HDP, women experience increased rates of heart failure, chronic hypertension, ischaemic heart and cerebral disease. The mechanism underlying the relationship between HDP in younger women and CV disease later in life could be explained by sharing pre-pregnancy CV risk factors or due to a direct impact of HDP on the maternal CV system conferring a state of increased susceptibility to future metabolic or haemodynamic insults. Racial disparities in CV risk and social determinants of health also play an important role in their remote CV risk. Although there is general agreement that women who suffered from HDP should undertake early CV screening to allow appropriate prevention and timely treatment, a screening and intervention protocol has not been standardized due to limited available evidence. In this review, we discuss why women with hypertensive pregnancy may be disproportionately affected by heart failure with preserved ejection fraction and how cardiac remodelling during or after pregnancy may influence its development.

Sodium-glucose cotransporter 2 inhibitors and contrast-induced nephropathy risk: a meta-analysis

BACKGROUND

Contrast-induced nephropathy (CIN) is an adverse renal event that occurs following the administration of contrast media for diagnostic procedures or therapeutic angiographic intervention. Nevertheless, there is currently no efficacious and safe agents for the treatment of CIN, except for hydration. We aimed to conduct a meta-analysis to verify the potential nephroprotective role of sodium-glucose cotransporter 2 inhibitors (SGLT2is) in the prevention of CIN.

METHODS

The PubMed, Web of Science, and China National Knowledge Infrastructure (CNKI) databases were searched from their respective inception dates up until 26 August 2024. The "Meta" package of R and Stata software was used for data analysis.

RESULTS

A total of 12 studies were included in the analysis, comprising 11 single-center retrospective studies and one prospective cohort study. Our meta-analysis determined that SGLT2is significantly decrease CIN (odds ratio (OR) 0.39, 95% confidence interval (CI) (0.31, 0.48), P < 0.0001, I2 = 0%) and mortality (OR 0.45, 95% CI (0.26, 0.77), P = 0.0039, I2 = 48%). No notable discrepancy was discerned in continuous renal replacement therapy (CRRT) (OR 0.53, 95% CI (0.15, 1.91), I2 = 0%) or contrast volume (MD - 9.68, 95% CI (- 19.38, 0.03), I2 = 71%).

CONCLUSION

The present study demonstrated that SGLT2is markedly reduce the incidence of contrast-induced nephropathy in diabetic patients. It is recommended that future large-scale randomized controlled trials (RCTs) are required to confirm these findings and to elucidate further the outcomes in patients without diabetes.

Oxidative impact on lipoprotein structure: Insights from dynamic light scattering

Cardiovascular disease (CVD) is the number one cause of mortality worldwide, with oxidative stress contributing significantly to its pathogenesis. Lipoproteins, key biomolecules in lipid transport, are particularly susceptible to oxidative modifications, which can contribute to atherogenesis. The need for advanced analytical tools to better understand the pathogenesis of cardiovascular disease (CVD) is critical due to its significant impact on public health. Clinicians often rely on indirect calculations of low-density lipoprotein (LDL) as a primary diagnostic indicator, which can oversimplify and overlook the complex changes in lipoprotein structure and function and therefore the complex etiology of CVD. Here it is demonstrated that dynamic light scattering (DLS) is sensitive and effective at measuring variation in lipoprotein size distributions following oxidative damage caused by peroxidation and nitration-two common physiological processes that play dual roles in both normal and pathogenic states. We establish the utility of DLS in detecting subtle variations in lipoprotein size, including potential aggregation and fission events resulting from chemical modifications. Our work highlights the value of DLS in advancing our understanding of the pathogenic mechanisms underlying CVD development, while also providing a foundational framework to study other biological processes and their effects on lipoproteins, ultimately guiding the development of therapies to address these harmful processes.

Prevalence of Aspirin or Clopidogrel Pharmacological Resistance in Ischemic Stroke: A Step Toward Precision Medicine

BACKGROUND AND OBJECTIVES

Currently, there is not sufficient data regarding the prevalence of resistance or inadequate platelet function inhibition with the use of antiplatelet therapy in patients with noncardioembolic stroke. This study was designed to evaluate the prevalence of antiplatelet inactivity to aspirin and clopidogrel in the setting of chronic use and presentation with primary or recurrent stroke.

METHODS

Patients who were taking aspirin, clopidogrel, or both at the time of presentation for stroke were selected in this study. Those with confirmed stroke on MRI or clinically determined TIA and age > 18 years were included. A standard laboratory test, VerifyNow aspirin or P2Y12 assay, was utilized to assess the responsiveness to the platelet inhibitors. A total of 158 patients were identified, 52 presenting with primary stroke and 106 with recurrent stroke. Data were analyzed using chi-squared or Fisher's exact as well as t-test analysis.

RESULTS

Of the primary stroke population, 4% of patients demonstrated resistance to aspirin and 30% to clopidogrel. Of the patients presenting with recurrent stroke, 13% demonstrated resistance to aspirin and 38% to clopidogrel. The data also suggest increased resistance to aspirin and clopidogrel in Caucasians compared to minorities, with 11% versus 8% in regard to aspirin and 33% versus 17% to clopidogrel. Additionally, this study demonstrated 17% resistance to aspirin in males compared to 4% in females and 13% in males compared to 36% in females, respectively, regarding resistance to clopidogrel. No difference in inactivity to either aspirin or clopidogrel was detected between patients with stroke mechanisms of small or large vessel disease.

CONCLUSIONS

The present result demonstrated that a sizeable portion of the population has inefficacious activity in the setting of specific antiplatelet agents. Additionally, sex and ethnicity differences in responsiveness to aspirin or clopidogrel have been noted. Determining a patient's response to medications could provide opportunities to individualize treatment and better prevent future strokes. Further studies of a larger scale are indeed needed to apply this information to pursue individualized treatment.

The influence of lipoprotein(a) on aortic valve calcification in patients undergoing transcatheter aortic valve replacement

BACKGROUND

Elevated levels of lipoprotein(a) (Lp[a]) have been recognized as substantial risk factors for cardiovascular disease and aortic stenosis (AS). However, the specific role of Lp(a) in promoting aortic valve calcification (AVC) and influencing mortality in elderly, multimorbid patients undergoing transcatheter aortic valve replacement (TAVR) remains unclear and warrants further investigation.

METHODS

A retrospective analysis was conducted on all consecutive patients who underwent TAVR between August 2019 and June 2020 at our clinic. Patients with missing data or prior aortic valve replacement were excluded. The study cohort was stratified based on an Lp(a) threshold of 60 mg/dl according to guidelines for lipoprotein apheresis in UK and Germany.1,2 RESULTS: In total, 454 patients were included into the analysis. Mean age was 81 ± 6 years and patients presented with a notable cardiovascular risk profile. Lp(a) values ≥ 60 mg/dl were detected in 102 (22.5%) patients, while 352 (77.5%) had Lp(a) values < 60 mg/dl. The median calcium volume of the total cohort was 894.5 [570.8; 1,382.8] mm2. No significant difference was observed between the groups (p = 0.83). Furthermore, Lp(a) did not emerge as a statistically significant predictor of calcium levels before TAVR. Notably, male gender (B = 404.11, p < 0.001) and mean trans-valvular pressure gradient (B = 15.64, p < 0.001) were identified as the strongest coefficients within the robust regression analysis. Log-rank tests indicated no prognostic utility of Lp(a) for 30-day all-cause mortality (p = 0.30) or 40 months long-term all-cause mortality (p = 0.60).

CONCLUSION

Lp(a) might not exert a significant effect on calcification levels or all-cause mortality in patients undergoing TAVR. Despite the study's highly selected population, these results align with current research, supporting the assumption that the influence of Lp(a) may be confined to the early stages of AS and its progression.

Lifetime risk and projected burden of dementia

Understanding the lifetime risk of dementia can inform public health planning and improve patient engagement in prevention. Using data from a community-based, prospective cohort study (n = 15,043; 26.9% Black race, 55.1% women and 30.8% with at least one apolipoprotein E4 (APOE ε4) allele), we estimated the lifetime risk of dementia (from age 55 years to 95 years), with mortality treated as a competing event. We applied lifetime risk estimates to US Census projections to evaluate the annual number of incident dementia cases from 2020 to 2060. The lifetime risk of dementia after age 55 years was 42% (95% confidence interval: 41-43). Rates were substantially higher in women, Black adults and APOE ε4 carriers, with lifetime risks ranging from approximately 45% to 60% in these populations. The number of US adults who will develop dementia each year was projected to increase from approximately 514,000 in 2020 to approximately 1 million in 2060. The relative growth in new dementia cases was especially pronounced for Black adults. These results highlight the urgent need for policies that enhance healthy aging, with a focus on health equity.

Trajectory of Cognitive Function After Incident Heart Failure

BACKGROUND

The magnitude of cognitive changes after incident heart failure (HF) is unclear. We assessed whether incident HF is associated with changes in cognition after accounting for pre-HF cognitive trajectories and known determinants of cognition.

METHODS

This pooled cohort study included adults without HF, stroke, or dementia from 6 US population-based studies from 1971 to 2019. Linear mixed-effects models estimated cognitive change with incident HF diagnosis and the rate of cognitive change over the years after HF, controlling for pre-HF cognitive trajectories and participant factors. Outcomes included change in global cognition (primary outcome), executive function, and memory (secondary outcomes). Cognitive outcomes were standardized to a t score metric (mean [SD], 50 [10]); a 1-point difference represented a 0.1-SD difference in cognition.

RESULTS

We included 29 614 adults (mean [SD] age was 61 [10] years, 55% female, 70% White). During a median follow-up of 6.6 (Q1-Q3, 5.0-19.8) years, 1407 (5%) adults received an incident diagnosis of HF. Incident HF diagnosis was associated with initial decreases in global cognition (-1.1 points [95% CI, -1.4 to -0.8]) and executive function (-0.6 points [95% CI, -1.0 to -0.3]). Larger decreases in global cognition after HF were seen with older age, female sex, and White race. Participants with incident HF diagnosis demonstrated faster and long-term declines in global cognition (-0.1 points per year [95% CI, -0.2 to -0.1]) and executive function (-0.2 points per year [95% CI, -0.2 to -0.1]). The change in memory with incident HF diagnosis was not statistically significant but showed a similar trend with an initial decline of -0.5 points (95% CI, -1.4 to +0.3) and a slope of -0.1 points per year (95% CI, -0.3 to 0.0).

CONCLUSIONS

In this pooled cohort study, incident HF diagnosis was associated with initial decreases in global cognition and executive function and faster, persistent declines in these domains at follow-up.

Cardiometabolic Risk Factors Associated with Physical Fitness and Activity Levels: An Exploratory Study of US College Students

College students are a vulnerable population at risk of developing and/or experiencing poor physical fitness and insufficient physical activity (PA) levels, both associated with poor cardiometabolic health. Thus, this study assessed the association of physical fitness and domain-specific PA levels on cardiometabolic risk factors (CMRFs) among college students. A volunteer sample of students enrolled in general health and wellness courses at a large, Northeastern U.S. institution from Spring 2023 - Spring 2024 (n=1418, 69.0% male, 89.9% non-Hispanic White) completed an objective health assessment as part of a required course assignment. CMRFs (e.g., cholesterol, blood pressure, fasting blood glucose, triglycerides, waist circumference), cardiorespiratory fitness (e.g., VO2 max), and markers of muscular strength and endurance (e.g., pushups, curl ups, hand grip, sit and reach) were assessed. Participants were then invited to complete a subjective health assessment (e.g., demographics, PA). Separate, unadjusted linear regressions examined the association of physical fitness and domain-specific PA levels (e.g., moderate and vigorous PA, active transportation PA, muscle-strengthening, meeting PA guidelines) on CMRFs, by biological sex. Socio-demographics of race/ethnicity, sexual orientation, semester standing, and grade point average served as covariates in separate, adjusted models to assess potential associations. Among males and females, cardiorespiratory fitness and markers of muscular strength and endurance were significantly associated with CMRFs, while PA levels and socio-demographics were not. Tailored screening approaches may provide students with the required support to reduce later-life adverse coronary events. Future work is required to improve our understanding of the potential role socio-demographics play in CMRFs among young adults.

Trends in heart failure-related mortality among middle-aged adults in the United States from 1999-2022

INTRODUCTION

Heart failure (HF) represents a significant contributor to morbidity and mortality. Heart failure mortality trends among the middle aged have not been fully characterized into the years of the COVID-19 pandemic. Our objective was to analyze the trends in mortality related to heart failure across various demographic and geographic categories-including gender, race, and census region-spanning from 1999 to 2022, with particular attention paid to the effect of the COVID-19 pandemic on HF mortality.

METHODS

Heart failure-related mortality data were extracted from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) database and stratified into different demographic and geographic groups. Statistically significant trends in mortality over time were identified using Joinpoint regression.

RESULTS

Heart failure mortality decreased among most studied demographic groups from 1999 to 2011-2013, then increased through 2022, often with a marked increase in mortality in the pandemic years of 2020-2022. Males, Black or African Americans, and the South generally had higher mortality rates than their demographic or geographic counterparts. Existing disparities between high-risk groups and others generally worsened during the pandemic.

CONCLUSION

The COVID-19 pandemic accelerated a decade of heart failure mortality increases, and in some categories worsened existing disparities. This is likely due to reduced access to healthcare during the pandemic, along with a direct increase in mortality from heart failure caused by COVID-19.

Area Deprivation and Patient Complexity Predict Low-Value Healthcare Utilization in Persons With Heart Failure

BACKGROUND

Heart failure (HF) is a debilitating condition affecting over 6.7 million adults in the United States. Social risks and complexity, or personal, social, and clinical aspects of persons' experiences, have been found to influence healthcare utilization and hospitalizations in persons with HF. Low-value utilization, or irregular outpatient visits with frequent emergency room use, or hospitalization is common among persons with complex conditions and social risk and requires further investigation in the HF population.

OBJECTIVES

The purpose of this research was to assess the influence of complexity and social risk on low-value utilization in persons with HF using machine learning approaches.

METHODS

Supervised machine learning, tree-based predictive modeling was conducted on an existing data set of adults with HF in the eight-county region of Western New York for the year 2022. Decision tree and random forest models were validated using a 70/30 training/testing data set and k -fold cross-validation. The models were compared for accuracy and interpretability using the area under the curve, Matthews correlation coefficient, sensitivity, specificity, precision, and negative predictive value.

RESULTS

Area deprivation index, a proxy for social risk, number of chronic conditions, age, and substance use disorders were predictors of low-value utilization in both the decision tree and random forest models. The decision tree model performed moderately, whereas the random forest model performed excellently and added hardship as an additional important variable.

DISCUSSION

This is the first known study to look at the outcome of low-value utilization, targeting individuals who are underutilizing outpatient services. The random forest model performed better than the decision tree; however, features were similar in both models, with area deprivation index as the key variable in predicting low-value utilization. The decision tree was able to produce specific cutoff points, making it more interpretable and useful for clinical application. Both models can be used to create clinical tools for identifying and targeting individuals for intervention and follow-up.

Association between body roundness index and stroke results from the 1999-2018 NHANES

IMPORTANCE

Obesity, especially visceral obesity, is a controllable risk factor associated with the incidence of stroke. The body roundness index (BRI) bridges the gap between traditional anthropometric methods of assessing fat distribution to predict the percentage of body fat and visceral adipose tissue, which can be used to decipher its population-based characteristics and potential association with stroke.

OBJECTIVE

The negative impact of accumulated visceral obesity on cerebrovascular health has been widely documented. However, the association between BRI and stroke has never been reported before. The purpose of this study was to elucidate the connection between BRI and the general incidence of stroke in the US population.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study extracted cross-sectional data from 39,454 U.S. adults (aged ≥20 years) from documents related to the National Health and Nutrition Examination Survey (NHANES) from 1999 through 2018.

METHODS

We evaluated the relationship between BRI and stroke using weighted logistic regression analysis, and we looked at any possible nonlinear relationships using restricted cubic spline (RCS) regression. Additionally, subgroup analysis and interaction tests were carried out.

RESULTS

The study involved 39,454 participants, of whom 1,427 (3.6 %) had a stroke. Fully adjusted logistic regression models showed that BRI was positively associated with stroke, with a 5.7 % increase in stroke incidence per unit increase in BRI (OR = 1.057, 95 % CI = 1.009,1.108, P = 0.020). RCS analysis revealed a nonlinear association, suggesting an elevated risk of stroke before the inflection point of 8.489. This positive correlation was consistent across settings, according to subgroup analyses and interaction tests (P > 0.05 for all interactions).

CONCLUSIONS AND RELEVANCE

There is a nonlinear positive correlation between BRI and stroke, according to this national cohort study. These results support the use of the BRI as a screening tool for assessing stroke risk; yet, because cross-sectional studies have inherent limitations, more thorough research is required until the BRI has been consistently validated in additional independent cohorts.

Cardiovascular Disease and Cancer: A Dangerous Liaison

The field of cardio-oncology has traditionally focused on the impact of cancer and its therapies on cardiovascular health. Mounting clinical and preclinical evidence, however, indicates that the reverse may also be true: cardiovascular disease can itself influence tumor growth and metastasis. Numerous epidemiological studies have reported that individuals with prevalent cardiovascular disease have an increased incidence of cancer. In parallel, studies using preclinical mouse models of myocardial infarction, heart failure, and cardiac remodeling support the notion that cardiovascular disorders accelerate the growth of solid tumors and metastases. These findings have ushered in a new and burgeoning field termed reverse cardio-oncology that investigates the impact of cardiovascular disease pathophysiology on cancer emergence and progression. Recent studies have begun to illuminate the mechanisms driving this relationship, including shared risk factors, reprogramming of immune responses, changes in gene expression, and the release of cardiac factors that result in selective advantages for tumor cells or their local milieu, thus exacerbating cancer pathology. Here, we review the evidence supporting the relationship between cardiovascular disease and cancer, the mechanistic pathways enabling this connection, and the implications of these findings for patient care.

Extracellular vesicles in atherosclerosis: Current and forthcoming impact

Atherosclerosis is the main pathogenic substrate for cardiovascular diseases (CVDs). Initially categorized as a passive cholesterol storage disease, nowadays, it is considered an active process, identifying inflammation among the key players for its initiation and progression. Despite these advances, patients with CVDs are still at high risk of thrombotic events and death, urging to deepen into the molecular mechanisms underlying atherogenesis, and to identify novel diagnosis and prognosis biomarkers for their stratification. In this context, extracellular vesicles (EVs) have been postulated as an alternative in search of novel biomarkers in atherosclerotic diseases, as well as to investigate the crosstalk between the cells participating in the processes leading to arterial remodelling. EVs are nanosized lipidic particles released by most cell types in physiological and pathological conditions, that enclose lipids, proteins, and nucleic acids from parental cells reflecting their activation status. First considered cellular waste disposal systems, at present, EVs have been recognized as active effectors in a myriad of cellular processes, and as potential diagnosis and prognosis biomarkers also in CVDs. This review summarizes the role of EVs as potential biomarkers of CVDs, and their involvement into the processes leading to atherosclerosis.

Understanding the Pain Experience and Treatment Considerations Along the Spectrum of Peripheral Artery Disease: A Scientific Statement From the American Heart Association

Peripheral artery disease (PAD) is an atherosclerotic condition that affects a growing number of individuals worldwide, with estimates exceeding 220 million. One of the central hallmarks of PAD is lower extremity pain, which may present as intermittent claudication and atypical leg pain, and, in more severe cases, ischemic rest pain, neuropathic pain, or phantom limb pain in those who underwent amputation. Although the majority of individuals with PAD may experience pain that is chronic in nature, the pathogenesis and phenomenology of pain may differ. Nociceptive, inflammatory, and neuropathic mechanisms all play a role in the generation of pain. Pain in PAD results in severe disability and can copresent with distress, sickness behaviors such as avoidance and further deconditioning, and concomitant depression, anxiety, and addiction secondary to opioid use. These factors potentially lead to chronic pain interacting with a multitude of domains of functioning, including physical, emotional, and behavioral. Whereas pain is a normal adaptive response, self-defeating behaviors and cognitions contribute to the persistence or worsening of the chronic pain experience, disability, and distress. Much remains unknown about the phenomenology of pain in PAD and its clinical subgroups and how it affects outcomes. Borrowing from other chronic pain syndromes, multimodal pain management strategies that emphasize a biopsychosocial model have generated a solid evidence base for the use of cognitive behavioral approaches to manage pain. Multimodal pain management in PAD is not the norm, but theoretical pathways and road maps for further research, assessment, and clinical implementation are presented in this scientific statement.