European Society of Cardiology: Cardiovascular Disease Statistics 2019

Current role and future perspectives of cardiac rehabilitation in coronary heart disease

Ischaemic heart disease (IHD) is a major cause of morbidity and mortality worldwide. While there have been major advances in this field, these patients are still a higher risk subgroup. As such, strategies to mitigate risk and tailor secondary prevention measures are of the utmost relevance. Cardiac rehabilitation (CR), encompassing several domains including exercise training, cardiovascular risk factor optimization, nutritional and psychological assessments, as well as other ancillary interventions has shown to be one of the pillars in the contemporary management of patients with IHD. Indeed, CR is associated with several benefits in this population, ranging from functional capacity to improvements in outcomes. Whilst this, there are still several issues concerning the optimal application of CR which are still not fully ascertained, such as lack of referral and completion, as well as questions related to programme design (particularly among patients with multiple comorbidities). In this review, we aim at presenting a pragmatic overview on the current role of CR in the management of individuals with IHD, while also discussing some of the caveats in the current data, as well as future concepts which could help improve the uptake and personalization of this pivotal time-tested intervention.

Modelling of longitudinal data to predict cardiovascular disease risk: a methodological review

OBJECTIVE

The identification of methodology for modelling cardiovascular disease (CVD) risk using longitudinal data and risk factor trajectories.

METHODS

We screened MEDLINE-Ovid from inception until 3 June 2020. MeSH and text search terms covered three areas: data type, modelling type and disease area including search terms such as "longitudinal", "trajector*" and "cardiovasc*" respectively. Studies were filtered to meet the following inclusion criteria: longitudinal individual patient data in adult patients with ≥3 time-points and a CVD or mortality outcome. Studies were screened and analyzed by one author. Any queries were discussed with the other authors. Comparisons were made between the methods identified looking at assumptions, flexibility and software availability.

RESULTS

From the initial 2601 studies returned by the searches 80 studies were included. Four statistical approaches were identified for modelling the longitudinal data: 3 (4%) studies compared time points with simple statistical tests, 40 (50%) used single-stage approaches, such as including single time points or summary measures in survival models, 29 (36%) used two-stage approaches including an estimated longitudinal parameter in survival models, and 8 (10%) used joint models which modelled the longitudinal and survival data together. The proportion of CVD risk prediction models created using longitudinal data using two-stage and joint models increased over time.

CONCLUSIONS

Single stage models are still heavily utilized by many CVD risk prediction studies for modelling longitudinal data. Future studies should fully utilize available longitudinal data when analyzing CVD risk by employing two-stage and joint approaches which can often better utilize the available data.

Can transcatheter aortic valve implantation [TAVI] be performed at institutions without on-site cardiac surgery department?

Transcatheter aortic valve implantation [TAVI] represents a paradigm shift in therapeutic options for patients with severe aortic stenosis [AS]. In less than 20 years, TAVI has rapidly disseminated to include a significant proportion of AS patients. The number of AS patients needing TAVI is expected to further increase. Since there is a limited number of centers performing TAVI, wait times are expected to increase. This might have a critical impact of AS patient life as mortality rate of AS patients awaiting TAVI, is substantial, ranging from 2 to 10%. With time, as more patients were treated, improved experience, better imaging and devices, this technology became safer with more reliable results. Today most TAVI complications are related to vascular access [4-6%] and there is less need for emergency thoracic bail out [0.2-0.5%]. In this review, we summarize the prognosis while waiting, the outcomes of patients undergoing TAVI at institutions without on-site cardiac surgery departments and the data describing rates and outcomes of TAVI patients requiring treatment of intra-procedural life-threatening complications. Similar to coronary interventions in the past, TAVI should be considered also in centers without on-site cardiac surgery departments under certain conditions such as, experienced operators, heart team discussion, well established imaging modalities, skilled and qualified support personal, and adequate pre- and post-care facility.

Role of Mitochondrial Protein Import in Age-Related Neurodegenerative and Cardiovascular Diseases

Mitochondria play a critical role in providing energy, maintaining cellular metabolism, and regulating cell survival and death. To carry out these crucial functions, mitochondria employ more than 1500 proteins, distributed between two membranes and two aqueous compartments. An extensive network of dedicated proteins is engaged in importing and sorting these nuclear-encoded proteins into their designated mitochondrial compartments. Defects in this fundamental system are related to a variety of pathologies, particularly engaging the most energy-demanding tissues. In this review, we summarize the state-of-the-art knowledge about the mitochondrial protein import machinery and describe the known interrelation of its failure with age-related neurodegenerative and cardiovascular diseases.

Histopathology-Based Deep-Learning Predicts Atherosclerotic Lesions in Intravascular Imaging

Background: Optical coherence tomography is a powerful modality to assess atherosclerotic lesions, but detecting lesions in high-resolution OCT is challenging and requires expert knowledge. Deep-learning algorithms can be used to automatically identify atherosclerotic lesions, facilitating identification of patients at risk. We trained a deep-learning algorithm (DeepAD) with co-registered, annotated histopathology to predict atherosclerotic lesions in optical coherence tomography (OCT). Methods: Two datasets were used for training DeepAD: (i) a histopathology data set from 7 autopsy cases with 62 OCT frames and co-registered histopathology for high quality manual annotation and (ii) a clinical data set from 51 patients with 222 OCT frames in which manual annotations were based on clinical expertise only. A U-net based deep convolutional neural network (CNN) ensemble was employed as an atherosclerotic lesion prediction algorithm. Results were analyzed using intersection over union (IOU) for segmentation. Results: DeepAD showed good performance regarding the prediction of atherosclerotic lesions, with a median IOU of 0.68 ± 0.18 for segmentation of atherosclerotic lesions. Detection of calcified lesions yielded an IOU = 0.34. When training the algorithm without histopathology-based annotations, a performance drop of >0.25 IOU was observed. The practical application of DeepAD was evaluated retrospectively in a clinical cohort (n = 11 cases), showing high sensitivity as well as specificity and similar performance when compared to manual expert analysis. Conclusion: Automated detection of atherosclerotic lesions in OCT is improved using a histopathology-based deep-learning algorithm, allowing accurate detection in the clinical setting. An automated decision-support tool based on DeepAD could help in risk prediction and guide interventional treatment decisions.

Global, regional, and national burden and quality of care index of endocarditis: the global burden of disease study 1990-2019

AIMS

Endocarditis accounts for significant morbidity and mortality. Timely diagnosis and prompt treatment are of paramount importance for optimal patient outcome. However, only few studies have assessed quality of care (QoC) in endocarditis. We aimed to describe QoC and changes in epidemiological features of endocarditis from 1990 to 2019.

METHODS AND RESULTS

Using primary indices of mortality, incidence, years of life lost, years lived with disability, and disability-adjusted life year, obtained from the Global Burden of Disease Study 2019, we calculated four secondary measures. Principal component analysis was performed to calculate QoC index (QCI), scored on a scale of 0-100 with higher values indicating better QoC, for different locations, age groups, and genders from 1990 to 2019. The all-ages incidence rate of endocarditis was estimated to increase significantly from 1990 to 2019, while mortality rate did not change. The age-standardized QCI was 73.6% globally, with higher values in high-income countries than in low-income countries. High-income North America (82.0%) and Asia Pacific (81.1%) had the highest QCI, whereas Eastern Europe (43.3%) had the lowest. Globally, the 30-49 and 95+ age groups had the highest (91.3%) and the lowest (71.7%) QCI, respectively. In most countries, particularly those with lower socio-demographic index, women had better QCI.

CONCLUSION

This is the first global assessment of QCI, shedding light on the current trends and highlighting the necessity of improving the endocarditis QoC, mainly by timely case detection, adherence to antibiotic prophylaxis guidelines, utilizing targeted antibiotics and advanced treatments, in the African region and resolving gender inequality in selected countries.

Frailty and Different Exercise Interventions to Improve Gait Speed in Older Adults after Acute Coronary Syndrome

Background and Objectives: The world’s population is rapidly aging, and it is estimated that, by 2050, every sixth person on earth will be older than 65 years. Around 30% of older adults entering cardiac rehabilitation (CR) meet the criteria of frailty. Frailty identification has not been included in the routine evaluation of CR patients yet, and there is a lack of evidence on what training regimen for improving physical performance in frail people is optimal. Therefore, the aim of our study was to determine the prevalence of frailty and to evaluate the effect of two different complementary training programs on the gait speed of older vulnerable and frail patients with acute coronary syndrome and mid-range-to-preserved left ventricular ejection fraction (≥40%) during short-term CR. Materials and Methods: This randomized controlled trial was conducted from January 2020 to September 2021. CR participants (n = 97) with a mean age of 73.1 ± 5.3 years were randomly allocated into three groups: control (CG, n = 32), intervention-1 (IG-1, n = 32) and intervention-2 (IG-2, n = 33). The patients of all three groups attended a usual inpatient CR program, and two intervention groups additionally received different resistance and balance training programs 3 days a week: the IG-1 underwent complementary training with traditional means of physical therapy, while the IG-2 underwent complementary training with mechanical devices. The mean CR duration was 18.9 ± 1.7 days. Frailty was assessed with the Edmonton Frail Scale, and the 5 m walk test was used to evaluate gait speed. Results: Frailty was determined in 37.1% of participants, and 42.3% met the criteria of being vulnerable. After CR, the gait speed of frail and vulnerable patients significantly improved in all three groups (p < 0.05). In the IG-2, slow gait speed was reversed to normal in the overwhelming majority of patients (p < 0.05), while the CG had the greatest proportion of patients who remained to be slow after CR (p < 0.05). Conclusions: A considerable part of patients entering CR are frail or vulnerable; therefore, it is of crucial importance to assess frailty status in all older people. All three CR programs improved gait speed in frail and vulnerable older patients with ischemic heart disease. Complementary resistance and balance training with mechanical devices more effectively reversed slow gait speed to normal during short-term CR.

A Random Walk with Restart Model Based on Common Neighbors for Predicting the Clinical Drug Combinations on Coronary Heart Disease

As the approaching of the clinical big data era, the prediction of whether drugs can be used in combination in clinical practice is a fundamental problem in the analysis of medical data. Compared with high-throughput screening, it is more cost-effective to treat this problem as a link prediction problem and predict by algorithms. Inspired by the rule of combined clinical medication, a new computational model is proposed. The drug-drug combination was predicted by combining the number of adjacent complete subgraphs shared by the two points with the restart random walk algorithm. The model is based on the semisupervised random walk algorithm, and the same neighborhood is used to improve the random walk with restart (CN-RWR). The algorithm can effectively improve the prediction performance and assign a score to any combination of drugs. To fairly compare the predictive performance of the improved model with that of the random walk with restart model (RWR), a cross-validation of the two models on the same drug data was performed. The AUROC of CN-RWR and RWR under the LOOCV validation framework is 0.9741 and 0.9586, respectively, and the improved model results are more reliable. In addition, the top 3 predictive drug combinations have been approved by the public. The new model is expected that this model can be extended to predict the use of combination drugs for other diseases to find combinations of drugs with potential clinical benefits.

Polygenic risk for coronary artery disease in the Scottish and English population

Background

Epidemiological studies have repeatedly observed a markedly higher risk for coronary artery disease (CAD) in Scotland as compared to England. Up to now, it is unclear whether environmental or genetic factors might explain this phenomenon.

Methods

Using UK Biobank (UKB) data, we assessed CAD risk, based on the Framingham risk score (FRS) and common genetic variants, to explore the respective contribution to CAD prevalence in Scotland (n = 31,963) and England (n = 317,889). We calculated FRS based on sex, age, body mass index (BMI), total cholesterol (TC), high density lipoprotein cholesterol (HDL-C), systolic blood pressure (SBP), antihypertensive medication, smoking status, and diabetes. We determined the allele frequency of published genome-wide significant risk CAD alleles and a weighted genetic risk score (wGRS) for quantifying genetic CAD risk.

Results

Prevalence of CAD was 16% higher in Scotland as compared to England (8.98% vs. 7.68%, P < 0.001). However, the FRS only predicted a marginally higher CAD risk (less than 1%) in Scotland (12.5 ± 10.5 vs.12.6 ± 10.6, P = 0.03). Likewise, the overall number of genome-wide significant variants affecting CAD risk (157.6 ± 7.7 and 157.5 ± 7.7; P = 0.12) and a wGRS for CAD (2.49 ± 0.25 in both populations, P = 0.14) were remarkably similar in the English and Scottish population. Interestingly, we observed substantial differences in the allele frequencies of individual risk variants. Of the previously described 163 genome-wide significant variants studied here, 35 variants had higher frequencies in Scotland, whereas 37 had higher frequencies in England (P < 0.001 each).

Conclusions

Neither the traditional risk factors included in the FRS nor a genetic risk score (GRS) based on established common risk alleles explained the higher CAD prevalence in Scotland. However, we observed marked differences in the distribution of individual risk alleles, which emphasizes that even geographically and ethnically closely related populations may display relevant differences in the genetic architecture of a common disease.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02398-4.

Reuse of cardiac implantable electronic devices in developing countries perspectives: A literature review

INTRODUCTION AND OBJECTIVES

Access to cardiac implantable electronic devices (CIEDs) is limited in developing countries. Postmortem CIED donation from developed countries to developing countries could be an important resource for those who cannot afford a new one. The objective of this paper was to identify and synthesize the perspectives on the donation of CIEDs for potential reuse in patients without resources living in developing countries.

METHODS

A bibliographic review was carried out in the PubMed, Web of Science and Scopus databases. The search strategy was limited to articles published in English or Spanish.

RESULTS

Eight publications were analyzed. The main results were grouped into two large frameworks on perceptions, preferences, attitudes and opinions of developed countries and developing countries towards the donation and reuse of CIEDs. Positive perspectives were identified towards the donation of CIEDs for their reuse in the majority of patients with a CIED, relatives, funeral homes and physicians of developed countries, as well as in physicians and potential recipient patients of developing countries.

CONCLUSIONS

This review highlights the positive perspectives on CIED donation from developed countries to patients in need of developing countries among all studied groups. In view of the feasibility of collecting postmortem devices, we advocate studying the feasibility of more local CIED donation initiatives.

Inflammation and ischemic heart disease: The next therapeutic target?

Inflammation plays an important role in several stages of the cardiovascular continuum. In recent decades a plethora of studies have provided new data highlighting the role of inflammation in atherogenesis and atherothrombosis in two-way interactions with various cardiovascular risk factors and further influencing these dynamic processes. The concept of targeting residual inflammatory risk among individuals with ischemic heart disease (IHD) is therefore gaining increasing attention. Recently, several landmark randomized controlled trials have assessed different pharmacological approaches that may mitigate this residual risk. The results of some of these studies, such as CANTOS with canakinumab and COLCOT and LoDoCo2 with colchicine, are promising and have provided data to support this concept. Moreover, though several aspects remain to be clarified, these trials have shown the potential of modulating inflammation as a new target to reduce the risk of cardiovascular events in secondary prevention patients. In the present review, we aim to present a pragmatic overview of the complex interplay between inflammation and IHD, and to critically appraise the current evidence on this issue while presenting future perspectives on this topic of pivotal contemporary interest.

Current state of cardiac rehabilitation in Portugal: Results of the 2019 national survey

INTRODUCTION

Cardiac rehabilitation (CR) programs have a central role in cardiovascular medicine, encompassing a comprehensive framework able to holistically address various facets of cardiovascular disease. However, several obstacles to their optimal application have been reported. Over the years, the Portuguese Society of Cardiology has periodically conducted a national survey on the state of CR in Portugal.

OBJECTIVES

This study reports the results of the 2019 survey on CR.

METHODS

In December 2019 a voluntary questionnaire was sent to centers offering CR programs, consisting of several items concerning this intervention.

RESULTS

In 2019, 25 centers provided structured CR programs. A total of 2182 patients underwent phase II programs, representing an increase of 13% from the previous survey. Of these, 67.2% were referred due to ischemic heart disease, and 14.5% due to heart failure. Acute coronary syndromes (ACS) comprised 49.3% of referrals, leading to an estimated 9.3% CR coverage. A total of 606 patients participated in phase III programs (a decrease of 37%). Drop-out rates ranged from 0-68%; 91% of centers presented drop-out rates <25%.

CONCLUSION

The present survey shows an increase in the number of centers and patients undergoing phase II CR, and an increase in the estimated CR coverage after ACS. Despite this, the level of increase means that overall patient representation remained below the optimal range, while the data also showed a decrease in the number of patients in phase III programs. These findings reinforce the importance of optimization of CR entry and maintenance, in order to improve the uptake of this pivotal intervention.

Determining propensity for sub-optimal low-density lipoprotein cholesterol response to statins and future risk of cardiovascular disease

BACKGROUND

Variability in low-density lipoprotein cholesterol (LDL-C) response to statins is underappreciated. We characterised patients by their statin response (SR), baseline risk of cardiovascular disease (CVD) and 10-year CVD outcomes.

METHODS AND RESULTS

A multivariable model was developed using 183,213 United Kingdom (UK) patients without CVD to predict probability of sub-optimal SR, defined by guidelines as <40% reduction in LDL-C. We externally validated the model in a Hong Kong (HK) cohort (n = 170,904). Patients were stratified into four groups by predicted SR and 10-year CVD risk score: [SR1] optimal SR & low risk; [SR2] sub-optimal SR & low risk; [SR3] optimal SR & high risk; [SR4] sub-optimal SR & high risk; and 10-year hazard ratios (HR) determined for first major adverse cardiovascular event (MACE). Our SR model included 12 characteristics, with an area under the curve of 0.70 (95% confidence interval [CI] 0.70-0.71; UK) and 0.68 (95% CI 0.67-0.68; HK). HRs for MACE in predicted sub-optimal SR with low CVD risk groups (SR2 to SR1) were 1.39 (95% CI 1.35-1.43, p<0.001; UK) and 1.14 (95% CI 1.11-1.17, p<0.001; HK). In both cohorts, patients with predicted sub-optimal SR with high CVD risk (SR4 to SR3) had elevated risk of MACE (UK HR 1.36, 95% CI 1.32-1.40, p<0.001: HK HR 1.25, 95% CI 1.21-1.28, p<0.001).

CONCLUSIONS

Patients with sub-optimal response to statins experienced significantly more MACE, regardless of baseline CVD risk. To enhance cholesterol management for primary prevention, statin response should be considered alongside risk assessment.

Suboptimal control of cardiovascular risk factors in myocardial infarction survivors in a cardiac rehabilitation program

INTRODUCTION AND OBJECTIVES

As short-term mortality continues to decrease after myocardial infarction (MI), secondary prevention strategies attain increasing relevance. This study aimed at assessing the control of cardiovascular (CV) risk factors, including dyslipidemia, hypertension and diabetes, in a contemporary cohort of MI survivors who completed an exercise-based cardiac rehabilitation (EBCR) program.

METHODS

Observational, retrospective cohort study including patients admitted to a tertiary center with acute MI between November 2012 and April 2017, who completed a phase II EBCR program after discharge. Achievement of low-density lipoprotein (LD) cholesterol, blood pressure and HbA1c guideline recommended targets was assessed. Lipid profile parameters were assessed and compared at three time points (hospitalization, beginning and end of the program).

RESULTS

A total of 379 patients were included. Mean age was 58.8±10.6 years; 81% were male. Considering the European Society of Cardiology's guidelines on contemporary data collection, 61%, 87% and 71% achieved the recommended LDL cholesterol, blood pressure and HbA1c targets, respectively, at the end of the program. Combining all three risk factors, 42% achieved the recommended targets. High-sensitivity C-reactive protein decreased between the beginning and the end of the program [0.14 (0.08-0.29) mg/L to 0.12 (0.06-0.26) mg/L; p<0.001].

CONCLUSION

Despite contemporary management strategies, including enrollment in a structured EBCR program, a substantial number of patients presented suboptimal control of CV risk factors. Considering the dyslipidemia, hypertension and diabetes results, less than half of the enrolled individuals achieved the recommended targets. These findings highlight a pivotal unmet need which could be particularly relevant in improving CV outcomes by enhancing secondary prevention profiles.

Association between deficient and insufficient 25(OH)D serum concentrations and cardiometabolic risk factors: Findings of a population-based study with older adults of southern Brazil

To investigate the association between deficient and insufficient serum concentrations of 25(OH)D and cardiometabolic risk factors (CMRF), considering that both conditions are important predictors of cardiovascular disease and diabetes mellitus. A cross-sectional study with a subsample of 526 older adults (63-93 years old) who participated in the second wave of the population-based longitudinal study EpiFloripa Idoso. The CMRF analyzed were abdominal obesity, high fasting glucose, high blood pressure, high triglycerides and high LDL-cholesterol. The exposure variable was 25(OH)D serum concentration (≤20 ng/mL = deficient; 21-29 ng/mL = insufficient, ≥30-<100 ng/mL = sufficient). The prevalences of 25(OH)D deficiency and insufficiency were estimated at 21.9% and 43.7%, respectively. The adjusted OR of prevalence of the abdominal obesity (OR 1.99;1.12-3.54), high blood pressure (OR 2.58;1.35-4.94) and high LDL-cholesterol (OR 2.73;1.63-4.6) were higher among those with deficient serum concentration of 25(OH)D. Participants with insufficient serum concentrations of 25(OH)D also presented higher adjusted OR of prevalence for abdominal obesity (OR 2.14;1.31-3.48). No significant adjusted association was found between 25(OH)D with the outcomes high fasting glucose and high triglycerides. Significant effect modification/interaction by age was also observed in the tested associations for abdominal obesity (P < 0.001), blood pressure (P < 0.001) and LDL-cholesterol (P < 0.001), in which deficient and insufficient 25(OH)D values were associated with higher values of these FRCM. 25(OH)D serum concentrations between 30 and 100 ng/mL can contribute to preventing and controlling CMRF such as abdominal obesity, high blood pressure and high LDL-cholesterol. The understanding this particular interaction may indicate ways to prevent/control cardiometabolic outcomes, health problems common in the older adults.

A computationally efficient physiologically comprehensive 3D-0D closed-loop model of the heart and circulation

Computer models of cardiac electro-mechanics (EM) show promise as an effective means for the quantitative analysis of clinical data and, potentially, for predicting therapeutic responses. To realize such advanced applications methodological key challenges must be addressed. Enhanced computational efficiency and robustness is crucial to facilitate, within tractable time frames, model personalization, the simulation of prolonged observation periods under a broad range of conditions, and physiological completeness encompassing therapy-relevant mechanisms is needed to endow models with predictive capabilities beyond the mere replication of observations. Here, we introduce a universal feature-complete cardiac EM modeling framework that builds on a flexible method for coupling a 3D model of bi-ventricular EM to the physiologically comprehensive 0D CircAdapt model representing atrial mechanics and closed-loop circulation. A detailed mathematical description is given and efficiency, robustness, and accuracy of numerical scheme and solver implementation are evaluated. After parameterization and stabilization of the coupled 3D-0D model to a limit cycle under baseline conditions, the model's ability to replicate physiological behaviors is demonstrated, by simulating the transient response to alterations in loading conditions and contractility, as induced by experimental protocols used for assessing systolic and diastolic ventricular properties. Mechanistic completeness and computational efficiency of this novel model render advanced applications geared towards predicting acute outcomes of EM therapies feasible.

Popular procedures without evidence of benefit: A case study of percutaneous coronary intervention for stable coronary artery disease

Despite limited benefit, percutaneous coronary intervention (PCI) remains a common procedure that is often performed for uncertain or inappropriate indications in patients with stable coronary artery disease (CAD). PCI cases per capita have increased year-over-year in most European countries, and many have higher rates than the U.S. Meanwhile, first-line therapy such as optimal medical therapy (OMT) and lifestyle changes, continue to be under-utilized. This article reviews the evidence on use of PCI in stable CAD. Specifically, we analyzed randomized control trials, systematic reviews, appropriate use criteria, and professional society guidelines that examine the risks and benefits of PCI compared to OMT. We then highlight utilization patterns as well as interventions that better align current practice with evidence-based care.

Risk factors for major adverse cardiovascular events after the first acute coronary syndrome

AIMS

To evaluate risk factors for major adverse cardiac event (MACE) after the first acute coronary syndrome (ACS) and to examine the prevalence of risk factors in post-ACS patients.

METHODS

We used Finnish population-based myocardial infarction register, FINAMI, data from years 1993-2011 to identify survivors of first ACS (n = 12686), who were then followed up for recurrent events and all-cause mortality for three years. Finnish FINRISK risk factor surveys were used to determine the prevalence of risk factors (smoking, hyperlipidaemia, diabetes and blood pressure) in post-ACS patients (n = 199).

RESULTS

Of the first ACS survivors, 48.4% had MACE within three years of their primary event, 17.0% were fatal. Diabetes (p = 4.4 × 10-7), heart failure (HF) during the first ACS attack hospitalization (p = 6.8 × 10-15), higher Charlson index (p = 1.56 × 10-19) and older age (p = .026) were associated with elevated risk for MACE in the three-year follow-up, and revascularization (p = .0036) was associated with reduced risk. Risk factor analyses showed that 23% of ACS survivors continued smoking and cholesterol levels were still high (>5mmol/l) in 24% although 86% of the patients were taking lipid lowering medication.

CONCLUSION

Diabetes, higher Charlson index and HF are the most important risk factors of MACE after the first ACS. Cardiovascular risk factor levels were still high among survivors of first ACS.

Rural patients' experience of education, surveillance, and self-care support after heart disease related hospitalisation: a qualitative study

People living in rural Iceland have a higher rate of cardiovascular risk factors and healthcare utilisation compared to people in urban areas.The aim of this qualitative study was to explore the experiences of people with coronary heart disease, living in rural Iceland regarding patient education, surveillance, and self-care support. The participants (N = 14, age 52‒79 years, 8 male), were interviewed 6 to 12 months after hospital discharge following a cardiac event (in 2018‒2019). Systematic text-condensation was used for analysis. The findings were categorised into three main themes: Education and support describes inadequate patient education and support from health-care professionals after discharge from hospitaland how the internet was the main information source supplemented with spouse's and family support. Local healthcare services describe thelack of and importance of access to health-care professionals, stable services, and underutilisation of telemedicine and primary healthcare in the local area, and Self-care behaviour describes the lack of professional support with lifestyle changes and how the participants manage self-care as well as their attitudes towards the disease.The results indicate that access to continuous healthcare services and person-centred support focusing on prevention strategies are widely impaired in rural areas in Iceland.

Contemporary Management of Severe Symptomatic Aortic Stenosis

BACKGROUND

There were gaps between guidelines and practice when surgery was the only treatment for aortic stenosis (AS).

OBJECTIVES

This study analyzed the decision to intervene in patients with severe AS in the EORP VHD (EURObservational Research Programme Valvular Heart Disease) II survey.

METHODS

Among 2,152 patients with severe AS, 1,271 patients with high-gradient AS who were symptomatic fulfilled a Class I recommendation for intervention according to the 2012 European Society of Cardiology guidelines; the primary end point was the decision for intervention.

RESULTS

A decision not to intervene was taken in 262 patients (20.6%). In multivariate analysis, the decision not to intervene was associated with older age (odds ratio [OR]: 1.34 per 10-year increase; 95% CI: 1.11 to 1.61; P = 0.002), New York Heart Association functional classes I and II versus III (OR: 1.63; 95% CI: 1.16 to 2.30; P = 0.005), higher age-adjusted Charlson comorbidity index (OR: 1.09 per 1-point increase; 95% CI: 1.01 to 1.17; P = 0.03), and a lower transaortic mean gradient (OR: 0.81 per 10-mm Hg decrease; 95% CI: 0.71 to 0.92; P < 0.001). During the study period, 346 patients (40.2%, median age 84 years, median EuroSCORE II [European System for Cardiac Operative Risk Evaluation II] 3.1%) underwent transcatheter intervention and 515 (59.8%, median age 69 years, median EuroSCORE II 1.5%) underwent surgery. A decision not to intervene versus intervention was associated with lower 6-month survival (87.4%; 95% CI: 82.0 to 91.3 vs 94.6%; 95% CI: 92.8 to 95.9; P < 0.001).

CONCLUSIONS

A decision not to intervene was taken in 1 in 5 patients with severe symptomatic AS despite a Class I recommendation for intervention and the decision was particularly associated with older age and combined comorbidities. Transcatheter intervention was extensively used in octogenarians.

Self-Similar Functional Circuit Models of Arteries and Deterministic Fractal Operators: Theoretical Revelation for Biomimetic Materials

In this paper, the self-similar functional circuit models of arteries are proposed for bioinspired hemodynamic materials design. Based on the mechanical-electrical analogous method, the circuit model can be utilized to mimic the blood flow of arteries. The theoretical mechanism to quantitatively simulate realistic blood flow is developed by establishing a fractal circuit network with an infinite number of electrical components. We have found that the fractal admittance operator obtained from the minimum repeating unit of the fractal circuit can simply and directly determine the blood-flow regulation mechanism. Furthermore, according to the operator algebra, the fractal admittance operator on the aorta can be represented by Gaussian-type convolution kernel function. Similarly, the arteriolar operator can be described by Bessel-type function. Moreover, by the self-similar assembly pattern of the proposed model, biomimetic materials which contain self-similar circuits can be designed to mimic physiological or pathological states of blood flow. Studies show that the self-similar functional circuit model can efficiently describe the blood flow and provide an available and convenient structural theoretical revelation for the preparation of in vitro hemodynamic bionic materials.

Effects of Supervised Cardiac Rehabilitation Programmes on Quality of Life among Myocardial Infarction Patients: A Systematic Review and Meta-Analysis

Coronary heart disease is the leading cause of death and disability worldwide. Traditionally, cardiac rehabilitation programmes are offered after cardiac events to aid recovery, improve quality of life, and reduce adverse events. The objective of this review was to assess the health-related quality of life, after a supervised cardiac rehabilitation programme, of patients who suffered a myocardial infarction. A systematic review was carried out in the CINAHL, Cochrane, LILACS, Medline, Scopus, and SciELO databases, according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Randomised controlled trials were selected. Meta-analyses were performed for the Short Form Health Survey SF-36, Myocardial Infarction Dimensional Assessment Scale (MIDAS), MacNew Heart Disease-Health-Related Quality of Life (HRQL) questionnaire, and European Quality of Life-Visual Analogue Scale (EuroQol-VAS) with the software Cochrane RevMan Web. Ten articles were found covering a total of 3577 patients. In the meta-analysis, the effect size of the cardiac rehabilitation programme was statistically significant in the intervention group for physical activity, emotional reaction, and dependency dimensions of the MIDAS questionnaire. For the control group, the score improved for SF-36 physical functioning, and body pain dimensions. The mean difference between the control and intervention group was not significant for the remaining dimensions, and neither for the MacNew Heart Disease-HRQL and EuroQol-VAS questionnaires. Supervised cardiac rehabilitation programmes were effective in improving health-related quality of life, however, there was a potential variability in the interventions; therefore, the results should be interpreted with caution. This study supports the importance of providing care and evaluating interventions via the supervision of trained health professionals, and further randomised clinical trials are needed to analyse the positive changes in mental and physical health outcomes.

Patients with stable coronary artery disease and type 2 diabetes but without prior myocardial infarction or stroke and THEMIS-like patients: real-world prevalence and risk of major outcomes from the SNDS French nationwide claims database

AIM AND HYPOTHESES

The THEMIS randomized trial compared ticagrelor plus aspirin versus placebo plus aspirin for patients with stable coronary artery disease and type 2 diabetes mellitus (CAD-T2DM), and without prior myocardial infarction (MI) or stroke. The aim of the study was to quantify the size of the CAD-T2DM population without prior MI or stroke population in a real-world setting, and more specifically populations with similar THEMIS selection criteria (THEMIS-like and THEMIS-PCI-like populations), as well as their risk of major outcomes in current practice.

METHODS

A 2-year follow-up cohort study included all CAD-T2DM without MI/stroke prevalent patients on January 1st, 2014 in the SNDS French nationwide claims database. The THEMIS-like population concerned those ≥ 50 years of age with similar THEMIS inclusion and exclusion criteria. Prevalence was standardized to the European population. The cumulative incidence function was used to estimate the incidence of clinical outcomes (MI, ischemic stroke, and major bleeding according to the TIMI classification) with death as competing risk, and the Kaplan-Meier estimate for all-cause death and a composite outcome of MI, stroke and all-cause death.

RESULTS

From a population of about 50 million adults, the prevalence of CAD-T2DM without MI/stroke, THEMIS-like and THEMIS-PCI-like populations was respectively at 6.04, 1.50 and 0.27 per 1000 adults, with a mean age of 72.7, 72.3 and 70.9 years and less comorbidities and diabetic complications for the THEMIS-like and THEMIS-PCI-like population. The 2-year cumulative incidence was respectively 1.7%, 1.3% and 1.6% for MI, 1.7%, 1.5% and 1.4% for stroke, 4.8%, 3.1% and 2.9% for major bleeding, 13.6%, 9.7% and 6.8% for all-cause death, and 16.2%, 12.0% and 9.5% for the composite outcome.

CONCLUSION

THEMIS-like prevalence was estimated at 1.50 per 1,000 adults, representing about a quarter of CAD-T2DM without MI/stroke patients, and 0.27 per 1000 adults for the THEMIS-PCI-like populations. In current French practice, the median age of both these populations was about 5-6 years older than in the THEMIS trial, with a 2-year incidence of major outcomes between two or four time above the ones of the placebo arm of the THEMIS trial using very close definitions. Registration No. EUPAS27402 ( http://www.ENCEPP.eu ).

Dose Reduction in Coronary Artery Calcium Scoring Using Mono-Energetic Images from Reduced Tube Voltage Dual-Source Photon-Counting CT Data: A Dynamic Phantom Study

In order to assess coronary artery calcium (CAC) quantification reproducibility for photon-counting computed tomography (PCCT) at reduced tube potential, an anthropomorphic thorax phantom with low-, medium-, and high-density CAC inserts was scanned with PCCT (NAEOTOM Alpha, Siemens Healthineers) at two heart rates: 0 and 60-75 beats per minute (bpm). Five imaging protocols were used: 120 kVp standard dose (IQ level 16, reference), 90 kVp at standard (IQ level 16), 75% and 45% dose and tin-filtered 100 kVp at standard dose (IQ level 16). Each scan was repeated five times. Images were reconstructed using monoE reconstruction at 70 keV. For each heart rate, CAC values, quantified as Agatston scores, were compared with the reference, whereby deviations >10% were deemed clinically relevant. Reference protocol radiation dose (as volumetric CT dose index) was 4.06 mGy. Radiation dose was reduced by 27%, 44%, 67%, and 46% for the 90 kVp standard dose, 90 kVp 75% dose, 90 kVp 45% dose, and Sn100 standard dose protocol, respectively. For the low-density CAC, all reduced tube current protocols resulted in clinically relevant differences with the reference. For the medium- and high-density CAC, the implemented 90 kVp protocols and heart rates revealed no clinically relevant differences in Agatston score based on 95% confidence intervals. In conclusion, PCCT allows for reproducible Agatston scores at a reduced tube voltage of 90 kVp with radiation dose reductions up to 67% for medium- and high-density CAC.

Perceptions of injectable therapies with cardiovascular benefit: an ACNAP survey of healthcare professionals to explore facilitators and barriers

AIMS

Injectable medicines are increasingly used to manage risk factors for cardiovascular (CV) events, such as dyslipidaemia and diabetes. These include proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists. Little is known about perceptions of injectable therapies among CV healthcare professionals (HCPs). This study explores their views to identify relevant facilitators and barriers to the use of injectables with CV benefit.

METHODS AND RESULTS

A 22-question survey was distributed internationally via online channels. In total, 192 anonymous responses were received (43.7% physicians, 32.6% nurses, 16.8% pharmacists, 6.8% others). Among respondents with experience of these medicines, 69.1% had used an injectable PCSK9 inhibitor and 67.0% had used an injectable GLP-1 receptor agonist. Commonly raised issues were resource problems (36.5%), lack of knowledge among colleagues (32.3%), paperwork (32.3%), and lack of patient knowledge (28.1%). Key barriers respondents felt made patients decline these treatments were fear of injection (56.6%), lack of awareness or education (26.4%), and administration issues (15.1%); potential reasons for discontinuation included side effects (46.4%), perceived lack of benefit (28.6%), and local reactions (21.4%). The main topics around injectables requiring further support included managing non-adherent patients (16.2%), troubleshooting with patients (16.2%), and educating colleagues about injectables (12.2%). Preferred educational methods to support HCPs were face-to-face training (43.5%) and online learning (26.1%); favoured formats were based on role playing and case studies.

CONCLUSION

Healthcare professionals highlighted various potential barriers to initiation, continuation, and adherence with injectable therapies in CV medicine. Although some require healthcare system changes, many could be addressed through simple measures based primarily on enhanced training and support for patients and HCPs.

A Population-Based Study of Cardiovascular Disease Mortality in Italian Cancer Patients

Simple Summary

Research suggests that lengthening the prognosis in cancer patients (which is certainly a positive thing) requires greater attention to be paid to the onset of other pathologies. The increase in cardiovascular mortality in cancer patients (due to both exposure to risk factors and the side effects of cytotoxic drugs) requires greater collaboration between oncologists and cardiologists, and the integration of shared follow-up paths. Particular attention to the follow-up of cancer patients can reduce this risk: in the present study, patients presented an excessive risk of cardiovascular mortality only in the first two years from cancer diagnosis.

Abstract

The present research describes 25 years of cardiovascular mortality in a cohort of patients in Northern Italy. The study included patients with malignant cancer enrolled in the period of 1996–2019, and describes cardiovascular and cancer mortality in relation to sex, age, year of diagnosis, months of survivorship, tumor site, and standardized mortality ratio (SMR). Out of 67,173 patients, 38,272 deaths (57.7%) were recorded: 4466 from cardiovascular disease (CVD) (6.6%), and 28,579 (42.6%) from cancer. The proportion of CVD death increased from 4.5% in the first two years after diagnosis, to 7.3% after more than 10 years, while the proportion of deaths from cancer decreased from 70.5% to 9.4%. The CVD SMR comparing cancer patients with the general population was 0.87 (95% CI: 0.82–0.92) in 1996–1999, rising to 0.95 (95% CI: 0.84–1.08) in 2015–2019, without differences in terms of sex or age. The risk of dying from CVD was higher compared with the general population (SMR 1.31; 95% CI: 1.24–1.39) only in the first two years after diagnosis. The trend over time underscored that CVD deaths increased in patients with breast, bladder, prostate, and colorectal cancers, and, in the more recent period, for kidney cancer and melanoma patients. Our data confirmed that cardiovascular mortality is an important issue in the modern management of cancer patients, suggesting the need for an extensive interdisciplinary approach.

Acute Aortic Syndrome Revisited: JACC State-of-the-Art Review

The purpose of this paper is to describe all available evidence on the distinctive features of a group of 4 life-threatening acute aortic pathologies gathered under the name of acute aortic syndrome (AAS). The epidemiology, diagnostic strategy, and management of these patients has been updated. The authors propose a new and simple diagnostic algorithm to support clinical decision making in cases of suspected AAS, thereby minimizing diagnostic delays, misdiagnoses, and unnecessary advanced imaging. AAS-related entities are reviewed, and a guideline to avoid imaging misinterpretation is provided. Centralization of patients with AAS in high-volume centers with high-volume surgeons is key to improving clinical outcomes. Thus, the role of multidisciplinary teams, an "aorta code" (streamlined emergent care pathway), and aortic centers in the management of these patients is boosted. A tailored patient treatment approach for each of these acute aortic entities is needed, and as such has been summarized. Finally, a set of prevention measures against AAS is discussed.

Effects of different exercise interventions on heart rate variability and cardiovascular health factors in older adults: a systematic review

BACKGROUND

Aging impairs physiological processes in the autonomic nervous, endocrine, and cardiovascular systems which are associated with increased risk of cardiovascular disease. Heart rate variability (HRV), the beat-to-beat variations of successive heartbeats, is an indicator of cardiac autonomic control and cardiovascular health. Physical activity has beneficial effects on cardiovascular health. However, no review has been conducted to summarize the effects of different exercise modalities on HRV in older adults. Therefore, the aim of this systematic review was to summarize the effects of endurance, resistance, coordinative, and multimodal exercise interventions on resting HRV and secondary health factors in healthy older adults aged 60 years in average and over.

METHODS

Five databases (PubMed, Scopus, SPORTDiscus, Ovid, and Cochrane Library) were searched for eligible studies published between 2005 and September 8th, 2020. Two reviewers independently assessed the studies for potential inclusion. Outcome measures were changes in resting HRV indices, baroreflex sensitivity, blood pressure, body fat, body mass, body mass index, cardiac output, distance in the six-minute walking test, stroke volume, total peripheral resistance, and VO2 max or VO2 peak from pre to post intervention. The methodological quality of the final data set was assessed using two scales (TESTEX and STARDHRV). This review was registered in PROSPERO: CRD42020206606.

RESULTS

The literature search retrieved 3991 articles, of which 13 were included in the review. Five studies used multimodal, three studies endurance, two studies resistance, two studies coordinative, and one study used an endurance and a resistance training intervention. The majority of the studies revealed significant positive effects on cardiac autonomic control, except for the resistance training interventions. All exercise modalities improved secondary health factors. The methodological quality assessment revealed a few criteria to improve the quality of and comparability between studies.

CONCLUSION

This systematic review revealed beneficial effects on cardiac autonomic control in healthy older adults through endurance, coordinative, and multimodal training but not through resistance training. Secondary health factors improved after all types of physical interventions. Future investigations should more thoroughly adhere to methodological standards of exercise interventions and ECG recording for the assessment of autonomic regulation.

Coronary Revascularization in Patients With Stable Coronary Artery Disease: The Role of Imaging

In the last decades, the effective management of some cardiovascular risk factors in the general population has led to a progressive decrease in the prevalence of coronary artery disease (CAD). Nevertheless, coronary heart disease remains the major cause of death in developed and developing countries and chronic coronary syndromes (CCS) are still a major target of utilization of non-invasive cardiac imaging and invasive procedures. Current guidelines recommend the use of non-invasive imaging in patients with CCS to identify subjects at higher risk to be referred for invasive coronary angiography and possible revascularization. These recommendations are challenged by two opposite lines of evidence. Recent trials have somewhat questioned the efficacy of coronary revascularization as compared with optimal medical therapy in CCS. As a consequence the role of imaging in these patients and in in patients with ischemic cardiomyopathy is under debate. On the other hand, real-life data indicate that a consistent proportion of patients undergo invasive procedure and are revascularized without any previous non-invasive imaging characterization. On top of this, the impact of COVID-19 pandemic on the sanitary systems caused a change in the current management of patients with CAD. In the present review we will discuss these conflicting data analyzing the evidence which has been recently accumulated as well as the gaps of knowledge which should still be filled.

Delivery of Nitric Oxide in the Cardiovascular System: Implications for Clinical Diagnosis and Therapy

Nitric oxide (NO) is a key molecule in cardiovascular homeostasis and its abnormal delivery is highly associated with the occurrence and development of cardiovascular disease (CVD). The assessment and manipulation of NO delivery is crucial to the diagnosis and therapy of CVD, such as endothelial dysfunction, atherosclerotic progression, pulmonary hypertension, and cardiovascular manifestations of coronavirus (COVID-19). However, due to the low concentration and fast reaction characteristics of NO in the cardiovascular system, clinical applications centered on NO delivery are challenging. In this tutorial review, we first summarized the methods to estimate the in vivo NO delivery process, based on computational modeling and flow-mediated dilation, to assess endothelial function and vulnerability of atherosclerotic plaque. Then, emerging bioimaging technologies that have the potential to experimentally measure arterial NO concentration were discussed, including Raman spectroscopy and electrochemical sensors. In addition to diagnostic methods, therapies aimed at controlling NO delivery to regulate CVD were reviewed, including the NO release platform to treat endothelial dysfunction and atherosclerosis and inhaled NO therapy to treat pulmonary hypertension and COVID-19. Two potential methods to improve the effectiveness of existing NO therapy were also discussed, including the combination of NO release platform and computational modeling, and stem cell therapy, which currently remains at the laboratory stage but has clinical potential for the treatment of CVD.

Cell-to-Cell Interactions Mediating Functional Recovery after Stroke

Ischemic damage in brain tissue triggers a cascade of molecular and structural plastic changes, thus influencing a wide range of cell-to-cell interactions. Understanding and manipulating this scenario of intercellular connections is the Holy Grail for post-stroke neurorehabilitation. Here, we discuss the main findings in the literature related to post-stroke alterations in cell-to-cell interactions, which may be either detrimental or supportive for functional recovery. We consider both neural and non-neural cells, starting from astrocytes and reactive astrogliosis and moving to the roles of the oligodendrocytes in the support of vulnerable neurons and sprouting inhibition. We discuss the controversial role of microglia in neural inflammation after injury and we conclude with the description of post-stroke alterations in pyramidal and GABAergic cells interactions. For all of these sections, we review not only the spontaneous evolution in cellular interactions after ischemic injury, but also the experimental strategies which have targeted these interactions and that are inspiring novel therapeutic strategies for clinical application.

Intrapericardial Delivery of APA-Microcapsules as Promising Stem Cell Therapy Carriers in an Experimental Acute Myocardial Infarction Model

The administration of cardiosphere-derived cells (CDCs) after acute myocardial infarction (AMI) is very promising. CDC encapsulation in alginate-poly-l-lysine-alginate (APA) could increase cell survival and adherence. The intrapericardial (IP) approach potentially achieves high concentrations of the therapeutic agent in the infarcted area. We aimed to evaluate IP therapy using a saline vehicle as a control (CON), a dose of 30 × 106 CDCs (CDCs) or APA microcapsules containing 30 × 106 CDCs (APA-CDCs) at 72 h in a porcine AMI model. Magnetic resonance imaging (MRI) was used to determine the left ventricular ejection fraction (LVEF), infarct size (IS), and indexed end diastolic and systolic volumes (EDVi; ESVi) pre- and 10 weeks post-injection. Programmed electrical stimulation (PES) was performed to test arrhythmia inducibility before euthanasia. Histopathological analysis was carried out afterwards. The IP infusion was successful in all animals. At 10 weeks, MRI revealed significantly higher LVEF in the APA-CDC group compared with CON. No significant differences were observed among groups in IS, EDVi, ESVi, PES and histopathological analyses. In conclusion, the IP injection of CDCs (microencapsulated or not) was feasible and safe 72 h post-AMI in the porcine model. Moreover, CDCs APA encapsulation could have a beneficial effect on cardiac function, reflected by a higher LVEF at 10 weeks.

Immuno-regenerative biomaterials for in situ cardiovascular tissue engineering - Do patient characteristics warrant precision engineering?

In situ tissue engineering using bioresorbable material implants - or scaffolds - that harness the patient's immune response while guiding neotissue formation at the site of implantation is emerging as a novel therapy to regenerate human tissues. For the cardiovascular system, the use of such implants, like blood vessels and heart valves, is gradually entering the stage of clinical translation. This opens up the question if and to what extent patient characteristics influence tissue outcomes, necessitating the precision engineering of scaffolds to guide patient-specific neo-tissue formation. Because of the current scarcity of human in vivo data, herein we review and evaluate in vitro and preclinical investigations to predict the potential role of patient-specific parameters like sex, age, ethnicity, hemodynamics, and a multifactorial disease profile, with special emphasis on their contribution to the inflammation-driven processes of in situ tissue engineering. We conclude that patient-specific conditions have a strong impact on key aspects of in situ cardiovascular tissue engineering, including inflammation, hemodynamic conditions, scaffold resorption, and tissue remodeling capacity, suggesting that a tailored approach may be required to engineer immuno-regenerative biomaterials for safe and predictive clinical applicability.

Cuff-less blood pressure estimation using wrist photoplethysmography

One of the most promising and at the same time rapidly growing sectors in healthcare is that of wearable medical devices. Population ageing constantly shifts towards a higher number of senior and elderly people with increased prevalence of chronic diseases often requiring long-term care and a need to decrease hospitalization time and cost. However, today most of the devices entering the market are not standardized nor medically approved, and they are highly inaccurate. In this work we present a system and a method to provide accurate measurement of systolic and diastolic blood pressure (BP) based solely on wrist photoplethysmography. We map morphological features to BP values using machine learning and propose ways to select high quality signals leading to an accuracy improvement of up to 33.5%, if compared against no signal selection, a mean absolute error of 1.1mmHg in a personalized scenario and 8.7mmHg in an uncalibrated leave-one-out scenario.

Adherence to a Plant-Based Diet and Consumption of Specific Plant Foods-Associations with 3-Year Weight-Loss Maintenance and Cardiometabolic Risk Factors: A Secondary Analysis of the PREVIEW Intervention Study

Plant-based diets are recommended by dietary guidelines. This secondary analysis aimed to assess longitudinal associations of an overall plant-based diet and specific plant foods with weight-loss maintenance and cardiometabolic risk factors. Longitudinal data on 710 participants (aged 26–70 years) with overweight or obesity and pre-diabetes from the 3-year weight-loss maintenance phase of the PREVIEW intervention were analyzed. Adherence to an overall plant-based diet was evaluated using a novel plant-based diet index, where all plant-based foods received positive scores and all animal-based foods received negative scores. After adjustment for potential confounders, linear mixed models with repeated measures showed that the plant-based diet index was inversely associated with weight regain, but not with cardiometabolic risk factors. Nut intake was inversely associated with regain of weight and fat mass and increments in total cholesterol and LDL cholesterol. Fruit intake was inversely associated with increments in diastolic blood pressure, total cholesterol, and LDL cholesterol. Vegetable intake was inversely associated with an increment in diastolic blood pressure and triglycerides and was positively associated with an increase in HDL cholesterol. All reported associations with cardiometabolic risk factors were independent of weight change. Long-term consumption of nuts, fruits, and vegetables may be beneficial for weight management and cardiometabolic health, whereas an overall plant-based diet may improve weight management only.

Doppler Echocardiography Assessment of Coronary Microvascular Function in Patients With Angina and No Obstructive Coronary Artery Disease

Echocardiographic evaluation is an essential part of the diagnostic work-up in patients with known or suspected cardiovascular disease. Transthoracic Doppler echocardiography (TTDE) enables straightforward and reliable visualization of flow in the left anterior descending artery. In the absence of obstructive coronary artery disease, low TTDE-derived coronary flow velocity reserve (CFVR) is considered a marker of coronary microvascular dysfunction (CMD). TTDE CFVR is free from ionizing radiation and widely available, utilizing high-frequency transducers, pharmacologic vasodilator stress, and pulsed-wave Doppler quantification of diastolic peak flow velocities. European Society of Cardiology guidelines recommend TTDE CFVR evaluation only following preceding anatomic invasive or non-invasive coronary imaging excluding obstructive CAD. Accordingly, clinical use of TTDE CFVR is limited and CMD frequently goes undiagnosed. An evolving body of evidence underlines that low CFVR is an important and robust predictor of adverse prognosis and continuing symptoms in angina patients both with and without obstructive CAD. The majority of angina patients have no obstructive CAD, particularly among women. This has led to the suggestion that there may be a gender-specific female atherosclerotic phenotype with less epicardial obstruction, and a low CFVR signifying CMD instead. Nevertheless, available evidence indicates low CFVR is an equally important prognostic marker in both men and women. In this review, TTDE CFVR was evaluated regarding indication, practical and technical aspects, and interpretation of results. Association with symptoms and prognosis, comparison with alternative invasive and non-invasive imaging modalities, and possible interventions in angina patients with low CFVR were discussed, and key research questions were proposed.

Innovative nanotools for vascular drug delivery: the atherosclerosis case study

Cardiovascular diseases are the leading cause of mortality in the Western world. Among them, atherosclerosis represents one of the most common diseases in the modern society due to a common sedentary lifestyle, high-fat diet, and smoking. In the near future, a new approach could potentially improve the therapy of vascular pathologies, where to date the non-specific treatments present several limitations, such as poor biodistribution, quick elimination from the body, and undesired side-effects. In this field, nanotechnology has a great potential for the therapy and diagnosis of atherosclerosis with more and more recent and innovative publications. This review is a critical analysis of the results reported in the literature regarding the different and possible new approaches for the therapy and diagnosis of atherosclerosis.

A computationally efficient dynamic model of human epicardial tissue

We present a new phenomenological model of human ventricular epicardial cells and we test its reentry dynamics. The model is derived from the Rogers-McCulloch formulation of the FitzHugh-Nagumo equations and represents the total ionic current divided into three contributions corresponding to the excitatory, recovery and transient outward currents. Our model reproduces the main characteristics of human epicardial tissue, including action potential amplitude and morphology, upstroke velocity, and action potential duration and conduction velocity restitution curves. The reentry dynamics is stable, and the dominant period is about 270 ms, which is comparable to clinical values. The proposed model is the first phenomenological model able to accurately resemble human experimental data by using only 3 state variables and 17 parameters. Indeed, it is more computationally efficient than existing models (i.e., almost two times faster than the minimal ventricular model). Beyond the computational efficiency, the low number of parameters facilitates the process of fitting the model to the experimental data.

Characterization of Atherosclerotic Plaque Coating for Thrombosis Microfluidics Assays

Introduction

Studying arterial thrombus formation by in vitro flow assays is a widely used approach. Incorporating human atherosclerotic plaque material as a thrombogenic surface in these assays represents a method to model the pathophysiological environment of thrombus formation upon plaque disruption. Up until now, achieving a homogeneous coating of plaque material and subsequent reproducible platelet adhesion has been challenging. Here, we characterized a novel method for coating of plaque material on glass coverslips for use in thrombosis microfluidic assays.

Methods

A homogenate of human atherosclerotic plaques was coated on glass coverslips by conventional manual droplet coating or by spin coating. Prior to coating, a subset of coverslips was plasma treated. Water contact angle measurements were performed as an indicator for the hydrophilicity of the coverslips. Homogeneity of plaque coatings was determined using profilometric analysis and scanning electron microscopy. Thrombogenicity of the plaque material was assessed in real time by microscopic imaging while perfusing whole blood at a shear rate of 1500 s⁻¹ over the plaque material.

Results

Plasma treatment of glass coverslips, prior to spin coating with plaque material, increased the hydrophilicity of the coverslip compared to no plasma treatment. The most homogeneous plaque coating and highest platelet adhesion was obtained upon plasma treatment followed by spin coating of the plaque material. Manual plaque coating on non-plasma treated coverslips yielded lowest coating homogeneity and platelet adhesion and activation.

Conclusion

Spin coating of atherosclerotic plaque material on plasma treated coverslips leads to a more homogenous coating and improved platelet adhesion to the plaque when compared to conventional droplet coating on non-plasma treated coverslips. These properties are beneficial in ensuring the quality and reproducibility of flow experiments.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12195-021-00713-9.

Health-Related Lifestyle Profiles in Healthy Adults: Associations with Sociodemographic Indicators, Dispositional Optimism, and Sense of Coherence

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality globally. Promoting healthy behaviors throughout life is an essential prevention tool. This study investigated the associations among lifestyle profiles (including diet, alcohol consumption, physical activity, cigarette smoking, and cardiovascular screening), sociodemographic factors (gender, age, education, and family history of CVDs), and psychological factors (sense of coherence and dispositional optimism). In total, 676 healthy adults (mean age = 35 years; range = 19-57; 46% male) participated in an online survey. Lifestyle profiles were identified through cluster analysis, and a multinomial logistic regression was then performed to explore their association with sociodemographic and psychological variables. Results show that men were more likely than women to belong to the lifestyle profile with the highest amount of physical activity (OR = 2.40; p < 0.001) and the greatest attention to cardiovascular screening (OR = 2.09; p < 0.01). Lower dispositional optimism was associated with the profile paying the greatest attention to cardiovascular screening (OR = 0.67; p < 0.05). Sense of coherence, in terms of lower comprehensibility (OR = 0.67; p < 0.05) and higher manageability (OR = 1.43; p < 0.05), was associated with the lifestyle profile characterized by an unhealthy diet, sedentary lifestyle, and nonsmoking. This study shed light on factors associated with different co-occurring health-related behaviors that should be considered in planning effective communication strategies promoting adherence to health claims.

A score appraising Paleolithic diet and the risk of cardiovascular disease in a Mediterranean prospective cohort

Purpose

To assess the association between a score appraising adherence to the PaleoDiet and the risk of cardiovascular disease (CVD) in a Mediterranean cohort.

Methods

We included 18,210 participants from the Seguimiento Universidad de Navarra (SUN) cohort study. The PaleoDiet score comprised six food groups promoted within this diet (fruit, nuts, vegetables, eggs, meat and fish) and five food groups whose consumption is discouraged (cereals and grains, dairy products, legumes, culinary ingredients, and processed/ultra-processed foods). CVD was defined as acute myocardial infarction with or without ST elevation, non-fatal stroke and cardiovascular death. Cox proportional hazards models adjusted for potential confounders were fitted to assess the association between the PaleoDiet score and CVD risk, and the PaleoDiet and MedDiet indices to explore differences between both diets.

Results

During 12.2 years of follow-up, 165 incident CVD cases were confirmed. A significant inverse association was found between the PaleoDiet score and CVD (HR Q5 vs. Q1: 0.45, 95% CI 0.27–0.76, P for trend = 0.007). A weaker association that became non-significant was observed when the item for low consumption of ultra-processed foods was removed from the score. Joint analysis of PaleoDiet and MedDiet Trichopoulou scores suggested that the inverse association between PaleoDiet and CVD was mainly present when adherence to the MedDiet was also high (HR for high adherence vs low adherence to both diet scores: 0.22, 95% CI 0.08–0.64).

Conclusions

Our findings suggest that the PaleoDiet may have cardiovascular benefits in participants from a Mediterranean country. Avoidance of ultra-processed foods seems to play a key role in this inverse association.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00394-021-02696-9.

Sinomenine in Cardio-Cerebrovascular Diseases: Potential Therapeutic Effects and Pharmacological Evidences

Cardio-cerebrovascular diseases, as a major cause of health loss all over the world, contribute to an important part of the global burden of disease. A large number of traditional Chinese medicines have been proved effective both clinically and in pharmacological investigations, with the acceleration of the modernization of Chinese medicine. Sinomenine is the main active constituent of sinomenium acutum and has been generally used in therapies of rheumatoid arthritis and neuralgia. Varieties of pharmacological effects of sinomenine in cardio-cerebrovascular system have been discovered recently, suggesting an inspiring application prospect of sinomenine in cardio-cerebrovascular diseases. Sinomenine may retard the progression of atherosclerosis by attenuating endothelial inflammation, regulating immune cells function, and inhibiting the proliferation of vascular smooth muscle cells. Sinomenine also alleviates chronic cardiac allograft rejection relying on its anti-inflammatory and anti-hyperplastic activities and suppresses autoimmune myocarditis by immunosuppression. Prevention of myocardial or cerebral ischemia-reperfusion injury by sinomenine is associated with its modulation of cardiomyocyte death, inflammation, calcium overload, and oxidative stress. The regulatory effects on vasodilation and electrophysiology make sinomenine a promising drug to treat hypertension and arrhythmia. Here, in this review, we will illustrate the pharmacological activities of sinomenine in cardio-cerebrovascular system and elaborate the underlying mechanisms, as well as give an overview of the potential therapeutic roles of sinomenine in cardio-cerebrovascular diseases, trying to provide clues and bases for its clinical usage.

Relationship of coronary heart disease and comorbide dental background

Cardiovascular disease has serious economic and social consequences that affect people, health systems and societies around the world. Ischemic heart disease is one of the main global causes of death of the population, and its growth is predicted in the coming years. This fact continues to be of serious concern to health, social and economic services. Cardiovascular disease remains the most common cause of death, and age-standardized rates are higher for men than for women. Cardiovascular comorbidity increases significantly with age.The combination of ischemic heart disease and comorbid pathology is noted in cancer incidence, bronchial asthma, non-alcoholic fatty liver disease, type 2 diabetes mellitus, chronic obstructive pulmonary disease, periodontal disease, etc. It is necessary to analyze the existing disease with past diseases, risk factors and predictors available in the patient. The presence of concomitant diseases quite often requires additional diagnostic methods and changes in the tactics of treating coronary heart disease due to the fact that some of them are a contraindication to the use of certain groups of drugs. Periodontal disease includes a wide range of inflammatory conditions that affect the supporting structures of the teeth, which can lead to tooth loss and contribute to systemic inflammation. Periodontal disease is associated with several systemic diseases, one of which is coronary artery disease. It is imperative that clinicians understand the link between periodontal disease and cardiovascular disease. Comprehensive treatment of periodontitis and restoration of a healthy periodontium can help reduce overall inflammation in the body and reduce the risks of coronary heart disease.