Adult asthma and risk of coronary heart disease, cerebrovascular disease, and heart failure: a prospective study of 2 matched cohorts

Mast cells: a novel therapeutic avenue for cardiovascular diseases?

Mast cells are tissue-resident immune cells strategically located in different compartments of the normal human heart (the myocardium, pericardium, aortic valve, and close to nerves) as well as in atherosclerotic plaques. Cardiac mast cells produce a broad spectrum of vasoactive and proinflammatory mediators, which have potential roles in inflammation, angiogenesis, lymphangiogenesis, tissue remodelling, and fibrosis. Mast cells release preformed mediators (e.g. histamine, tryptase, and chymase) and de novo synthesized mediators (e.g. cysteinyl leukotriene C4 and prostaglandin D2), as well as cytokines and chemokines, which can activate different resident immune cells (e.g. macrophages) and structural cells (e.g. fibroblasts and endothelial cells) in the human heart and aorta. The transcriptional profiles of various mast cell populations highlight their potential heterogeneity and distinct gene and proteome expression. Mast cell plasticity and heterogeneity enable these cells the potential for performing different, even opposite, functions in response to changing tissue contexts. Human cardiac mast cells display significant differences compared with mast cells isolated from other organs. These characteristics make cardiac mast cells intriguing, given their dichotomous potential roles of inducing or protecting against cardiovascular diseases. Identification of cardiac mast cell subpopulations represents a prerequisite for understanding their potential multifaceted roles in health and disease. Several new drugs specifically targeting human mast cell activation are under development or in clinical trials. Mast cells and/or their subpopulations can potentially represent novel therapeutic targets for cardiovascular disorders.

Pediatric asthma comorbidities: Global impact and unmet needs

Real-world data on the range and impact of comorbid health conditions that affect pediatric asthma are scant, especially from developing countries. Lack of data hinders effective diagnosis, treatment, and overall management of these complex cases. We, hereby, describe the common pediatric asthma comorbid conditions in terms of evidence for association, potential mechanisms of impact on asthma control, and treatment benefit. Obesity, upper airway allergies, dysfunctional breathing, multiple sensitizations, depressive disorders, food allergy, and gastro-esophageal reflux are common associations with difficult-to-treat asthma. On the other hand, asthma symptoms and/or management may negatively impact the well-being of children through drug adverse effects, worsening of anaphylaxis symptoms, and disturbing mental health. Awareness of these ailments may be crucial for designing the optimum care for each asthmatic child individually and may ultimately improve the quality of life of patients and their families. A multidisciplinary team of physicians is required to identify and manage such comorbidities aiming to mitigate the over-use of asthma pharmacotherapy. Asthma research should target relevant real-world difficulties encountered at clinical practice and focus on interventions that would mitigate the impact of such comorbidities. Finally, policymakers and global healthcare organizations are urged to recognize pediatric asthma control as a healthcare priority and allocate resources for research and clinical interventions. In other words, global asthma control needs support by compassionate scientific partnership.

Genetic susceptibility to chronic diseases leads to heart failure among Europeans: the influence of leukocyte telomere length

BACKGROUND

Genetic susceptibility to various chronic diseases has been shown to influence heart failure (HF) risk. However, the underlying biological pathways, particularly the role of leukocyte telomere length (LTL), are largely unknown. We investigated the impact of genetic susceptibility to chronic diseases and various traits on HF risk, and whether LTL mediates or modifies the pathways.

METHODS

We conducted prospective cohort analyses on 404 883 European participants from the UK Biobank, including 9989 incident HF cases. Multivariable Cox regression was used to estimate associations between HF risk and 24 polygenic risk scores (PRSs) for various diseases or traits previously generated using a Bayesian approach. We assessed multiplicative interactions between the PRSs and LTL previously measured in the UK Biobank using quantitative PCR. Causal mediation analyses were conducted to estimate the proportion of the total effect of PRSs acting indirectly through LTL, an integrative marker of biological aging.

RESULTS

We identified 9 PRSs associated with HF risk, including those for various cardiovascular diseases or traits, rheumatoid arthritis (P = 1.3E-04), and asthma (P = 1.8E-08). Additionally, longer LTL was strongly associated with decreased HF risk (P-trend = 1.7E-08). Notably, LTL strengthened the asthma-HF relationship significantly (P-interaction = 2.8E-03). However, LTL mediated only 1.13% (P < 0.001) of the total effect of the asthma PRS on HF risk.

CONCLUSIONS

Our findings shed light onto the shared genetic susceptibility between HF risk, asthma, rheumatoid arthritis, and other traits. Longer LTL strengthened the genetic effect of asthma in the pathway to HF. These results support consideration of LTL and PRSs in HF risk prediction.

Systemic Inflammation in Asthma: What Are the Risks and Impacts Outside the Airway?

Airway inflammation in asthma has been well recognized for several decades, with general agreement on its role in asthma pathogenesis, symptoms, propensity toward exacerbation, and decline in lung function. This has led to universal recommendation in asthma management guidelines to incorporate the use of inhaled corticosteroid as an anti-inflammatory therapy for all patients with persistent asthma symptoms. However, there has been limited attention paid to the presence and potential impact of systemic inflammation in asthma. Accumulating evidence from epidemiological observations and cohort studies points to a host of downstream organ dysfunction in asthma especially among patients with longstanding or more severe disease, frequent exacerbations, and underlying risk factors for organ dysfunction. Most studies to date have focused on cognitive impairment, depression/anxiety, metabolic syndrome, and cardiovascular abnormalities. In this review, we summarize some of the evidence demonstrating these abnormalities and highlight the proposed mechanisms and potential benefits of treatment in limiting these extrapulmonary abnormalities in patients with asthma. The goal of this commentary is to raise awareness of the importance of recognizing potential extrapulmonary conditions associated with systemic inflammation of asthma. This area of treatment of patients with asthma is a large unmet need.

Effect of chronic lung diseases on angina pectoris among Indian adults: longitudinal ageing study in India

The study aimed to evaluate the effect of chronic lung diseases, namely chronic obstructive pulmonary diseases (COPD) and asthma, on angina pectoris in individuals aged 45 years and above. Identifying vulnerable subpopulations suffering from COPD and asthma at higher risk of future cardiovascular events using the rose angina questionnaire is imperative for tailored primary and secondary prevention approaches. The present study utilizes the data from the Longitudinal Ageing Study in India, wave 1, conducted during 2017-2018. The sample size included 58,830 individuals aged 45 years and above. Angina was measured based on seven questions from Rose's questionnaires. Descriptive statistics and bivariate analysis were employed to examine the prevalence of angina among individuals with COPD and asthma. Further, multivariable logistic regression and propensity score matching (PSM) methods were used to assess the independent effect of COPD and asthma on angina after controlling the selected background characteristics. We employed PSM in two different models and included various additional factors in model 2, such as smoking, chewing tobacco, alcohol use, ADL, IADL, body mass index, physical activity, high cholesterol, hypertension, diabetes, and chronic heart disease. The current study shows that the prevalence of angina pectoris, COPD and asthma was 6.0%, 2.3% and 4.7%, respectively, among individuals aged 45 years and above in India. The prevalence of angina pectoris was higher among individuals with COPD (9.6% vs. 5.8%) and asthma (9.9% vs. 5.7%) than those without COPD and asthma, respectively. Additionally, angina pectoris was more prevalent among females and rural respondents with COPD (10.8% and 11.0%) and asthma (10.3% and 10.3%) compared to males and urban respondents with COPD (8.0% and 5.7%) and asthma (8.9% and 7.9%). Moreover, in the adjusted model, individuals with COPD (AOR 1.43, 95% CI 1.03 1.98) and asthma (AOR 1.44, 95% CI 1.17 1.77) had nearly 1.5-fold higher odds of having angina pectoris than those without COPD and asthma. The PSM estimates showed that individuals with COPD had 8.4% and 5.0% increased risk of angina pectoris compared to those without COPD in model 1 and model 2, respectively. We observed that, after adjusting to lifestyle, health-related and morbidity factors in model 2, both average treatment effect on untreated (ATU) and average treatment effect (ATE) values decreased by nearly 3.5%. Additionally, the PSM estimates demonstrated that individuals with asthma had a 3.4% and 2.9% increased risk of angina pectoris compared to those without asthma in model 1 and model 2, respectively. The study suggests that COPD and asthma are significantly associated with angina pectoris, and individuals with COPD and asthma have a higher risk of developing angina pectoris. Additionally, angina pectoris was more prevalent among females, rural respondents and adults aged 45-54 with COPD compared to males, urban respondents and those aged 65 and above, respectively, with COPD. Moreover, the findings of our study underscore the targeted primary and secondary interventions and team-based care approach among individuals with COPD and asthma to reduce the risk of CVD events in future.

Comorbidity Burden in Severe and Nonsevere Asthma: A Nationwide Observational Study (FINASTHMA)

BACKGROUND

Asthma, affecting more than 330 million people worldwide, is associated with a high level of morbidity, mortality, and socioeconomic costs.

OBJECTIVE

In this cross-sectional study, we analyzed the comorbidity burden in patients with severe asthma compared with nonsevere asthma and investigated the role of corticosteroid use on the risk of comorbidities.

METHODS

All adults (≥18 y) with a diagnosis of asthma (International Classification of Diseases-10th revision code J45.x) between 2014 and 2017 were identified and data were collected until 2018 from Finnish nationwide registers. Asthma was defined as continuously or transiently severe or nonsevere based on annual dispensed inhaled corticosteroids (ICS), oral corticosteroids (OCS), and hospitalizations.

RESULTS

Of 193,730 adult identified patients diagnosed with asthma, 86.3% had nonsevere, 8.1% transiently severe, and 5.6% continuously severe asthma. Excess prevalence of pneumonia was observed in continuously (22%) and transiently severe (14%) compared with nonsevere patients after adjusting for age and sex. Cataract, osteoporosis, obesity, heart failure, and atrial fibrillation were also more frequent in severe asthma patients. The ICS and/or OCS use contributed to the risk of several comorbidities in a dose-dependent manner, particularly pneumonia, osteoporosis, obesity, heart failure, and atrial fibrillation. High OCS use and the presence of comorbidities were associated with increased health care resource use.

CONCLUSIONS

Patients with severe asthma have a high burden of comorbidities, especially pneumonia. Many of the comorbidities have a strong dose-dependent association with ICS and OCS treatment, suggesting that corticosteroid doses should be carefully evaluated in clinical practice.

Safety outcomes of salbutamol: A systematic review and meta-analysis

PURPOSE

Salbutamol has been used to alleviate bronchospasm in airway disease for decades, while its potential risks have not been systematically investigated yet. The risk of any potential adverse events (AEs) in patients treated with salbutamol was assessed through systematic review and meta-analysis.

METHODS

A systematic search of the literature was conducted, using EMBASE, PubMed and Cochrane library, until 3 April 2023. Once the AE incidence was evaluated, randomized controlled trials (RCTs) were eligible for review. The endpoints included the incidence of total AEs, severe AEs, treatment discontinuation and specific AEs. The pooled AEs incidence was analysed via random-effects model in a single-arm meta-analysis. A subgroup study was carried out to examine whether the pooled incidence of AE differed by indications or formulations.

RESULTS

Of the 8912 studies that were identified, 58 RCTs met the inclusion criteria and involved 12 961 participants. The analysis showed the pooled incidences of total AEs, severe AEs and treatment discontinuation in patients treated with salbutamol were 34%, 2% and 3%, respectively. Subgroup analysis indicated that premature labour users and intravenous salbutamol users were more likely associated with total AEs. The most frequently observed specific AEs were palpitations or tachycardia.

CONCLUSION

This meta-analysis indicated that salbutamol was associated with a very common risk of palpitations or tachycardia. Clinical vigilance and research efforts are needed to optimize the safe use of salbutamol.

Asthma and incident coronary heart disease: an observational and Mendelian randomisation study

BACKGROUND

Observational studies suggest asthma is a risk factor for coronary heart disease (CHD) and sex modifies the risk, but they may suffer from methodological limitations. To overcome these, we applied a "triangulation approach", where different methodologies, with different potential biases, were leveraged to enhance confidence in findings.

METHODS

First, we conducted an observational study using UK medical records to match asthma patients 1:1, by age, sex and general practitioner (GP) practice, to the general population. We measured the association between asthma and incident CHD (myocardial infarction: hospitalisation/death) by applying minimal sufficient adjustment: model 1, smoking, body mass index, oral corticosteroids, atopy and deprivation; model 2, additionally adjusting for healthcare behaviour (GP consultation frequency). Second, we conducted a Mendelian randomisation (MR) study using data from the UK Biobank, Trans-National Asthma Genetic Consortium (TAGC) and Coronary Artery Disease Genome-wide Replication and Meta-analysis consortium (CARDIoGRAM). Using 64 asthma single nucleotide polymorphisms, the effect of asthma on CHD was estimated with inverse variance-weighted meta-analysis and methods that adjust for pleiotropy.

RESULTS

In our observational study (n=1 522 910), we found asthma was associated with 6% increased risk of CHD (model 1: HR 1.06, 95% CI 1.01-1.13); after accounting for healthcare behaviour, we found no association (model 2: HR 0.99, 95% CI 0.94-1.05). Asthma severity did not modify the association, but sex did (females: HR 1.11, 95% CI 1.01-1.21; males: HR 0.91, 95% CI 0.84-0.98). Our MR study (n=589 875) found no association between asthma and CHD (OR 1.01, 95% CI 0.98-1.04) and no modification by sex.

CONCLUSIONS

Our findings suggest that asthma is not a risk factor for CHD. Previous studies may have suffered from detection bias or residual confounding.

Cardio-respiratory interactions in acute asthma

Asthma encompasses of respiratory symptoms that occur intermittently and with varying intensity accompanied by reversible expiratory airflow limitation. In acute exacerbations, it can be life-threatening due to its impact on ventilatory mechanics. Moreover, asthma has significant effects on the cardiovascular system, primarily through heart-lung interaction-based mechanisms. Dynamic hyperinflation and increased work of breathing caused by a sharp drop in pleural pressure, can affect cardiac function and cardiac output through different mechanisms. These mechanisms include an abrupt increase in venous return, elevated right ventricular afterload and interdependence between the left and right ventricle. Additionally, Pulsus paradoxus, which reflects the maximum consequences of this heart lung interaction when intrathoracic pressure swings are exaggerated, may serve as a convenient bedside tool to assess the severity of acute asthma acute exacerbation and its response to therapy.

Impact of airway challenges on cardiovascular risk in asthma - a randomized controlled trial

BACKGROUND

People experiencing asthma exacerbations are at increased risk of cardiovascular events. To better understand the relationship between asthma exacerbations and cardiovascular risk, this randomized case-control, cross-over controlled trial assessed the immediate systemic inflammatory and vascular responses to acutely induced pulmonary inflammation and bronchoconstriction in people with asthma and controls.

METHODS

Twenty-six people with asthma and 25 controls underwent three airway challenges (placebo, mannitol, and methacholine) in random order. Markers of cardiovascular risk, including serum C-reactive protein, interleukin-6, and tumor necrosis factor, endothelial function (flow-mediated dilation), microvascular function (blood-flow following reactive hyperemia), and arterial stiffness (pulse wave velocity) were evaluated at baseline and within one hour following each challenge. The systemic responses in a) asthma/control and b) positive airway challenges were analyzed. (ClinicalTrials.gov reg# NCT02630511).

RESULTS

Both the mannitol and methacholine challenges resulted in clinically significant reductions in forced expiratory volume in 1 second (FEV1) in asthma (-7.6% and -17.9%, respectively). Following positive challenges, reduction in FEV1 was -27.6% for methacholine and -14.2% for mannitol. No meaningful differences in predictors of cardiovascular risk were observed between airway challenges regardless of bronchoconstrictor response.

CONCLUSION

Neither acutely induced bronchoconstriction nor pulmonary inflammation and bronchoconstriction resulted in meaningful changes in systemic inflammatory or vascular function. These findings question whether the increased cardiovascular risk associated with asthma exacerbations is secondary to acute bronchoconstriction or inflammation, and suggest that other factors need to be further evaluated such as the cardiovascular impacts of short-acting inhaled beta-agonists.

Asthma and increased risk of myocardial infarction and mortality among hypertensive Korean patients

This study aimed to evaluate the effects of asthma on cardiovascular disease incidence in patients with hypertension. A total of 639,784 patients with hypertension from the Korea National Health Insurance Service database were included, of whom 62,517 had history of asthma after propensity score matching. The risks of all-cause mortality, myocardial infarction (MI), stroke, and end-stage renal disease (ESRD) were assessed according to the presence of asthma, long-acting β2-agonist (LABA) inhaler usage, and/or systemic corticosteroid usage for up to 11 years. In addition, whether these risks were modified by average blood pressure (BP) levels during the follow-up period was examined. Asthma was associated with an increased risk of all-cause mortality (hazard ratio [HR], 1.203; 95% confidence interval [CI], 1.165-1.241) and MI (HR, 1.244; 95% CI, 1.182-1.310) but not the risk of stroke or ESRD. LABA inhaler usage was associated with a higher risk of all-cause mortality and MI, and systemic corticosteroids usage showed a higher risk of ESRD as well as all-cause mortality and MI among hypertensive patients with asthma. Compared to patients without asthma, there was a graded increase in the risk of all-cause mortality and MI in those with asthma without LABA inhaler/systemic corticosteroid usage and in those with asthma with LABA inhaler/systemic corticosteroid usage. These associations were not significantly modified by BP levels. This nationwide population-based study supports that asthma may be a clinical factor that increases the risk of poor outcomes in patients with hypertension.

Strength of association between comorbidities and asthma: a meta-analysis

BACKGROUND

The strength of association between comorbidities and asthma has never been ranked in relation to the prevalence of the comorbidity in the nonasthma population. We investigated the strength of association between comorbidities and asthma.

METHODS

A comprehensive literature search was performed for observational studies reporting data on comorbidities in asthma and nonasthma populations. A pairwise meta-analysis was performed and the strength of association calculated by anchoring odds ratios and 95% confidence intervals with the rate of comorbidities in nonasthma populations via Cohen's d method. Cohen's d=0.2, 0.5 and 0.8 were cut-off values for small, medium and large effect sizes, respectively; very large effect size resulted for Cohen's d >0.8. The review was registered in the PROSPERO database; identifier number CRD42022295657.

RESULTS

Data from 5 493 776 subjects were analysed. Allergic rhinitis (OR 4.24, 95% CI 3.82-4.71), allergic conjunctivitis (OR 2.63, 95% CI 2.22-3.11), bronchiectasis (OR 4.89, 95% CI 4.48-5.34), hypertensive cardiomyopathy (OR 4.24, 95% CI 2.06-8.90) and nasal congestion (OR 3.30, 95% CI 2.96-3.67) were strongly associated with asthma (Cohen's d >0.5 and ≤0.8); COPD (OR 6.23, 95% CI 4.43-8.77) and other chronic respiratory diseases (OR 12.85, 95% CI 10.14-16.29) were very strongly associated with asthma (Cohen's d >0.8). Stronger associations were detected between comorbidities and severe asthma. No bias resulted according to funnel plots and Egger's test.

CONCLUSION

This meta-analysis supports the relevance of individualised strategies for disease management that look beyond asthma. A multidimensional approach should be used to assess whether poor symptom control is related to uncontrolled asthma or to uncontrolled underlying comorbidities.

Cardiovascular Disease Among Adults With Work-Related Asthma, 2012-2017

INTRODUCTION

Asthma is associated with an increased risk for cardiovascular disease, and adults with persistent, severe asthma have a significantly higher risk of cardiovascular disease than adults with intermittent or no asthma.

METHODS

The objective of this cross-sectional study was to assess the association between work-related asthma status and cardiovascular disease among ever-employed adults (aged 18-64 years) with current asthma using data from the 2012-2017 Behavioral Risk Factor Surveillance System Asthma Call-Back Survey from 37 states and the District of Columbia. Weighted prevalence ratios and 95% CIs, adjusted for age, sex, race/ethnicity, education, household income, smoking status, chronic obstructive pulmonary disease, diabetes, and BMI, were calculated. In addition, the associations of cardiovascular disease with adverse asthma outcomes and asthma control among adults with work-related asthma were examined. Analyses were conducted in 2021.

RESULTS

Among an estimated annualized 14.8 million ever-employed adults aged 18-64 years with current asthma, adults with work-related asthma (prevalence ratio=1.5; 95% CI=1.2, 1.8) and possible work-related asthma (prevalence ratio=1.2; 95% CI=1.0, 1.5) were significantly more likely to have cardiovascular disease than adults with non-work-related asthma. Among adults with work-related asthma, those with very poorly controlled asthma (prevalence ratio=1.8; 95% CI=1.3, 2.5) and an asthma-related emergency room visit (prevalence ratio=1.5; 95% CI=1.1, 2.0) were significantly more likely to have cardiovascular disease.

CONCLUSIONS

Adults with work-related asthma were more likely to have cardiovascular disease than those with non-work-related asthma. Primary prevention, early diagnosis, and implementation of optimal work-related asthma management are essential for workers' health. Cardiovascular disease should be considered where appropriate when diagnosing and recommending treatment and interventions for adults with work-related asthma.

Long-term safety and efficacy of tezepelumab in people with severe, uncontrolled asthma (DESTINATION): a randomised, placebo-controlled extension study

BACKGROUND

Tezepelumab is a human monoclonal antibody that blocks thymic stromal lymphopoietin. The drug has been tested previously in the phase 3 NAVIGATOR (NCT03347279) and SOURCE (NCT03406078) studies, and was subsequently approved as a treatment for severe asthma. This extension study recruited from NAVIGATOR and SOURCE and aimed to evaluate the long-term safety and efficacy of tezepelumab in individuals with severe, uncontrolled asthma.

METHODS

DESTINATION was a phase 3, multicentre, randomised, double-blind, placebo-controlled, long-term extension study. The study was done across 182 sites (including hospitals, clinics, medical centres, clinical trial centres, and private practices) in 18 countries. Participants (aged 12-80 years) were required to have good treatment compliance in the parent study. Randomisation was stratified by the parent study and all participants were re-randomised. Those who were previously randomised to receive tezepelumab in either parent study continued treatment of subcutaneous tezepelumab (210 mg every 4 weeks); those who were previously randomised to receive placebo in either parent study were re-randomised 1:1 to receive either subcutaneous tezepelumab (210 mg every 4 weeks) or placebo (every 4 weeks) using a randomisation list prepared by a computerised system. Total treatment duration (including the parent studies) was 104 weeks for all groups. Participants, investigators, and site staff were masked to treatment assignment. The primary endpoints were exposure-adjusted incidence of adverse events and serious adverse events and the secondary endpoint was the annualised asthma exacerbation rate; these were assessed from week 0 of the parent studies to week 104 of DESTINATION in all participants who were randomised and who received at least one dose of tezepelumab or placebo in either of the parent studies. The trial is registered with ClinicalTrials.gov, NCT03706079, and is closed to new participants.

FINDINGS

Participants were recruited between Jan 7, 2019, and Oct 15, 2020. For individuals who initially received tezepelumab (n=528) in NAVIGATOR, incidence of adverse events over 104 weeks was 49·62 (95% CI 45·16 to 54·39) per 100 patient-years, compared with 62·66 (56·93 to 68·81) for those receiving placebo (n=531; difference -13·04, 95% CI -17·83 to -8·18). For serious adverse events, incidence was 7·85 (6·14 to 9·89) per 100 patient-years for individuals who initially received tezepelumab and 12·45 (9·97 to 15·35) for those who received placebo (difference -4·59, -7·69 to -1·65). In SOURCE, incidence of adverse events was 47·15 (36·06 to 60·56) per 100 patient-years for those who initially received tezepelumab (n=74) and 69·97 (54·54 to 88·40) for those who received placebo (n=76; difference -22·82, -34·77 to -10·01). For serious adverse events, incidence was 13·14 (7·65 to 21·04) per 100 patient-years for those who initially received tezepelumab and 17·99 (10·66 to 28·44) for those who received placebo (difference -4·85, -14·88 to 4·53). Tezepelumab reduced the annualised asthma exacerbation rate over 104 weeks compared with placebo. In participants initially from NAVIGATOR, the annualised asthma exacerbation rate ratio over 104 weeks was 0·42 (95% CI 0·35 to 0·51); in those initially from SOURCE, the ratio over 104 weeks was 0·61 (0·38 to 0·96).

INTERPRETATION

Tezepelumab treatment was well tolerated for up to 2 years and resulted in sustained, clinically meaningful reductions in asthma exacerbations in individuals with severe, uncontrolled asthma. These findings are consistent with previous randomised, placebo-controlled studies and show the long-term safety and sustained efficacy of tezepelumab in individuals with severe, uncontrolled asthma.

FUNDING

AstraZeneca and Amgen.

Asthma as a Systemic Disease: Cardiovascular Effects Associated with Asthma

Asthma and cardiovascular disease (CVD) pose significant public health burdens. Airway inflammation is central to asthma pathophysiology and systemic inflammation, which occurs in asthma, is central to CVD pathophysiology. Numerous robust epidemiological studies have demonstrated deleterious systemic cardiovascular effects associated with the asthma syndrome. The cardiovascular effects associated with asthma include arterial injury, atherosclerotic CVD events, atrial fibrillation, and hypertension. Asthma is a heterogeneous disease, however, and the risk of CVD is not homogeneous across the various clinical phenotypes and molecular endotypes, highlighting prior inconsistent associations of asthma and its subtypes with various forms of CVD. The mechanistic underpinnings of the increased CVD risk in asthma remain multifactorial and undefined. Collectively, this supports the need for a precision approach in the identification of individuals with asthma who remain at elevated risk of development of cardiovascular diseases to guide both diagnostic and preventive interventions to decrease CVD risk among individuals living with asthma.

Systemic corticosteroids in asthma: A call to action from World Allergy Organization and Respiratory Effectiveness Group

Systemic corticosteroids (SCS) are a highly effective treatment for acute exacerbations and long-term symptom control in asthma. Long-term SCS use is highly prevalent across all asthma severities, occurring in over 20% of patients with severe or uncontrolled disease globally. It is now well known that exposure to both long-term and repeated acute courses of SCS is associated with a high risk of serious adverse effects (AEs), such as osteoporosis, and metabolic and cardiovascular complications, especially when prescribed onto a background of other corticosteroids. The aim of this call-to-action article, endorsed by the World Allergy Organization and the Respiratory Effectiveness Group, is to review the accumulating evidence on the burden of SCS on patients with asthma and provide an overview of potential strategies for implementing SCS Stewardship. Primary prevention of exacerbations and improvement of asthma control is a key first step in achieving SCS Stewardship, by optimizing maintenance asthma medications and addressing modifiable risk factors, such as adherence and inhaler technique. Other key elements of SCS Stewardship include increasing appropriate specialist referrals for multidisciplinary review, assessment of biomarkers, and consideration of oral corticosteroid-sparing add-on therapies (eg, biologics). In cases where SCS use is deemed clinically justified, it should be tapered to the lowest possible dose. In addition, patients receiving long-term SCS or frequent acute courses should be closely monitored for emergence of SCS-related AEs. Because of the extensive data available on the costly and burdensome AEs associated with SCS use, as well as the range of treatment options now available, there is a need for healthcare providers (HCPs) to carefully evaluate whether the benefits of SCS outweigh the potential harms, to adopt SCS-sparing and Stewardship strategies, and to consider alternative therapies where possible. Development of a structured and collaborative SCS Stewardship approach is urgently required to protect patients from the potential harm of SCS use.

The impact of type 2 immunity and allergic diseases in atherosclerosis

Allergic diseases are allergen-induced immunological disorders characterized by the development of type 2 immunity and IgE responses. The prevalence of allergic diseases has been on the rise alike cardiovascular disease (CVD), which affects arteries of different organs such as the heart, the kidney and the brain. The underlying cause of CVD is often atherosclerosis, a disease distinguished by endothelial dysfunction, fibrofatty material accumulation in the intima of the artery wall, smooth muscle cell proliferation, and Th1 inflammation. The opposed T-cell identity of allergy and atherosclerosis implies an atheroprotective role for Th2 cells by counteracting Th1 responses. Yet, the clinical association between allergic disease and CVD argues against it. Within, we review different phases of allergic pathology, basic immunological mechanisms of atherosclerosis and the clinical association between allergic diseases (particularly asthma, atopic dermatitis, allergic rhinitis and food allergy) and CVD. Then, we discuss putative atherogenic mechanisms of type 2 immunity and allergic inflammation including acute allergic reactions (IgE, IgG1, mast cells, macrophages and allergic mediators such as vasoactive components, growth factors and those derived from the complement, contact and coagulation systems) and late phase inflammation (Th2 cells, eosinophils, type 2 innate-like lymphoid cells, alarmins, IL-4, IL-5, IL-9, IL-13 and IL-17).

Asthma can Promote Cardiomyocyte Mitophagy in a Rat Model

Clinical observations have shown the risk of cardiovascular disease during asthmatic changes. Whether and how asthma causes heart failure is the subject of debate. Here, we aimed to investigate the possibility of cardiomyocyte mitophagy in a rat model of asthma. Twelve mature Wistar rats were randomly allocated into the Control and Asthmatic rats (n = 6). To induce asthma, ovalbumin was injected intraperitoneally on days 1 and 8 and procedure followed by nebulization from days 14 to 32. After 2 weeks, we performed the pathological examination of both lungs and heart using Hematoxylin-Eosin staining. Real-time PCR analysis was used to measure the expression of mitophagic factors, such as Optineurin, Pink1, and mitofusin 1 and 2. Typical changes like increased inter-alveolar septa thickness and interstitial pneumonia were evident in asthmatic lungs. In cardiac tissue, slight inflammatory response, and hydropic degeneration with an eosinophilic appearance were detected in the cytoplasm of cardiomyocytes. Real-time PCR analysis showed mitophagic response in pulmonary and cardiac tissues via upregulation of mitophagy-related genes like Optineurin and Pink-1 in asthmatic lungs and hearts compared to the control group (p < 0.05). Likewise, asthmatic changes increased the expression of genes associated with mitochondrial fusion in the lungs and heart. The expression of mitofusin1 and 2 was significantly increased following inflammatory response in pulmonary and cardiac tissues (p < 0.05). Our findings showed the expression of certain factors related to mitophagy during chronic asthmatic conditions. The findings open a new avenue in the understanding of cardiomyocyte injury during asthma.

Genetic liability to asthma and risk of cardiovascular diseases: A Mendelian randomization study

Background and Aims: Epidemiological studies have suggested positive associations between asthma and the risk of cardiovascular diseases (CVDs). However, causality remains inconclusive. We aim to explore the causal associations between asthma and CVDs risk using the Mendelian Randomization (MR) approach.

Methods: We obtained summary-level data for eight CVDs [including atrial fibrillation (AF), coronary artery disease (CAD), heart failure (HF), stroke, ischemic stroke, large artery stroke, small vessel stroke, and cardioembolic stroke] from several large genome-wide association studies (GWASs) and the FinnGen consortium. Nine lead single-nucleotide polymorphisms associated with asthma (p < 5 × 10⁻⁸) were identified from the GWAS conducted by the Trans-National Asthma Genetic Consortium. MR analyses were performed using the inverse variance weighted method, supplemented by the weighted median and MR-Egger methods.

Results: Inverse variance weighted method showed suggestive effects of genetically determined asthma on AF (odds ratio (OR), 1.08; 95% confidence interval (CI), 1.02, 1.14; p = 0.009) and HF (OR, 1.05; 95% CI, 1.01, 1.09; p = 0.029). We found no causal associations between asthma and other CVDs. No horizontal pleiotropy was observed.

Conclusion: This MR study provides genetic evidence suggesting a causal association between asthma and the risk of AF and HF, although not at the level of significance after multiple testing correction. Programs aimed at treating asthma among asthmatics might help prevent the adverse health effects inflicted by CVDs.

Systemic vascular health is compromised in both confirmed and unconfirmed asthma

INTRODUCTION

Asthma is associated with increased risk of cardiovascular diseases. Despite many presenting with symptoms of asthma, asthma cannot always be confirmed by physiological assessment. It is thus far unknown if the heightened cardiovascular risk applies to this group. The purpose of this study was to examine markers of cardiovascular risk, including endothelial function, arterial stiffness, and systemic inflammation, in individuals with confirmed asthma, unconfirmed asthma, and healthy controls. As short-acting beta agonist (SABA) use is associated with increased cardiovascular risk, a secondary analysis was conducted to investigate the impact of regular SABA use on vascular outcomes.

METHODS

Individuals with confirmed asthma (n = 26), unconfirmed asthma (n = 15), and healthy controls (n = 26) were recruited for this cross-sectional study. Asthma was confirmed by FEV₁ reversibility, methacholine challenge, or exercise challenge. Endothelial function was assessed using flow-mediated dilation (FMD), arterial stiffness using pulse wave velocity (PWV), and systemic inflammation by C-reactive protein (CRP) levels.

RESULTS

FMD was significantly lower in both asthma groups compared to controls (confirmed: 7.7 ± 3.6%, unconfirmed: 7.3 ± 3.5%, controls: 10.4 ± 3.6%, p = 0.02). No difference was found in PWV nor CRP. Asthma participants who used SABA had increased arterial stiffness compared to those without SABA (9.2 ± 2.7 m/s, 7.7 ± 1.1 m/s respectively, p = 0.03). No difference was seen in FMD or CRP between SABA groups.

CONCLUSION

Individuals with a clinical history of asthma symptoms demonstrate vascular impairments regardless of physiological confirmation of disease. Regular SABA use increases arterial stiffness. Avoiding potentially inappropriate SABA use among people without physiologically confirmed asthma may thus be beneficial in curbing cardiovascular risk.

Metformin and the Development of Asthma in Patients with Type 2 Diabetes

We conducted this study to compare the risks of asthma development and exacerbation between metformin users and nonusers. Overall, 57,743 propensity score-matched metformin users and nonusers were identified from Taiwan’s National Health Insurance Research Database between 1 January 2000, and 31 December 2017. We used the Cox proportional hazards model with robust standard error estimates to compare the risks of asthma onset, exacerbation, and hospitalization for asthma in participants with type 2 diabetes (T2D). Compared with metformin nonuse, the aHRs (95% CI) for metformin use in asthma development, exacerbation, and hospitalization for asthma were 1.13 (1.06−1.2), 1.62 (1.35−1.95), and 1.5 (1.22−1.85), respectively. The cumulative incidences of asthma development, exacerbation, and hospitalization for asthma were significantly higher in metformin users than nonusers (p < 0.001). A longer cumulative duration of metformin use for more than 728 days was associated with significantly higher risks of outcomes than metformin nonuse. Our study demonstrated that metformin users showed significantly higher risks of asthma development, exacerbation, and hospitalization for asthma than metformin nonusers. Moreover, metformin use for more than 728 days was associated with higher risks of outcomes. A randomized control study is warranted to verify our results.

Impact of COPD and asthma on in-hospital mortality and management of patients with heart failure in England and Wales: an observational analysis

OBJECTIVE

To evaluate the association between having concomitant chronic obstructive pulmonary disease (COPD) or asthma, and in-patient mortality and post-discharge management among patients hospitalised for acute heart failure (HF).

SETTING

Data were obtained from patients enrolled in the National Heart Failure Audit.

PARTICIPANTS

217 329 patients hospitalised for HF in England-Wales between March 2012 and 2018.

OUTCOMES

In-hospital mortality, referrals to cardiology follow-up and prescriptions for HF medications were compared between patients with comorbid COPD (COPD-HF) or asthma (asthma-HF) versus HF-alone using mixed-effects logistic regression.

RESULTS

Patients with COPD-HF were more likely to die during hospitalisation, and those with asthma-HF had a reduced likelihood of death, compared with patients who had HF-alone ((adjusted)OR_adj, 95% CI: 1.10, 1.06 to 1.14 and OR_adj, 95% CI: 0.84, 0.79 to 0.88). In patients who survived to discharge, referral to HF follow-up services differed between groups: patients with COPD-HF had reduced odds of cardiology follow-up (OR_adj, 95% CI 0.79, 0.77 to 0.81), while cardiology referral odds for asthma-HF were similar to HF-alone. Overall, proportions of HF medication prescriptions at discharge were low for both COPD-HF and asthma-HF groups, particularly prescriptions for beta-blockers.

CONCLUSIONS

In this nationwide analysis, we showed that COPD and asthma significantly impact the clinical course in patients hospitalised for HF. COPD is associated with higher in-patient mortality and lower cardiology referral odds, while COPD and asthma are both associated with lower use of prognostic HF therapies on discharge. These data highlight therapeutic gaps and a need for better integration of cardiopulmonary services to improve healthcare provision for patients with HF and coexisting respiratory disease.

Meta-Analysis of the Association Between Asthma and the Risk of Stroke

Introduction

Asthma and stroke share many risk factors. Previous meta-analysis has indicated that asthma is associated with an increased risk of stroke. However, this study were limited by the small number of articles included and the lack of subgroup analyses of different stroke types and different populations. This meta-analysis aimed to synthesize evidence systematically to investigate the impact of asthma on stroke.

Methods

We searched Medline (via PubMed), Web of Science and EMBASE databases and manually identified eligible studies (inception dates to December 25, 2021) that analyzed the association between asthma and stroke. We conducted quality assessment to evaluate the risk of bias of studies and sensitivity analyses to test the robustness of results.

Results

We included 8 cohort studies and 10 cross-sectional studies comprised 3,011,016 participants. We found patients with asthma had a higher risk of stroke than patients without asthma [relative risk (RR): 1.34, 95% confidence interval (CI): 1.21–1.47]. Moreover, asthma significantly increased the risk of ischemic stroke (RR: 1.25, 95% CI: 1.06–1.47) without increasing the risk of hemorrhagic stroke (RR: 1.08, 95% CI: 0.87–1.34). Asthma increased the risk of stroke in both men (RR: 1.20, 95% CI: 1.10–1.32) and women (RR: 1.29, 95% CI: 1.12–1.48) with no significant difference between the sexes. We also found that patients with inactive asthma, child-onset asthma, or no smoking history did not have an increased risk of stroke.

Conclusions

These results supported the finding that asthma could significantly increase the risk of stroke, but this impact was not consistent in different populations.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=290745, identifier: CRD42021290745.

Allergic asthma aggravates angiotensin Ⅱ-induced cardiac remodeling in mice

Cardiovascular disease remains the leading cause of death globally, and heart failure (HF) represents its terminal stage. Asthma, one of the most common chronic diseases, has been reported to be associated with an increased risk of cardiovascular disease. However, the link between asthma and HF has rarely been studied, and the possible mechanisms by which asthma affects HF are unclear. This study aimed to explore the influence of asthma on HF and the possible mechanisms. We analyzed data from the National Health and Nutrition Examination Survey and found a higher prevalence of HF among asthmatic individuals, and identified an independent association between HF and asthma. Subsequently, we produced mice with concurrent ovalbumin (OVA) sensitization-induced allergic asthma and angiotensin Ⅱ infusion-induced cardiac remodeling to explore the effect of asthma on cardiac remodeling in vivo. The results showed that OVA-induced asthma impaired heart function and aggravated cardiac remodeling in mice. We also found that OVA sensitization increased the expression levels of immunoglobulin E (IgE) in serum and IgE receptor (FcεR1) in the heart, and enhanced the activation of downstream signaling molecules of IgE-FcεR1 in the heart. Importantly, blockage of IgE-FcεR1 using FcεR1-deficient mice or an anti-IgE antibody prevented asthma-induced decline of cardiac function, and alleviated cardiac remodeling. These findings demonstrate the adverse effects of allergic asthma on the heart, and suggest the potential application of anti-IgE therapy in the treatment of asthma complicated with heart conditions.

Association of Circulating IgE and CML Levels with In-Stent Restenosis in Type 2 Diabetic Patients with Stable Coronary Artery Disease

Background: We investigated whether serum levels of immunoglobin (Ig) E and Nε-carboxymethyl-lysine (CML) are related to in-stent restenosis (ISR) in patients with stable coronary artery disease and type 2 diabetes mellitus (T2DM). Methods: Serum levels of IgE and CML were measured in 196 ISR patients and 220 non-ISR patients with stable angina and T2DM who received angiographic follow-up 12 months after percutaneous coronary intervention (PCI) with third-generation drug-eluting stent (DES) implantation for de novo lesions. Multivariate logistic regression analysis was performed to assess the association between IgE or CML and ISR. Results: Both IgE and CML levels were higher in patients with ISR compared with non-ISR patients (IgE: 187.10 (63.75−489.65) vs. 80.25 (30.65−202.50), p < 0.001; CML: 203.26 (164.50−266.84) vs. 174.26 (130.85−215.56), p < 0.001). The rate of ISR increased stepwise with increasing tertiles of IgE and CML levels (p for all trends < 0.001), and IgE correlated significantly with CML. After adjusting for potential confounders, IgE and CML levels remained independently associated with ISR. Moreover, IgE and CML levels improved the predictive capability of traditional risk factors for ISR, and there existed an interaction between IgE and CML in relation to ISR (p for interaction < 0.01). Conclusion: Elevated circulating IgE and CML levels confer an increased risk for ISR after DES-based PCI in type 2 diabetic patients with stable coronary artery disease.

Association Between Asthma and All-Cause Mortality and Cardiovascular Disease Morbidity and Mortality: A Meta-Analysis of Cohort Studies

Background

Asthma and cardiovascular disease (CVD) share many risk factors. Previous meta-analyses indicated that asthma is associated with an increased risk of CVD and all-cause mortality, but these studies were limited by unstandardized search strategies and the number of articles included.

Objective

We sought to systematically synthesize evidence investigating the impact of asthma on all-cause mortality and CVD morbidity and mortality.

Methods

We searched in PubMed and EMBASE for observational cohort studies (inception dates to November 10, 2021) that had both asthma groups and control groups. We also manually searched the reference lists of correlative articles to include other eligible studies. Data for associations between asthma and all-cause mortality and CVD morbidity and mortality were needed.

Results

We summarized the findings from 30 cohort studies comprising 4,157,823 participants. Asthma patients had increased CVD morbidity [relative risk (RR) = 1.28, 95% confidence interval (CI) = 1.16–1.40] and increased CVD mortality (RR = 1.25, 95% CI = 1.14–1.38). Asthma patients also had increased risk of all-cause mortality (RR = 1.38, 95% CI = 1.07–1.77). In subgroup analyses, female asthma patients had a higher risk of CVD morbidity and all-cause mortality than male asthma patients, and late-onset asthma patients had a higher risk of CVD morbidity than early-onset asthma patients.

Conclusion

Asthma patients have increased risk of all-cause mortality and CVD morbidity and mortality. This information reminds clinicians to be aware of the risk of CVD and all-cause mortality in asthma patients.

Systematic Review Registration

http://www.crd.york.ac.uk/PROSPERO/, PROSPERO, identifier: CRD 42021290082.

Shared Genetic Architecture and Causal Relationship Between Asthma and Cardiovascular Diseases: A Large-Scale Cross-Trait Analysis

Background: Accumulating evidence has suggested that there is a positive association between asthma and cardiovascular diseases (CVDs), implying a common architecture between them. However, the shared genetic architecture and causality of asthma and CVDs remain unclear.

Methods: Based on the genome-wide association study (GWAS) summary statistics of recently published studies, our study examined the genetic correlation, shared genetic variants, and causal relationship between asthma (N = 127,669) and CVDs (N = 86,995–521,612). Statistical methods included high-definition likelihood (HDL), cross-trait meta-analyses of large-scale GWAS, transcriptome-wide association studies (TWAS), and Mendelian randomization (MR).

Results: First, we observed a significant genetic correlation between asthma and heart failure (HF) (Rg = 0.278, P = 5 × 10⁻⁴). Through cross-trait analyses, we identified a total of 145 shared loci between asthma and HF. Fifteen novel loci were not previously reported for association with either asthma or HF. Second, we mapped these 145 loci to a total of 99 genes whose expressions are enriched in a broad spectrum of tissues, including the seminal vesicle, tonsil, appendix, spleen, skin, lymph nodes, breast, cervix and uterus, skeletal muscle, small intestine, lung, prostate, cardiac muscle, and liver. TWAS analysis identified five significant genes shared between asthma and HF in tissues from the hemic and immune system, digestive system, integumentary system, and nervous system. GSDMA, GSDMB, and ORMDL3 are statistically independent genetic effects from all shared TWAS genes between asthma and HF. Third, through MR analysis, genetic liability to asthma was significantly associated with heart failure at the Bonferroni-corrected significance level. The odds ratio (OR) is 1.07 [95% confidence interval (CI): 1.03–1.12; p = 1.31 × 10⁻³] per one-unit increase in log_e odds of asthma.

Conclusion: These findings provide strong evidence of genetic correlations and causal relationship between asthma and HF, suggesting a shared genetic architecture for these two diseases.

The association of allergic asthma and carotid intima-media thickness in adolescence: data of the prospective early vascular ageing (EVA)-Tyrol cohort study

BACKGROUND

In recent years, there has been increasing evidence that asthma is associated with atherosclerosis and cardiovascular disease. However, data in children and adolescents are scarce and conflicting. We aimed to assess the impact of asthma with and without an allergic component on the carotid intima-media thickness in a large pediatric population.

METHODS

The community-based early vascular ageing-Tyrol cohort study was performed between May 2015 and July 2018 in North, East (Austria) and South Tyrol (Italy) and recruited youngster aged 14 years and above. Medical examinations included anthropometric measurements, fasting blood analysis, measurement of the carotid intima-media thickness by high-resolution ultrasound, and a physician guided interview.

RESULTS

The mean age of the 1506 participants was 17.8 years (standard deviation 0.90). 851 (56.5%) participants were female. 22 subjects had a physician diagnosis of non-allergic asthma, 268 had inhalative allergies confirmed by a positive radio-allergo-sorbent-test and/or prick test, and 58 had allergic asthma. Compared to healthy controls, participants with non-allergic asthma (411.7 vs. 411.7 µm; p = 0.932) or inhalative allergy (420.0 vs. 411.7 µm; p = 0.118) did not have significantly higher carotid intima-media thickness (cIMT). However, participants with allergic asthma had significantly higher cIMT (430.8 vs. 411.7; p = 0.004) compared to those without and this association remained significant after multivariable adjustment for established cardiovascular risk factors.

CONCLUSION

Allergic asthma in the youth is associated with an increased carotid intima-media thickness. Physicians should therefore be aware of allergic asthma as a potential cardiovascular risk factor in children and adolescents. Trial Registration Number The EVA-Tyrol Study has been retrospectively registered at clinicaltrials.gov under NCT03929692 since April 29, 2019.

Oral corticosteroids stewardship for asthma in adults and adolescents: A position paper from the Thoracic Society of Australia and New Zealand

Oral corticosteroids (OCS) are frequently used for asthma treatment. This medication is highly effective for both acute and chronic diseases, but evidence indicates that indiscriminate OCS use is common, posing a risk of serious side effects and irreversible harm. There is now an urgent need to introduce OCS stewardship approaches, akin to successful initiatives that optimized appropriate antibiotic usage. The aim of this TSANZ (Thoracic Society of Australia and New Zealand) position paper is to review current knowledge pertaining to OCS use in asthma and then delineate principles of OCS stewardship. Recent evidence indicates overuse and over-reliance on OCS for asthma and that doses >1000 mg prednisolone-equivalent cumulatively are likely to have serious side effects and adverse outcomes. Patient perspectives emphasize the detrimental impacts of OCS-related side effects such as weight gain, insomnia, mood disturbances and skin changes. Improvements in asthma control and prevention of exacerbations can be achieved by improved inhaler technique, adherence to therapy, asthma education, smoking cessation, multidisciplinary review, optimized medications and other strategies. Recently, add-on therapies including novel biological agents and macrolide antibiotics have demonstrated reductions in OCS requirements. Harm reduction may also be achieved through identification and mitigation of predictable adverse effects. OCS stewardship should entail greater awareness of appropriate indications for OCS prescription, risk-benefits of OCS medications, side effects, effective add-on therapies and multidisciplinary review. If implemented, OCS stewardship can ensure that clinicians and patients with asthma are aware that OCS should not be used lightly, while providing reassurance that asthma can be controlled in most people without frequent use of OCS.

FEV1 Predicts Cardiac Status and Outcome in Chronic Heart Failure

BACKGROUND

COPD is an established predictor of clinical outcome in patients with chronic heart failure (HF). However, little evidence is available about the predictive value of FEV₁ in chronic HF.

RESEARCH QUESTION

Is pulmonary function related to the progression of chronic HF?

STUDY DESIGN AND METHODS

The MyoVasc study (ClinicalTrials.gov Identifier: NCT04064450) is a prospective cohort study of HF. Information on pulmonary and cardiac functional and structural status was obtained by body plethysmography and echocardiography. The primary study end point was worsening of HF.

RESULTS

Overall 2,998 participants (age range, 35-84 years) with available FEV₁ data were eligible for analysis. Linear multivariate regression analysis revealed an independent relationship of FEV₁ (per -1 SD) with deteriorated systolic and diastolic left ventricle (LV) function as well as LV hypertrophy under adjustment of age, sex, height, cardiovascular risk factors (CVRFs), and clinical profile (LV ejection fraction: β-estimate, -1.63% [95% CI, -2.00% to -1.26%]; E/E' ratio: β-estimate, 0.82 [95% CI, 0.64-0.99]; and LV mass/height^2.7: β-estimate, 1.58 [95% CI, 1.07-2.10]; P < .001 for all). During a median time to follow-up of 2.6 years (interquartile range, 1.1-4.1 years), worsening of HF occurred in 235 individuals. In Cox regression model adjusted for age, sex, height, CVRF, and clinical profile, pulmonary function (FEV₁ per -1 SD) was an independent predictor of worsening of HF (hazard ratio [HR], 1.44 [95% CI, 1.27-1.63]; P < .001). Additional adjustment for obstructive airway pattern and C-reactive protein mitigated, but did not substantially alter, the results underlining the robustness of the observed effect (HR_FEV1, 1.39 [95% CI, 1.20-1.61]; P < .001). The predictive value of FEV₁ was consistent across subgroups, including individuals without obstruction (HR, 1.55 [95% CI, 1.34-1.77]; P < .001) and nonsmokers (HR, 1.72 [95% CI, 1.39-1.96]; P < .001).

INTERPRETATION

FEV₁ represents a strong candidate to improve future risk stratification and prevention strategies in individuals with chronic, stable HF.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT04064450; URL: www.clinicaltrials.gov.

Recorded prevalence of nasal polyps increases with age

INTRODUCTION

Nasal polyps are a multifactorial inflammatory condition of the upper airways. Nasal polyps typically affect middle-aged and elderly patients, average age at diagnosis is 40 to 60, and men are affected more commonly than women.

AIM

To analyse the reported prevalence of nasal polyps in the Polish population, including demographics and co-morbidities, and to estimate the costs of outpatient and hospital (inpatient) services financed by the National Health Fund.

MATERIAL AND METHODS

Statistical analysis of data extracted from the National Health Fund (NHF) registers for 2008-2018.

RESULTS

In 2018, the recorded prevalence of nasal polyps in Poland was 52.0/10,000 population (0.52%), amounting to 64.6/10,000 (0.65%) in men and 40.2/10,000 (0.40) in women. Nasal polyps were much more frequent in patients aged 55-59 (98.1/10000) and 75-79 years (98.7/10,000). Among men, the highest prevalence was found in the 75-79 age group (164.3/10,000 population), and among women in the 55-59 age group (75.1/10,000). In 2018, the Polish NHF spent PLN 17.2 million (equivalent to EUR 4.0 million/USD 4.7 million) on health services related to the diagnosis of nasal polyps. Hospital services accounted for 77.4% of the total cost.

CONCLUSIONS

Nasal polyps are more than one and a half times as prevalent in men than in women. The recorded prevalence of nasal polyps increases with age, with the rates peaking in those between 75 and 79 years old, and is more often in urban than rural areas.

[What not to do in the therapeutic management of bronchial asthma. Delphi consensus recommendations for physicians who treat asthma]

Asthma is one of the most prevalent diseases in Spain, yet despite the great diagnostic and therapeutic advances made in this field, health outcomes suggest that up to 80% of patients do not have their asthma well controlled. Although the causes of this situation are diverse, there are some practices among the professionals who treat asthma that are not conducive to improving health outcomes in this disease. Our working group has prepared this document in order to remind clinicians of a series of basic guidelines, aligned with current guidelines and recent literature, and agreed by a multidisciplinary expert panel using Delphi methodology. These recommendations about what not to do in the management of asthma in the adult patient are structured into four areas: diagnosis, monitoring, treatment and prevention of exacerbations.

Asthma and high-intensity interval training have no effect on clustered cardiometabolic risk or arterial stiffness in adolescents

PURPOSE

Cardiometabolic risk, including arterial stiffness, is increasing in youth. Those with asthma are suggested to be particularly at risk of cardiovascular disease. Efficient and effective strategies are required to prevent the atherosclerotic process in youth. The purpose of this study was to investigate the effect of 6 months high-intensity interval training (HIIT) on cardiometabolic risk in youth with and without asthma.

METHODS

65 adolescents (31 mild asthma; 34 non-asthma) were recruited, 32 (16 asthma) of whom were randomly allocated to receive HIIT three times per week for 6 months. At baseline, mid-intervention, post-intervention and at a 3-month follow-up, anthropometric, metabolic and vascular determinants of cardiometabolic risk were assessed. Following principal component analysis (PCA), linear mixed models were used to assess the influence of asthma, HIIT and their interaction.

RESULTS

Seven factors were identified which explained 88% of the common variance shared among the parameters. Those with asthma demonstrated lower arterial stiffness factor scores mid-intervention (P = 0.047) and lower cholesterol factor scores post-intervention (P = 0.022) but there was no effect of the intervention, or interaction effects, on any PCA-identified factor, at any time-point. HIIT was associated with a lower low-density lipoprotein and diastolic blood pressure at mid-intervention.

DISCUSSION

Neither arterial stiffness nor clustered cardiometabolic risk are influenced by HIIT in adolescents with or without asthma, despite important changes in blood lipid and pressure profiles. Blood pressure, augmentation and pulse wave velocity should be considered physiologically distinct constructs and as potential markers of cardiovascular health.

The Relationship Between Asthma and Cardiovascular Disease: An Examination of the Framingham Offspring Study

BACKGROUND

Although asthma has been suggested as a risk factor for cardiovascular disease (CVD), robust longitudinal evidence of this relationship is limited.

RESEARCH QUESTION

Using Framingham Offspring Cohort data, the goal of this study was to longitudinally examine the association between asthma and lifetime risk of CVD while controlling for cardiovascular risk factors included in the Framingham Risk Score.

STUDY DESIGN AND METHODS

Data were analyzed from a prospective population-based cohort of 3,612 individuals, ages 17 to 77 years, who participated in Framingham Offspring Study examinations from 1979 to 2014. Asthma was defined based on physician diagnosis during study interviews. Incident CVD included myocardial infarction, angina, coronary insufficiency, stroke, transient ischemic attack, and heart failure. Time-dependent Cox regression models were used to evaluate the relationship between asthma and CVD incidence.

RESULTS

Overall, 533 (15%) participants had a diagnosis of asthma and 897 (25%) developed CVD during the course of the study. Unadjusted analyses revealed that asthma was associated with increased CVD incidence (hazard ratio, 1.40; 95% CI, 1.17-1.68). Cox regression also showed an adjusted association between asthma and CVD incidence (hazard ratio, 1.28; 95% CI, 1.07-1.54) after controlling for established cardiovascular risk factors.

INTERPRETATION

This prospective analysis with > 35 years of follow-up shows that asthma is a risk factor for CVD after adjusting for potential confounders. When assessing risk of cardiovascular disease, asthma should be evaluated and managed as a risk factor contributing to morbidity and mortality.

Association between asthma and cardiovascular disease

BACKGROUND

Epidemiological studies on the association between asthma and cardiovascular disease have reported conflicting results. This cross-sectional study evaluated the association between asthma and ischaemic heart disease (IHD)/stroke in Korean adults.

MATERIALS AND METHODS

Data from the Korean Genome and Epidemiology Study-Health Examinees were used. Among 173 209 participants, 3162 asthmatic and 159 408 control participants were selected. Histories of asthma, IHD and stroke were obtained. Participants were categorized according to their current status of asthma management: 'well-controlled', 'being treated', and 'not being treated'. Crude and adjusted (age, gender, body mass index, income, smoking, alcohol consumption, hypertension, diabetes, dyslipidaemia and nutritional intake) odds ratios (ORs) for IHD and stroke in asthmatic patients were analysed using a multiple logistic regression model.

RESULTS

Participants with asthma reported a significantly higher prevalence of IHD (6.0% vs 3.0%) and stroke (2.3% vs 1.4%) than those without asthma (P < .001). Asthmatic participants had a higher OR (1.46, 95% confidence interval [CI] = 1.251-1.71, P < .001) for IHD than those without asthma. The association between asthma and IHD was significant only in patients aged ≥53 years (men: adjusted OR = 1.31, 95% CI = 1.01-1.70, P = .046; women: adjusted OR = 1.64, 95% CI = 1.32-2.03, P < .001) according to age and sex and in the 'not being treated' asthma group (adjusted OR = 1.47, 95% CI = 1.14-1.91, P = .003) according to the asthma management status. Stroke was not significantly associated with asthma (adjusted OR = 1.17, 95% CI = 0.92-1.48, P = .203) in the adjusted model and all subgroup analyses.

CONCLUSION

Asthma was associated with IHD, mainly in older patients and untreated asthma patients, but not with stroke.

Asthma and stroke: a narrative review

Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation, bronchial reversible obstruction and hyperresponsiveness to direct or indirect stimuli. It is a severe disease causing approximately half a million deaths every year and thus possessing a significant public health burden. Stroke is the second leading cause of death and a major cause of disability worldwide. Asthma and asthma medications may be a risk factors for developing stroke. Nevertheless, since asthma is associated with a variety of comorbidities, such as cardiovascular, metabolic and respiratory, the increased incidence of stroke in asthma patients may be due to a confounding effect. The purpose of this review is to analyze the complex relationship between asthma and stroke.

Burden and impact of arrhythmias in asthma-related hospitalizations: Insight from the national inpatient sample

BACKGROUND

This study aimed to analyze the burden and impact of cardiac arrhythmias in adult patients hospitalized with asthma exacerbation using the nationwide inpatient database.

METHODS

We used the National Inpatient Sample (NIS) database (2010-2014) to identify arrhythmias in asthma-related hospitalization and its impact on inpatient mortality, hospital length of stay (LOS), and hospitalization charges. We also used multivariable analysis to identify predictors of in-hospital arrhythmia and mortality.

RESULTS

We identified 12,988,129 patients hospitalized with primary diagnosis of asthma; among them, 2,014,459(16%) patients had cardiac arrhythmia. The most frequent arrhythmia identified is atrial fibrillation (AFib) (8.95%). The AFib and non-AFib arrhythmia group had higher mortality (3.40% & 2.22% vs 0.74%), mean length of stay (LOS) (5.9 & 5.4 vs 4.2 days), and hospital charges ($53,172 & $51,105 vs $34,585) as compared to the non-arrhythmia group (P < .005). Predictors of arrhythmia in asthma-related hospitalization were history of PCI or CABG, valvular heart disease, congestive heart failure (CHF), and acute respiratory failure. Predictors of higher mortality in arrhythmia group were acute respiratory failure, sepsis, and acute myocardial infarction.

CONCLUSIONS

Around 16% of adult patients hospitalized with asthma exacerbation experience arrythmia (mostly AFib 8.95%). The presence of arrhythmias was associated with higher in-hospital mortality, LOS, and hospital charges in hospitalized asthmatics.

Adults with current asthma but not former asthma have higher all-cause and cardiovascular mortality: a population-based prospective cohort study

Higher mortality in asthmatics has been shown previously. However, evidence on different asthma phenotypes on long-term mortality risk is limited. The aim was to evaluate the impact of asthma phenotypes on mortality in general population. Data from the National Health and Nutrition Examination Survey from 2001–2002 to 2013–2014 linked mortality files through December 31, 2015, were used (N = 37,015). Cox proportional hazards regression was used to estimate the risk of all-cause and cause-specific mortality adjusting for sociodemographic characteristics, smoking, body mass index, and chronic conditions. During the mean follow-up time of 7.5 years, 4326 participants died from a variety of causes. Current asthma, but not former asthma was associated with increased all-cause mortality (current asthma: HR = 1.37; 95% CI 1.20–1.58; Former asthma: HR = 0.93; 95% CI 0.73–1.18); as well as mortality from cardiovascular disease (HR_Current = 1.41; 95% CI 1.08–1.85) and chronic lower respiratory diseases (HR_Current = 3.17; 95% CI 1.96–5.14). In addition, we found that the HR for cardiovascular disease (CVD) mortality was slightly greater in people with childhood-onset asthma than those with adult-onset asthma. The HR for chronic lower respiratory diseases (CLRD) mortality was greater in people with adult-onset asthma than those with childhood-onset asthma. However, the differences were not statistically significant. Our study suggested that current asthma but not former asthma was associated with increased all-cause, CLRD and CVD mortality. Future well-designed studies with larger sample are required to demonstrate the association and clarify the potential mechanisms involved.

Montelukast Use Decreases Cardiovascular Events in Asthmatics

Cysteinyl leukotrienes are proinflammatory mediators with a clinically established role in asthma and a human genetic and preclinical role in cardiovascular pathology. Given that cardiovascular disease has a critical inflammatory component, the aim of this work was to conduct an observational study to verify whether the use of a cysteinyl leukotriene antagonist, namely, montelukast, may protect asthmatic patients from a major cardiovascular event and, therefore, represent an innovative adjunct therapy to target an inflammatory component in cardiovascular disease. We performed an observational retrospective 3-year study on eight hundred adult asthmatic patients 18 years or older in Albania, equally distributed into two cohorts, exposed or nonexposed to montelukast usage, matched by age and gender according to information reported in the data collection. Patients with a previous history of myocardial infarction or ischemic stroke were excluded. In summary, 37 (4.6%) of the asthmatic patients, 32 nonexposed, and five exposed to montelukast suffered a major cardiovascular event during the 3-year observation period. All the cardiovascular events, in either group, occurred among patients with an increased cardiovascular risk. Our analyses demonstrate that, independent from gender, exposure to montelukast remained a significant protective factor for incident ischemic events (78% or 76% risk reduction depending on type of analysis). The event-free Kaplan–Meier survival curves confirmed the lower cardiovascular event incidence in patients exposed to montelukast. Our data suggest that there is a potential preventative role of montelukast for incident cardiac ischemic events in the older asthmatic population, indicating a comorbidity benefit of montelukast usage in asthmatics by targeting cysteinyl leukotriene-driven cardiac disease inflammation.

Role of IgE-FcεR1 in Pathological Cardiac Remodeling and Dysfunction

BACKGROUND

Immunoglobulin E (IgE) belongs to a class of immunoglobulins involved in immune response to specific allergens. However, the roles of IgE and IgE receptor (FcεR1) in pathological cardiac remodeling and heart failure are unknown.

METHODS

Serum IgE levels and cardiac FcεR1 expression were assessed in diseased hearts from human and mouse. The role of FcεR1 signaling in pathological cardiac remodeling was explored in vivo by FcεR1 genetic depletion, anti-IgE antibodies, and bone marrow transplantation. The roles of the IgE-FcεR1 pathway were further evaluated in vitro in primary cultured rat cardiomyocytes and cardiac fibroblasts (CFs). RNA sequencing and bioinformatic analyses were used to identify biochemical changes and signaling pathways that are regulated by IgE/FcεR1.

RESULTS

Serum IgE levels were significantly elevated in patients with heart failure as well as in 2 mouse cardiac disease models induced by chronic pressure overload via transverse aortic constriction and chronic angiotensin II infusion. Interestingly, FcεR1 expression levels were also significantly upregulated in failing hearts from human and mouse. Blockade of the IgE-FcεR1 pathway by FcεR1 knockout alleviated transverse aortic constriction- or angiotensin II-induced pathological cardiac remodeling or dysfunction. Anti-IgE antibodies (including the clinical drug omalizumab) also significantly alleviated angiotensin II-induced cardiac remodeling. Bone marrow transplantation experiments indicated that IgE-induced cardiac remodeling was mediated through non-bone marrow-derived cells. FcεR1 was found to be expressed in both cardiomyocytes and CFs. In cultured rat cardiomyocytes, IgE-induced cardiomyocyte hypertrophy and hypertrophic marker expression were abolished by depleting FcεR1. In cultured rat CFs, IgE-induced CF activation and matrix protein production were also blocked by FcεR1 deficiency. RNA sequencing and signaling pathway analyses revealed that transforming growth factor-β may be a critical mediator, and blocking transforming growth factor-β indeed alleviated IgE-induced cardiomyocyte hypertrophy and cardiac fibroblast activation in vitro.

CONCLUSIONS

Our findings suggest that IgE induction plays a causative role in pathological cardiac remodeling, at least partially via the activation of IgE-FcεR1 signaling in cardiomyocytes and CFs. Therapeutic strategies targeting the IgE-FcεR1 axis may be effective for managing IgE-mediated cardiac remodeling.

Subclinical cardiovascular dysfunction in children and adolescents with asthma

BACKGROUND

There is close association between asthma and cardiovascular functions as both diseases share common inflammatory pathways. The current study was aimed at investigating the risk factors, associated with endothelial and cardiac functions in children with newly-diagnosed mild-persistent asthma.

METHODS

A total of 33 steroid-naive asthmatic children [median(interquartile-range); 9.1 years(7.8-13.5)] and 16 healthy controls [11.5 years(9.9-13.6)] were included. Their demographic, clinical and laboratory findings were recorded. Carotid Artery intima-media thickness (CIMT), stiffness, distensibility and strain were measured as atheroclerosis markers. Conventional and tissue Doppler imaging was performed to evaluate ventricular function.

RESULTS

The patients with asthma had higher CIMT and stiffness and lower strain and distensibility compared to controls (p < 0.001 for all). There was a significant correlation between the duration of asthmatic symptoms and subclinical-atherosclerosis as well as peripheral eosinophil count (p < 0.001, p < 0.05). The patients had lower tricuspid-annular-plane-systolic-excursion (TAPSE), ejection time, and higher isovolumetric relaxation time (IRT), isovolumetric contraction time (ICT), and left ventricle myocardial performance index (LVMPI) than the control subjects (p < 0.001 for all). A positive correlation was also observed between the duration of asthmatic-symptoms and cardiac-function parameters.

CONCLUSION

Children with mild persistent asthma had subclinical atherosclerosis and ventricular dysfunction even in the early stage of disease. Symptom duration was closely associated with both subclinical atherosclerosis and ventricular dysfunction. Myocardial performance index was abnormal in the asthmatic children when assessed by tissue Doppler Imaging even though they had normal ejection fraction in conventional echocardiography. Future prospective studies with larger sample sizes are needed to confirm these findings and to assess the possible protective effect of ICSs in the prevention of subclinical atherosclerosis.

Assessment of biventricular function with speckle tracking echocardiography in newly-diagnosed adult-onset asthma

OBJECTIVE

There is limited number of studies on the effect of asthma disease on cardiac functions. The aim of this study was to investigate if there was any association between adult onset asthma and cardiac dysfunction.

METHODS

Total of 83 nonsmoking adult onset asthma patients aged between 18 and 65, and 83 control subjects with comparable age and sex distribution were included in the study.None of the subjects had any chronic cardiovascular or systemic diseases.Two-dimensional, M-mode and tissue Doppler examinations were performed. STE analysis was obtained using the QLAB software. Complete blood count and high-sensitive C-reactive protein (hsCRP) levels were measured.

RESULTS

There was no difference between two groups in terms of standard echocardiography and Doppler parameters. While tricuspid annular plane systolic excursion (TAPSE) was observed to be lower in asthmatics (24.9 ± 2.0 vs. 25.5 ± 2.1, p = 0.043), right ventricular myocardial performance index (RV MPI) was higher (0.36 ± 0.07 vs 0.32 ± 0.06, p˂0.001). There was no significant difference between the groups in terms of left ventricular STE parameters. Measurements of right ventricular global longitudinal strain (RVGLS) and right ventricular free wall strain (RVfree) were observed to be lower in the asthma group (-20.3 ± 2.9 vs -21.5 ± 2.9, p = 0.007; -24.0 ± 3.0 vs 25.1 ± 2.9, p = 0.009, respectively).

CONCLUSION

-We demonstrated that while adult onset mild-stage asthma patients have normal parameters in standard echocardiography, they have reduced right ventricular functions by STE.

Exposure to Road Traffic Noise and Incidence of Acute Myocardial Infarction and Congestive Heart Failure: A Population-Based Cohort Study in Toronto, Canada

BACKGROUND

Epidemiological evidence for the association between traffic-related noise and the incidence of major cardiovascular events such as acute myocardial infarction (AMI) and congestive heart failure (CHF) is inconclusive, especially in North America.

OBJECTIVES

We evaluated the associations between long-term exposure to road traffic noise and the incidence of AMI and CHF.

METHODS

Our study population comprised ∼1 million people 30-100 years of age who lived in Toronto, Canada, from 2001 to 2015 and were free of AMI (referred to as the AMI cohort) or CHF (the CHF cohort) at baseline. Outcomes were ascertained from health administrative databases using validated algorithms. Annual average noise levels were estimated as the A-weighted equivalent sound pressure level over the 24-h period (LAeq24) and during nighttime (LAeqNight), respectively, using propagation modeling, and assigned to participants' annual six-digit postal code addresses during follow-up. We calculated hazard ratios (HRs) and 95% confidence intervals (CIs) for incident AMI and CHF in relation to LAeq24 and LAeqNight using random-effects Cox proportional hazards models adjusting for individual- and census tract-level covariates, including traffic-related air pollutants [e.g., ultrafine particles (UFPs) and nitrogen dioxide].

RESULTS

During follow-up, there were 37,441 AMI incident cases and 95,138 CHF incident cases. Each interquartile range change in LAeq24 was associated with an increased risk of incident AMI (HR=1.07; 95% CI: 1.06, 1.08) and CHF (HR=1.07; 95% CI: 1.06, 1.09). Similarly, LAeqNight was associated with incident AMI (HR=1.07; 95% CI: 1.05, 1.08) and CHF (HR=1.06; 95% CI: 1.05, 1.07). These results were robust to various sensitivity analyses and remained elevated after controlling for long-term exposure to UFPs and nitrogen dioxide. We found near-linear relationships between noise and the incidence of AMI and CHF with no evidence of threshold values.

CONCLUSION

In this large cohort study in Toronto, Canada, chronic exposure to road traffic noise was associated with elevated risks for AMI and CHF incidence. https://doi.org/10.1289/EHP5809.

Ventricular Ectopy and Arrhythmia Characteristics for Persons Living with HIV and Uninfected Controls

Background:

Persons with HIV have elevated risk for cardiovascular disease, but little is known about the risk of ventricular ectopy and ventricular tachycardia (VE/VT) for HIV-infected (HIV+) persons.

Methods:

We evaluated the presence and anatomic origin of VE/VT for HIV+ persons and controls by screening a cohort using International Classification of Diseases codes and adjudicating positive screens by chart review. We sought to evaluate (1) presence of VE/VT and (2) likely anatomic origin of the VE/VT based on electrocardiogram.

Results:

There was no significant difference in the prevalence of VE/VT for HIV+ or uninfected persons. Among HIV+ persons, worse HIV control was associated with significantly greater odds of VE/VT. Exploratory analyses suggested that HIV+ persons may have a greater likelihood of VE/VT originating from the left ventricle.

Conclusion:

Although worse HIV control was associated with higher odds of VE/VT among persons with HIV, odds of VE/VT were not higher for persons with HIV than uninfected persons.

A nationwide study of asthma correlates among adolescents in Saudi Arabia

Background

Asthma is a chronic airway inflammation disease that is frequently found in children and adolescents with an increasing prevalence. Several studies are linking its presence to many lifestyle and health correlates. The objective of this study was to explore these correlates and find characteristics of self-reported asthmatics among adolescents in Saudi Arabia.

Methods

This is a cross-sectional, school-based study carried out in all 13 regions of Saudi Arabia. Sampling was randomly done from intermediate and secondary school students. Data in our study consisted of demographic characteristics, health conditions and lifestyle patterns and were compared between the two groups: asthmatics versus non-asthmatics. Comparison between the two groups was done by analyzing our data using Statistical Analysis Software SURVEYFREQ procedure (SAS Version 9; SAS Institute, Cary, NC).

Results

Among a sample of 11,348 participants, the prevalence of self-reported asthma was found to be 8.2%. Various characteristics were found significantly different between the 2 groups including the gender, the weight, the family’s education, and dietary patterns. Self –reported asthmatic were more likely to be males, overweight or obese, with a lower father’s level of education and a higher consumption of milk and power drinks.

Conclusion

Asthma disease remains prevalent among adolescents in Saudi Arabia and requires higher awareness and better guidance for its prevention and treatment. Further efforts should focus on health promotion and lifestyle wellness to support preventive efforts of this chronic disease condition.