Association of physical activity with all-cause and cardiovascular mortality in 7666 adults with hypertrophic cardiomyopathy (HCM): more physical activity is better

2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy" provides recommendations to guide clinicians in the management of patients with hypertrophic cardiomyopathy.

METHODS

A comprehensive literature search was conducted from September 14, 2022, to November 22, 2022, encompassing studies, reviews, and other evidence on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through May 23, 2023, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Hypertrophic cardiomyopathy remains a common genetic heart disease reported in populations globally. Recommendations from the "2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy" have been updated with new evidence to guide clinicians.

2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy" provides recommendations to guide clinicians in the management of patients with hypertrophic cardiomyopathy.

METHODS

A comprehensive literature search was conducted from September 14, 2022, to November 22, 2022, encompassing studies, reviews, and other evidence on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through May 23, 2023, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Hypertrophic cardiomyopathy remains a common genetic heart disease reported in populations globally. Recommendations from the "2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy" have been updated with new evidence to guide clinicians.

Physical Activity and the incidence of sepsis: A 10-year observational study among 4 million adults

BACKGROUND

As the group at high risk for sepsis is increasing with the aging of the population, physical activity (PA), which has beneficial effects on various diseases, needs to be considered as a personalized prevention strategy for sepsis without direct anti-sepsis drug.

PURPOSE

To examine the association between the amount of PA (based on intensity, duration, and frequency) and the incidence rates of sepsis and mortality after sepsis.

METHODS

This was a large-scale, retrospective, longitudinal cohort study using data from the Korean National Health Insurance Service and the biennial general health screening program. The amount of PA self-reported at the time of the health screening was categorized as non-PA, mild (<500 metabolic equivalents [METs]-Min/Week), moderate (500-1000), severe (1000-1500), and extreme (≥1500). The multivariable regression model was adjusted for age, sex, income, body mass index, smoking, alcohol consumption, diabetes, hypertension, dyslipidemia, and chronic diseases.

RESULTS

From 4,234,415 individuals who underwent a health screening in 2009, 3,929,165 subjects were selected after exclusion for wash-out period and a 1-year lag period, and then observed for the event of sepsis or all-cause death until December 2020. During a median 10.3 years of follow-up, 83,011 incidents of sepsis were detected. The moderate-PA group showed the lowest incidence (1.56/1000 person-years) and risk for sepsis, with an adjusted hazard ratio (aHR) of 0.73 (95% CI, 0.72-0.75, P < 0.001) compared with the non-PA group. The occurrence of sepsis among people aged ≥65 years and ex-smokers were significantly lower in the moderate-PA group (aHR; 0.77, 95% CI; 0.74-0.79; and 0.68, 0.64-0.71, respectively, Ps < 0.001). The long-term all-cause mortality after sepsis was significantly lower in the PA group than in the non-PA group (overall P = 0.003).

CONCLUSIONS

Physical activity is associated with a lower risk of sepsis, especially in elderly people who have the highest incidence of sepsis. The protective effects of aerobic PA on sepsis might need to be incorporated with other interventions in sepsis guidelines through the accumulation of future studies.

Implementing a clinical scientist-led screening clinic for hypertrophic and dilated cardiomyopathies

BACKGROUND

The burden of screening for inherited cardiac conditions on health services grows ever larger, with each new diagnosis necessitating screening of additional family members. Screening these usually asymptomatic, low-risk individuals is currently performed by consultant cardiologists, consuming vital clinic resources that could otherwise be diverted to sicker patients requiring specialist consultant input. Clinical scientists now constitute a highly skilled and often underutilised group of individuals with training in areas such as clinical evaluation, 12-lead electrocardiography (ECG) interpretation, and echocardiography. These skills place them in a unique position to offer a full screening evaluation in a single consultation. The aim of this study was to implement and evaluate a novel clinical scientist-led screening clinic for first-degree relatives of patients with hypertrophic cardiomyopathy (HCM) and dilated cardiomyopathy (DCM). The clinical scientist-led screening clinic was established at a London tertiary centre to allow review of asymptomatic, first-degree relatives of patients with a confirmed diagnosis of HCM or DCM, independent of a cardiology consultant. Patients were evaluated with history, examination, ECG, and echocardiography, with further investigations if deemed necessary. A retrospective review was performed of the first 200 patients seen in the clinic.

RESULTS

Of the 200 individuals reviewed between September 2019 and July 2022, 99 had a proband with HCM and 101 a proband with DCM. Overall, 169 individuals (85%) revealed normal screenings and were discharged. Thirty-one individuals (15.5%), all asymptomatic, revealed ECG changes and/or significant echocardiographic findings. Of these, 21 individuals (10.5% of the total cohort) were subsequently diagnosed with a cardiomyopathy or early phenotypic changes consistent with a cardiomyopathy (11 with HCM and 10 with DCM). These individuals were referred on to an inherited cardiac conditions consultant clinic for regular follow-up. Overall, 179 consultant clinic appointments were saved which could instead be allocated to patients requiring specialist consultant input.

CONCLUSIONS

This is the first description of a clinical scientist-led screening clinic for first-degree relatives of patients with HCM and DCM. The findings demonstrate that implementation of such a service into routine clinical practice is feasible, effective, safe, and can free up capacity in consultant clinics for patients requiring specialist input.

Physical Activity, Inactivity and Sleep in Individuals with Hypertrophic Cardiomyopathy

Physical activity presents an important cornerstone in the management and care of individuals with hypertrophic cardiomyopathy (HCM). Twenty-one individuals with HCM (age: 52±15 years old, body mass index (BMI): 30±7 kg/m2) completed 7-day monitoring using wrist-worn triaxial accelerometers (GENEActiv, ActivInsights Ltd, UK) and were compared to age and sex-matched healthy controls (age: 51±14 years old, BMI: 25±4 kg/m2). For individuals with HCM, clinical parameters (left atrial diameter and volume, peak oxygen consumption, NTproBNP and Minnesota Living with Heart Failure (MLHF)) were correlated with accelerometry. After adjusting for BMI, individuals with HCM spent less time in moderate-vigorous physical activity (MVPA) (86 (55-138) vs. 140 (121-149) minutes/day, p<0.05) compared to healthy controls. Individuals with HCM engaged in fewer MVPA-5 min (6 (2-15) vs. 27 (23-37) minutes/day, p<0.01) and MVPA-10 min bouts (9 (0-19) vs. 35 (17-54) minutes/day, p<0.01) versus healthy controls. For HCM only, peak oxygen consumption was correlated with MVPA (r=0.60, p<0.01) and MVPA-5 min bouts (r=0.47, p<0.05). MLHF score was correlated with sleep duration (r=0.45, p<0.05). Individuals with HCM should be encouraged to engage in moderate-intensity physical activity bouts and reduce prolonged periods of inactivity in order to potentially improve exercise tolerance and reduce disease burden.

Age-dependent association of metabolic dyslipidemia with clinical expression of hypertrophic cardiomyopathy

BACKGROUND

Previous studies have shown that the clinical expression of hypertrophic cardiomyopathy (HCM) can be determined by obesity and metabolic syndrome. The present study aimed to investigate the association between triglyceride and high-density lipoprotein cholesterol (HDLC) level, the two dyslipidemia-related components of metabolic syndrome, and the incidence of HCM. We also explored an age-dependent association between them.

METHODS

Individuals without previous HCM diagnosis who underwent a designated national health examination in 2009 were recruited. Individuals who used lipid-lowering medications within 1-year of the baseline were excluded. The outcome of interest was a newly diagnosed HCM.

RESULTS

Our cohort consisted of 8,652,709 individuals (mean 46 years, 55.6% men). During the median 9.3 years of follow-up, 5932 (0.07%) individuals were newly diagnosed with HCM. There was a gradual increase in the incidence of HCM towards higher triglyceride and lower HDL-C levels (log-rank p < 0.001). When stratified by age, the incidence of HCM was highest in individuals aged ≥65 years, followed by those aged 40-64 and 20-39 years (0.22% vs. 0.07% vs. 0.03%, log-rank p < 0.001). In individuals aged 20-39 years, a higher triglyceride level was associated with a higher incidence of HCM (i.e., ≥200 vs. <100 mg/dL: adjusted hazard ratio 2.28, 95% confidence interval 1.89-2.75), whereas there was no significant association in older groups (p-for-interaction<0.001). Similarly, a lower HDL-C level was associated with a higher incidence of HCM, particularly in individuals aged 20-39 years (p-for-interaction = 0.001).

CONCLUSIONS

High triglyceride and low HDL-C levels are associated with a higher incidence of HCM, particularly in young individuals.

Physical activity has a more beneficial effect on the risk of all-cause mortality in patients with metabolic syndrome than in those without

BACKGROUND

It has not been clarified whether physical activity (PA) has more benefit in terms of health outcomes, including mortality risk, among those with metabolic syndrome (MS) compared to those without. Therefore, the aim of this study is to elucidate whether regular PA has interaction with MS on health outcomes.

METHODS

Participants with no underlying cardiovascular diseases who underwent national health screening in 2009 were included. According to the metabolic equivalent (MET)-minutes/week, the amount of PA among the participants was grouped as follows: Group 1 (0 MET-minutes/week), Group 2 (1-499), Group 3 (500-999), Group 4 (1000-1499), and Group 5 (≥ 1500). Multivariable Cox proportional hazard models were applied to evaluate the impacts of the amount of PA on health outcomes among those with and without MS. Health outcomes included all-cause mortality and incident cardiovascular diseases (CVDs).

RESULTS

Of 9,628,109 total participants, 335,970 deaths occurred during a median 8.3-year follow-up. After adjustment for age, sex, smoking status, alcohol consumption, and body mass index, the higher the PA amount was, the lower the risk of all-cause mortality in both those with MS [adjusted hazard ratio (aHR) compared with Group 1, 0.86 (95% CI 0.85, 0.87) in Group 2; 0.82 (95% CI 0.81, 0.83) in Group 3; 0.75 (95% CI 0.74, 0.77) in Group 4; and 0.78 (95% CI 0.76, 0.80) in Group 5; P for trend < 0.001] and those without MS [aHR compared with Group 1, 0.87 (95% CI 0.86, 0.88) in Group 2; 0.84 (95% CI 0.83, 0.85) in Group 3, 0.79 (95% CI 0.78, 0.80) in Group 4, and 0.82 (95% CI 0.81, 0.84) in Group 5; P for trend < 0.001]. The beneficial effects of the amount of PA on all-cause mortality were larger among those with MS than among those without MS in a multiplicative interaction (P for interaction < 0.001). The results were similar in the analysis of the relationship between the PA amount and incident CVD.

CONCLUSIONS

More PA was associated with a lower risk of all-cause mortality, which was more prominent in those with MS than in those without MS. Physicians should emphasize more the importance of PA in patients with MS.

Association of duration and intensity of exercise with phenotypic expression in hypertrophic cardiomyopathy

OBJECTIVES

There is limited data regarding the impact of exercise on phenotypic expression in hypertrophic cardiomyopathy (HCM). We aimed to investigate whether such an association exists in a cohort of genotype-positive HCM patients.

METHODS

In this cross-sectional study of genotype-positive HCM families, we used structured questionnaires to obtain data regarding intensity and duration of exercise of participants starting at the age of 10, as well as data regarding exercise recommendations and their impact on quality of life (QOL). The association of cumulative metabolic-equivalent hours of exercise at different ages with different measures of phenotypic expression (maximal wall thickness, left atrial diameter, extent of late gadolinium enhancement) was analyzed.

RESULTS

The study included 109 patients from 55 families, including 43 male (39%) and 90 (83%) phenotype-positive. No association was identified between exercise duration or intensity with any of the phenotypic markers with the exception of greater cumulative exercise associated with younger age at presentation. Similar results were obtained when analysis was limited to exercise until the age of 20, until the age of 30 or only after 30. Among phenotype-positive patients, 89% recalled receiving recommendations regarding exercise restriction, 29% noted reduction in exercise level following such recommendations and 25% noted this having a significant impact on their QOL.

CONCLUSION

We found no association between exercise intensity or duration and phenotypic expression in genotype-positive HCM patients. These findings are important for physician-patient discussions and support the recent trend towards more permissive exercise restrictions in HCM.

Association between regular physical activity and lower incidence of colorectal cancer in patients with diabetes mellitus: a nationwide cohort study

AIM

The aim of this work was to investigate the association between changes in physical activity (PA) status and the development of colorectal cancer (CRC) in patients with diabetes.

METHOD

This nationwide population study included 1 439 152 patients with diabetes who underwent a health screening provided by the Korean National Health Insurance Service between January 2009 and December 2012 and a follow-up screening after 2 years. Based on changes in PA status, participants were categorized into four groups: remained inactive, remained active, active-to-inactive and inactive-to-active.

RESULTS

During the median follow-up period of 5.2 years, 38 244 new cases of CRC were diagnosed. Compared with the remained inactive group, among the three other groups, the remained active group had the lowest risk of CRC [adjusted hazard ratio (aHR) 0.93; 95% CI 0.90-0.96], followed by the inactive-to-active group (aHR 0.97; 95% CI 0.94-1.00) and active-to-inactive group (aHR 0.99; 95% CI 0.96-1.02), after adjusting for confounding variables (p = 0.0007). This reduction in cancer incidence in the remained active group was observed for both rectal cancer (aHR 0.87, 95% CI 0.79-0.95) and colon cancer (aHR 0.93, 95% CI 0.90-0.97), irrespective of sex. In terms of the intensity and amount of PA, moderate intensity PA was the most effective, and a positive correlation was found between the amount of PA and the reduction in CRC incidence.

CONCLUSION

Regular PA was independently associated with a decreased risk of CRC in patients with diabetes. The intensity and amount of physical activity both play a role in reducing the risk.

Association of Physical Activity with Total and Cause-specific Mortality in Patients with Diabetes: A Nationwide Population-based Cohort Study

AIMS

Physical inactivity is a modifiable risk factor for cardiovascular disease (CVD) in patients with type 2 diabetes mellitus (T2DM); however, little is known about its association with mortality due to other causes. Herein, we investigated the association between physical activity (PA) and cause-specific mortality in patients with T2DM.

METHODS

We analyzed data from the Korean National Health Insurance Service and claims database of adults with T2DM aged >20 years at baseline (n=2,651,214). Each participant's PA volume was measured as the metabolic equivalent of tasks (METs)-min per week, and hazard ratios of all-cause and cause-specific mortality relative to PA levels were estimated.

RESULTS

During the 7.8 years of follow-up, all-cause, CVD, respiratory, cancer, and other causes of mortality were lowest in patients engaged in vigorous PA. MET-min/week was inversely associated with mortality after adjusting for covariates. The reduction in total and cause-specific mortality was greater in patients aged ≥65 years than in those aged <65 years.

CONCLUSIONS

Increasing PA may facilitate a reduction in mortality from various causes, especially among older patients with T2DM. Clinicians should encourage such patients to increase their daily PA levels to reduce their risk of mortality.

Vigorous Exercise in Patients With Hypertrophic Cardiomyopathy

Importance

Whether vigorous intensity exercise is associated with an increase in risk of ventricular arrhythmias in individuals with hypertrophic cardiomyopathy (HCM) is unknown.

Objective

To determine whether engagement in vigorous exercise is associated with increased risk for ventricular arrhythmias and/or mortality in individuals with HCM. The a priori hypothesis was that participants engaging in vigorous activity were not more likely to have an arrhythmic event or die than those who reported nonvigorous activity.

Design, Setting, and Participants

This was an investigator-initiated, prospective cohort study. Participants were enrolled from May 18, 2015, to April 25, 2019, with completion in February 28, 2022. Participants were categorized according to self-reported levels of physical activity: sedentary, moderate, or vigorous-intensity exercise. This was a multicenter, observational registry with recruitment at 42 high-volume HCM centers in the US and internationally; patients could also self-enroll through the central site. Individuals aged 8 to 60 years diagnosed with HCM or genotype positive without left ventricular hypertrophy (phenotype negative) without conditions precluding exercise were enrolled.

Exposures

Amount and intensity of physical activity.

Main Outcomes and Measures

The primary prespecified composite end point included death, resuscitated sudden cardiac arrest, arrhythmic syncope, and appropriate shock from an implantable cardioverter defibrillator. All outcome events were adjudicated by an events committee blinded to the patient's exercise category.

Results

Among the 1660 total participants (mean [SD] age, 39 [15] years; 996 male [60%]), 252 (15%) were classified as sedentary, and 709 (43%) participated in moderate exercise. Among the 699 individuals (42%) who participated in vigorous-intensity exercise, 259 (37%) participated competitively. A total of 77 individuals (4.6%) reached the composite end point. These individuals included 44 (4.6%) of those classified as nonvigorous and 33 (4.7%) of those classified as vigorous, with corresponding rates of 15.3 and 15.9 per 1000 person-years, respectively. In multivariate Cox regression analysis of the primary composite end point, individuals engaging in vigorous exercise did not experience a higher rate of events compared with the nonvigorous group with an adjusted hazard ratio of 1.01. The upper 95% 1-sided confidence level was 1.48, which was below the prespecified boundary of 1.5 for noninferiority.

Conclusions and Relevance

Results of this cohort study suggest that among individuals with HCM or those who are genotype positive/phenotype negative and are treated in experienced centers, those exercising vigorously did not experience a higher rate of death or life-threatening arrhythmias than those exercising moderately or those who were sedentary. These data may inform discussion between the patient and their expert clinician around exercise participation.

Sport activity in patients with cardiomyopathies: a review

Exercise has undisputable benefits and is an important therapy component for most cardiovascular diseases, with a proven role in reducing mortality. On the contrary, exercise may paradoxically trigger sudden cardiac arrest in patients with cardiomyopathies requiring refrain from competitive sports participation. The 2020 European guidelines for patients with cardiovascular disease provided indication for sports participation for patients with cardiac conditions, including cardiomyopathies. Although in some cases, the knowledge of the natural history of the disease and the risk of death during intensive exercise is more robust, in others, the evidence is scarce. Therefore, recommendations are not available for all possible scenarios with several uncertainties. In addition, many patients aspire to continue competitive sports or practise recreational activities after a diagnosis of cardiomyopathy. These aspects generate concern for the physician, who should make complex decisions, and confronts the request to design specific exercise programmes without specific indications. This article will review the available evidence on the sports-related risk of sudden cardiac death or cardiovascular events and the progression of the disease in cardiomyopathies.

Impact of coronary artery revascularization on long-term outcome in hypertrophic cardiomyopathy patients: a nationwide population-based cohort study

Limited data are available on the long-term outcomes in patients with hypertrophic cardiomyopathy (HCM) patients with significant coronary artery disease (CAD) requiring revascularization. We investigated the risk of cardiovascular outcomes in HCM patients who underwent coronary revascularization compared to the control group without HCM. HCM patients aged ≥ 20 years were enrolled from the Korean National Health Insurance Database. Information on the diagnosis and previous medical history was obtained from the claims data. Cardiovascular outcomes were identified during 8-year after coronary revascularization in HCM patients (HCM group) and matched controls without HCM (non-HCM control group). A total of 431 patients in the HCM group and 1968 in the non-HCM control group were analyzed. The risk of all-cause death, cardiovascular death, sudden cardiac death (SCD), ischemic stroke, and hospitalization due to heart failure was significantly higher in the HCM group than in the non-HCM group, with prominent risk increase of cardiovascular death (adjusted hazard ratio [HR] 2.27, 95% confidence interval [CI] 1.63-3.15, P < 0.001) and ischemic stroke (adjusted HR 2.38, 95% CI 1.55-3.64, P < 0.001). Beyond 1-year after revascularization, the HCM group still had a significantly higher risk of cardiovascular death, SCD, and ventricular fibrillation/tachycardia compared to the non-HCM group. Mortality and major cardiovascular outcomes occurred more frequently in HCM patients with significant CAD requiring revascularization, compared to the matched non-HCM control group. Active and regular surveillance for concomitant risk factors and relevant intervention are warranted in HCM patients at increased risk for CAD.

Risk of incident mental disorders in hypertrophic cardiomyopathy: a nationwide propensity-matched study

AIMS

We sought to determine the risk of mental disorders in patients with hypertrophic cardiomyopathy (HCM) compared with those without HCM.

METHODS AND RESULTS

This is a retrospective propensity score-matched cohort study using nationwide population-based data from the Korean National Health Insurance Service. Overall, 4046 patients with HCM and 12138 matched individuals were followed up until the first diagnosis of mental disorders or the end of the follow up. The primary outcome was a composite of incident mood, anxiety, stress-related, or somatoform disorders. Secondary outcomes included two components of the primary outcome (i.e. mood disorders and anxiety/stress-related/somatoform disorders). During a median follow-up period of 4.1 years, the incidence rate of the primary outcome was 54.4 and 31.5/1000 person-years among the HCM and control groups, respectively, resulting in a hazard ratio (HR) of 1.719 (95% confidence interval: 1.589-1.860). Within the first month after HCM diagnosis, the HR for the primary outcome was 3.074 (2.096-4.508). Beyond 1 month, the HRs decreased, ranging from 2.281 (1.952-2.665) during 1-12 months, to 2.087 (1.831-2.380) during 12-36 months and 1.258 (1.090-1.452) after 36 months of follow up. Similar results were observed for the secondary outcomes. In sensitivity analysis, the risk of the specific categories of mental disorders, including single or recurrent depressive episodes and anxiety disorders, was also higher in patients with HCM than matched controls.

CONCLUSION

HCM was significantly associated with the risk of incident mental disorders, particularly within 1 year after HCM diagnosis, underscoring the importance of screening mental health problems, including mood and anxiety disorders, in patients with HCM.

Rediscovering the value of exercise in patients with hypertrophic cardiomyopathy

It was previously thought that hypertrophic cardiomyopathy is the leading cause of sudden cardiac death in athletes. This was also extrapolated to the general population. Thereby, exercise was restrained in patients with hypertrophic cardiomyopathy. However, recent studies have shown that hypertrophic cardiomyopathy is not the main cause of sudden cardiac death, and moderate exercise is not only safe but beneficial for patients with hypertrophic cardiomyopathy. With the accumulation of evidence, relevant guidelines recommend low-intensity exercise from the beginning, then gradually recommend moderate-high intensity exercise for patients with hypertrophic cardiomyopathy. This suggests that we should rediscover the value of exercise in patients with hypertrophic cardiomyopathy. It is now widely accepted that patients with hypertrophic cardiomyopathy can benefit from the positive effects of exercise through an individualized exercise prescription based on a comprehensive assessment. This review summarizes the evidence showing patients with hypertrophic cardiomyopathy can exercise safely, and the methods to formulate related exercise prescriptions.

Associations between migraine and major cardiovascular events in type 2 diabetes mellitus

BACKGROUND

Migraine is one of the most common primary headache disorders and a well-known risk factor for cardiovascular disorders. We aimed to investigate the association between migraine and major cardiovascular outcomes, including myocardial infarction (MI), ischemic stroke (IS), and cardiovascular death (CVD) in people with type 2 diabetes.

RESEARCH DESIGN AND METHODS

A total of 2,229,598 people from the nationwide Korean National Health Insurance Service database with type 2 diabetes but without a previous history of MI and IS were included in this study. We identified patients over 20 years of age with migraine using the claim data of International Statistical Classification of Diseases Related Health Problems, Tenth Revision (ICD-10) code G43. The patients with migraine were divided according to their migraine aura status.

RESULTS

Migraine was present in 6.3% of the study population. Cases observed for MI, IS, CVD, and all-cause death were 2.6%, 3.6%, 5.9%, and 7.9%, respectively. The diagnosis of migraine was significantly associated with an increased risk of MI, IS, and CVD. The results remained significant after adjusting for covariates, including age, sex, body mass index, alcohol intake, smoking habits, physical activity, economic status, hypertension history, dyslipidemia, and duration of type 2 diabetes (MI, adjusted hazard ratio [aHR]: 1.182, 95% confidence interval [CI]: 1.146-1.219; IS, aHR: 1.111, 95% CI 1.082-1.14; CVD, aHR: 1.143, 95% CI 1.12-1.167). In particular, the presence of aura was associated with a higher risk of MI development compared to the non-aura group. The difference became more prominent with progressing age.

CONCLUSIONS

In this nationwide population-based study, people with type 2 diabetes and migraines were found to be at a significantly higher risk for major cardiovascular events, including MI, IS, and CVD. The risk of MI and CVD significantly increased with the presence of aura symptoms among patients with migraine.

Athletic Activity for Patients With Hypertrophic Cardiomyopathy and Other Inherited Cardiovascular Diseases: JACC Focus Seminar 3/4

As explored throughout this JACC Focus Seminar series, participation in regular exercise offers significant positive benefits for cardiovascular health. However, patients with underlying inherited cardiovascular diseases, such as hypertrophic cardiomyopathy, have historically been restricted from sports participation because of the risk of sudden cardiac death. Over the last decade, new data has challenged this restrictive approach. Today, the notion of individualized, patient-centered shared decision-making is being progressively adopted to guide patients with an inherited cardiovascular disease to decide if they can undertake regular exercise, or even if they can participate in competitive sports. Here in this part 3 of a 4-part seminar series, we focus on these concepts and recent data with respect to exercise and the heart in patients with hypertrophic cardiomyopathy and other inherited cardiovascular diseases, with particular emphasis on participation in recreational and competitive sports for these individuals.

Augmented risk of ischemic stroke in hypertrophic cardiomyopathy patients without documented atrial fibrillation

Although atrial fibrillation (AF) is a well-established risk factor for ischemic stroke (IS) in hypertrophic cardiomyopathy (HCM), the risk of IS in HCM patients without documented AF is less recognized. This nationwide population-based cohort study using Korean National Health Insurance database included 8,328 HCM patients without documented AF and 1:2 propensity score-matched 16,656 non-HCM controls between 2010 and 2016. The primary outcome was an incident IS. During a mean follow-up of 6.1 years, IS occurred in 328/8,328 (3.9%) patients with HCM and 443/16,656 (2.7%) controls. The overall incidence of IS was 0.72/100 person-years in the HCM group, which was significantly higher than that in the control group (0.44/100 person-years) (HR 1.64; 95% CI 1.424–1.895; P < 0.001). The overall incidence of IS was 1.36/100 person-years in HCM patients aged ≥ 65 and 2.32/100 person-years years in those with heart failure, respectively. In the HCM group, age ≥ 65 years (adjusted HR 2.74; 95% CI 2.156–3.486; P < 0.001) and chronic heart failure (adjusted HR 1.75; 95% CI 1.101–2.745; P = 0.018) were independent risk factors for IS. HCM patients without documented AF are at a greater risk of IS, especially in those 65 years of age or older or those with chronic heart failure.

U-Shaped Associations Between Body Weight Changes and Major Cardiovascular Events in Type 2 Diabetes Mellitus: A Longitudinal Follow-up Study of a Nationwide Cohort of Over 1.5 Million

OBJECTIVE

Despite the benefits of weight loss on metabolic profiles in patients with type 2 diabetes mellitus (T2DM), its association with myocardial infarction (MI), ischemic stroke (IS), atrial fibrillation (AF), heart failure (HF), and all-cause death remains elusive.

RESEARCH DESIGN AND METHODS

Using the National Health Insurance Service Database, we screened subjects who underwent general health checkups twice in a 2-year interval between 2009 and 2012. After identifying 1,522,241 patients with T2DM without a previous history of MI, IS, AF, and HF, we followed them until December 2018. Patients were stratified according to the magnitude of weight changes between two general health checkups: ≤ -10%, -10 to ≤ -5%, -5 to ≤5%, 5 to ≤10%, and >10%.

RESULTS

During the follow-up (median 7.0 years), 32,106 cases of MI, 44,406 cases of IS, 34,953 cases of AF, 68,745 cases of HF, and 84,635 all-cause deaths occurred. Patients with weight changes of -5 to ≤5% showed the lowest risk of each cardiovascular event. Both directions of weight change were associated with an increased cardiovascular risk. Stepwise increases in the risks of MI, IS, AF, HF, and all-cause death were noted with progressive weight gain (all P < 0.0001). Similarly, the more weight loss occurred, the higher the cardiovascular risks observed (all P < 0.0001). The U-shaped associations were consistently observed in both univariate and multivariate analyses. Explorative subgroup analyses also consistently showed a U-shaped association.

CONCLUSIONS

Both weight loss and gain >5% within a 2-year interval were associated with an increased risk of major cardiovascular events in patients with T2DM.

Comparison of mortality and cause of death between adults with and without hypertrophic cardiomyopathy

Insufficient evidence is available comparing mortality and cause of death between general hypertrophic cardiomyopathy (HCM) and general non-HCM populations. We aimed to investigate how causes of death and mortality differ in subjects with and without HCM. Using the National Health Insurance Service database from 2009 to 2016, individuals who underwent health check-up(s) with or without a history of HCM were identified. Participants in the HCM group were matched at a 1:1 ratio with those in the non-HCM group using propensity scores calculated from the baseline covariates. Mortality rates and risks were compared between the groups. In total, 14,858 participants (7,429 each in the HCM and non-HCM groups) were followed up over a mean 4.4 ± 2.2 years (mean age, 61.0 years; male proportion, 66.8%). Compared to the non-HCM group, the HCM group showed a higher risk of all-cause and HCM-related mortality and a similar risk for non-cardiovascular mortality (hazard ratio [95% confidence interval] 1.57 [1.38–1.78], 2.71 [1.92–3.83], and 1.04 [0.88–1.23], respectively). The sensitivity analyses consistently showed that the HCM group showed higher risks of all-cause and HCM-related mortality than the non-HCM group. The female participants with HCM were associated with an increasing trend of the risks of all-cause mortality but not HCM-related mortality compared to their male counterparts (p for interaction < 0.001 and 0.185, respectively). In conclusion, compared to the non-HCM population, the general HCM population showed higher risks of both all-cause and HCM-related mortality, but had a similar risk of non-cardiovascular mortality.

Impact of diabetes mellitus on the outcomes of subjects with hypertrophic cardiomyopathy: A nationwide cohort study

AIMS

Diabetes mellitus (DM) often coexists in elderly hypertrophic cardiomyopathy (HCM) patients; however, its impact on clinical outcomes is unclear.

METHODS

We compared clinical outcomes according to the presence of DM in a nationwide HCM cohort.

RESULTS

In 9,883 HCM subjects (mean age 58.5 ± 13.1, men 71.7%), 1,327 (13.4%) had DM. During follow-up (mean 5.9 ± 2.5 years), end-stage renal disease (ESRD) progression, coronary events (myocardial infarction, coronary revascularization), heart failure (HF), cardiovascular mortality, and all-cause mortality occurred in 80 (0.8%), 365 (3.7%), 1,558 (15.8%), 354 (3.6%), and 877 (8.9%) subjects, respectively. DM HCM subjects had significantly higher risks of ESRD progression (HR 3.49, 95% CI 2.20-5.54) and HF (HR 1.15, 95% CI 1.01-1.32) compared to non-DM HCM subjects, independent of age, sex, ischemic heart disease, atrial fibrillation, and other comorbidities. There was a tendency for greater risk of ESRD progression, HF, and all-cause death in subjects with more advanced stage of DM (p-for-trend < 0.05 for all). Insulin-treated DM was associated with the highest risk.

CONCLUSIONS

DM HCM subjects have higher risk of ESRD progression and HF. Considering the extended life expectancy of HCM and increasing number of elderly HCM subjects, active surveillance and management of DM-related outcomes should be highlighted.

Young adults with nonalcoholic fatty liver disease, defined using the fatty liver index, can be at increased risk of myocardial infarction or stroke

AIM

To investigate the relationship between nonalcoholic fatty liver disease (NAFLD) and cardiovascular events among a nationally representative sample of young adults in Korea.

METHODS AND RESULTS

This population-based cohort study from the Korean National Health Insurance Service included adults who were aged 20 to 39 years when they underwent a health examination between 2009 and 2012. NAFLD was defined as a fatty liver index (FLI) ≥60, and participants were divided into three groups according to FLI (<30, 30-59 and ≥60) to investigate the dose-dependent effect of FLI score. Among 5 324 410 participants, 9.8% had an FLI ≥60. There were 13 051 myocardial infarctions (MIs; 0.39%) and 8573 strokes (0.26%) during a median follow-up of 8.4 years. In multivariable analysis, NAFLD was associated with a higher risk of MI and stroke (hazard ratio [HR] 1.69, 95% confidence interval [CI] 1.61-1.77 and HR  1.73, 95% CI 1.63-1.84, respectively). MI and stroke had dose-dependent relationships with FLI (HR 1.28 in participants with FLI 30-59 and 1.73 in those with FLI ≥60 for MI and HR 1.18 in participants with FLI 30-59 and 1.41 in those with FLI ≥60 for stroke, respectively).

CONCLUSIONS

Nonalcholic fatty liver disease was an independent predictor of MI and stroke in young adults. These results suggest that primary prevention of cardiovascular disease should be emphasized in young adults with NAFLD.

Exercise prescription in individuals with hypertrophic cardiomyopathy: what clinicians need to know

Hypertrophic cardiomyopathy (HCM) is the most frequently cited cause of exercise-related sudden cardiac death (SCD) in young individuals and has claimed the lives of some high-profile athletes. The circumstantial link between exercise and SCD from HCM has resulted in conservative exercise recommendations which focus on activities that should be avoided rather than the minimal amount of physical activity required to reap the multiple rewards of exercise. Consequently, most patients with HCM are confined to a sedentary lifestyle through fear of SCD, with accruing risk factors such as obesity and low cardiorespiratory fitness that confer a worse prognosis. Recent exercise programmes in asymptomatic and symptomatic individuals with HCM have shown that mild and moderate exercise is safe and accompanied by increased functional capacity and improved quality of life. Population studies also reveal that individuals with HCM in the higher quartiles of self-reported physical activity have lower total cardiovascular mortality compared with those in the lower quartiles. The impact of vigorous exercise on the natural history of HCM is unknown, although current experience suggests that affected adults with mild morphology and absence of high-risk factors may partake in such activity without adverse events. This review highlights the evidence base that has resulted in a paradigm shift in the approach to exercise in HCM and liberalised recent international exercise guidelines in HCM. Practical tips for prescribing exercise in symptomatic patients and relevant precautions are provided to aid clinicians when recommending exercise as part of the management plan for all patients with HCM.

Continuing regular physical activity and maintaining body weight have a synergistic interaction in improving survival: a population-based cohort study including 6.5 million people

AIMS

Continuing physical activity (PA) and maintaining body weight are tightly intertwined; however, no study investigated whether these two factors have interactions in terms of the mortality. The aim of this study is to elucidate whether continuing regular PA and maintaining body weight have interactions in terms of all-cause mortality risk.

METHODS AND RESULTS

Participants with health screening from both 2009 and 2011 without underlying cancer or cardiovascular disease were included. Physical activity change was grouped as remained active, inactive-to-active, active-to-inactive, or remained inactive. Body weight change was categorized as stable (weight change < 5%), weight gain, or loss. Outcome included all-cause mortality. Of 6 572 984 total participants, 91 347 deaths occurred during a median 7.4-year follow-up. Compared with the remained active and stable weight group, most other groups had a higher mortality risk. The weight loss and remained inactive group [adjusted hazard ratio (aHR), 2.30; 95% confidence interval (CI), 2.22-2.38] and the weight gain and remained inactive group (aHR, 2.17; 95% CI, 2.09-2.25) showed the highest mortality risks. Among stable weight participants, the ranking of the groups from highest to lowest in terms of mortality risk was as follows: remained inactive (aHR, 1.46; 95% CI, 1.41-1.50), active-to-inactive (aHR, 1.24; 95% CI, 1.19-1.29), inactive-to-active (aHR, 1.15; 95% CI, 1.11-1.20), and remained active (reference). Remaining active and maintaining a stable body weight had a synergistic interaction on decreasing all-cause mortality risk (multiplicative P for interaction < 0.001; relative excess risk due to interaction, 0.38; 95% CI, 0.31-0.46; attributable proportion, 0.18; 95% CI, 0.15-0.22).

CONCLUSIONS

Continuing regular PA as recommended and maintaining body weight have multiplicative and additive interactions on reducing all-cause mortality. Healthcare providers should emphasize the importance of both regular PA and body weight maintenance for the general public.

Physical Activity and the Risk of COVID-19 Infection and Mortality: A Nationwide Population-Based Case-Control Study

Regular physical activity (PA) is known to reduce the risk of serious community-acquired infections. We examined the association of PA with the morbidity and mortality resulting from coronavirus disease (COVID-19) infection in the South Korean population. Patients who tested positive for severe acute respiratory coronavirus 2 and who underwent public health screening between 2014 and 2017 (n = 6288) were included. Age- and sex-matched controls (n = 125,772) were randomly selected from the Korean National Health Insurance Service database. Leisure-time PA was assessed using a self-reported questionnaire. The mean PA levels were lower in the patient than in the control group (558.2 ± 516.3 vs. 580.2 ± 525.7 metabolic equivalent of task (MET)-min/week, p = 0.001). Patients with moderate to vigorous PA (MVPA) were associated with a lower risk of COVID-19 morbidity (odds ratio (OR), 0.90; 95% confidence interval (CI), 0.86-0.95). In addition, a standard deviation (SD) increment in MET/week (525.3 MET-min/week) was associated with a 4% decrease in the risk of COVID-19 morbidity (OR, 0.96; 95% CI, 0.93-0.99). MVPA and an SD increment in MET/week were associated with lower mortality (MVPA: OR, 0.47; 95% CI, 0.26-0.87; per SD increment: OR, 0.65; 95% CI, 0.48-0.88). Higher levels of regular PA were associated with a lower risk of COVID-19 infection and mortality, highlighting the importance of maintaining appropriate levels of PA along with social distancing amid the COVID-19 pandemic.

Exercise in hypertrophic cardiomyopathy: restrict or rethink

The detailed physiological consequences of aerobic training, in patients with hypertrophic cardiomyopathy (HCM), are not well understood. In athletes and nonathletes with HCM, there are two hypothetical concerns with respect to exercise: exercise-related worsening of the phenotype (e.g., promoting hypertrophy and fibrosis) and/or triggering of arrhythmia. The former concern is unproven and animal studies suggest an opposite effect, where exercise has been shown to be protective. The main reason for exercise restriction in HCM is fear of exercise-induced arrhythmia. Although the safety of sports in HCM has been reviewed, even more recent data suggest a substantially lower risk for sudden cardiac death (SCD) in HCM than previously thought, and there is an ongoing debate about restrictions of exercise imposed on individuals with HCM. This review outlines the pathophysiology of HCM, the impact of acute and chronic exercise (and variations of exercise intensity, modality, and athletic phenotype) in HCM including changes in autonomic function, blood pressure, cardiac dimensions and function, and cardiac output, and the underlying mechanisms that may trigger exercise-induced lethal arrhythmias. It provides a critical evaluation of the evidence regarding risk of SCD in athletes and the potential benefits of targeted exercise prescription in adults with HCM. Finally, it provides considerations for personalized recommendations for sports participation based on the available data.