Coronary heart disease and atrial fibrillation: a vicious cycle

Stroke Prevention With Oral Anticoagulants in High-Risk Atrial Fibrillation in an Aging Population

Aging societies will pose unique health challenges in the near future. Elderly and very elderly patients often have complex medical needs, including comorbidities and polypharmacy. Contributing to this, atrial fibrillation (AF) is common among elderly patients. Direct oral anticoagulants are widely used to prevent stroke in patients with AF. However, patients in randomized controlled trials tend to be younger than many patients with AF and may not have the complicating factors that can influence treatment decisions. In this review, we summarize what is currently known about direct oral anticoagulants in elderly (age 65-79 years) and very elderly (age ≥80 years) patients with AF, and highlight the remaining gaps in the literature. Although further randomized controlled trials are needed, the ELDERCARE-AF (Edoxaban Low-Dose for Elder Care Atrial Fibrillation Patients) trial may have contributed to filling these gaps.

Multi-omics analysis identifies Sphingomonas and specific metabolites as key biomarkers in elderly Chinese patients with coronary heart disease

Background

Abnormal component changes of gut microbiota are related to the pathogenesis and progression of coronary heart disease (CHD), and gut microbiota-derived metabolites are key factors in host-microbiome interactions. This study aimed to explore the key gut microbiota and metabolites, as well as their relationships in CHD.

Methods

Feces samples and blood samples were collected from CHD patients and healthy controls. Then, the obtained feces samples were sent for 16s rRNA gene sequencing, and the blood samples were submitted for metabolomics analysis. Finally, conjoint analysis of 16s rRNA gene sequencing and metabolomics data was performed.

Results

After sequencing, there were no significant differences in Chao 1, observed species, Simpson, Shannon, Pielou's evenness and Faith's PD between the CHD patients and controls. At phylum level, the dominant phyla were Firmicutes, Bacteroidetes, Proteobacteria, and Actinobacteria. At genus level, the abundance of Sphingomonas, Prevotella, Streptococcus, Desulfovibrio, and Shigella was relatively higher in CHD patients; whereas Roseburia, Corprococcus, and Bifidobacterium was relatively lower. Randomforest analysis showed that Sphingomonas was more important for CHD. Through metabolomic analysis, a total of 155 differential metabolites were identified, and were enriched in many signaling pathways. Additionally, the AUC of the conjoint analysis (0.908) was higher than that of gut microbiota species (0.742).

Conclusion

In CHD patients, the intestinal flora was disordered, as well as Sphingomonas and the identified differential metabolites may serve as was candidate biomarkers for CHD occurrence and progression.

Association Between Anemia and Prognosis in Patients With Acute Coronary Syndrome and Atrial Fibrillation

Patients with acute coronary syndromes (ACS) and atrial fibrillation (AF) have more complex conditions, making risk stratification crucial. The added discriminatory power of including anemia in the CHA2DS2-VASc ([congestive heart failure, hypertension, age [>65 = 1 point, >75 = 2 points], diabetes, previous stroke/systemic embolism/transient ischemic attack [2 points], vascular disease, age 65-74 years, and sex category]) score for poor prognosis in this population remains unclear. This study investigates the impact of anemia on 1166 patients with ACS and AF from 2017 to 2019. Multivariate Cox regression analysis showed anemia significantly increased the risk of all-cause mortality (Hazard ratio [HR] = 1.935, 95% CI: 1.106-3.384, P = .021) and major adverse cardiovascular events (MACE; HR = 1.857, 95% CI: 1.171-2.945, P = .009), but not thromboembolic events (HR = 0.651, 95% CI: 0.210-2.022, P = .458). Receiver operating characteristic (ROC) curves showed that hemoglobin's area under the curve (AUC) for mortality and MACE was 0.722 and 0.710, respectively, improving to 0.770 and 0.772 when combined with the CHA2DS2-VASc score. Integrated discrimination improvement (IDI) and net reclassification improvement (NRI) metrics showed significant improvement in predicting mortality (NRI = 0.258, P = .004; IDI = 0.037, P < .001) and MACE (NRI = 0.232, P = .002; IDI = 0.026, P = .004). Adding hemoglobin to the CHA2DS2-VASc score enhances its predictive performance.

Helicobacter pylori and Atrial Fibrillation: Insights into Their Inter-Relationship

Helicobacter pylori (H. pylori) infection and atrial fibrillation (AF) are prevalent global health concerns that significantly impact societal and economic well-being. This study explored the potential associations between H. pylori infection and the incidence and progression of AF. Emerging research suggests that H. pylori may influence AF through various pathways, including systemic inflammation, metabolic disturbances, immune responses, and changes in the gut microbiota. These pathways provide a novel perspective on the etiology of AF, suggesting that chronic H. pylori infection could exacerbate or even initiate the arrhythmic events typical of AF. Current evidence, while preliminary, points to significant correlations, particularly through changes in markers such as C-reactive protein (CRP) and lipid metabolism, which are heightened in individuals with active H. pylori infection. However, the exact mechanisms and causal nature of this relationship remain elusive, with studies showing conflicting results. This inconsistency underscores the need for more comprehensive and rigorously designed clinical and experimental research to elucidate fully the interactions between H. pylori infection and AF. Understanding these connections is crucial for developing innovative treatments and management strategies targeting microbial influences in AF patients. Future research should focus on defining the role of H. pylori eradication in the clinical management of AF assessing its impact on disease progression and patient outcomes.

Decreased plasma lipoxin A4, resolvin D1, protectin D1 are correlated with the complexity and prognosis of coronary heart disease: A retrospective cohort study

This study aimed to assess the predictive capacity of specialized pro-resolving mediators (SPMs) regarding the complexity and prognosis of coronary heart disease (CHD). Total of 602 CHD patients were included in this study and categorized into low-risk, medium-risk, and high-risk groups based on the Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score. Follow-up was conducted for two years, during which patients were dichotomized into poor and good prognosis groups. Additionally, twenty healthy controls were incorporated. Plasma concentrations of lipoxin A4 (LXA4), resolvin D1 (RvD1), protectin D1 (PD1), C-reactive protein (CRP), interleukin-6 (IL-6), and IL-10 were quantified. Plasma LXA4, RvD1, PD1, and the ratios LXA4/IL-6, RvD1/IL-6, PD1/IL-6 exhibited a gradual decrease across control, low-risk, medium-risk, and high-risk groups and exhibited a negative correlation with the SYNTAX score. Spearman's correlation analysis revealed negative correlations between plasma LXA4, RvD1, PD1, and both CRP and IL-6, and positive correlations with IL-10. Multiple linear regression models demonstrated negative associations between plasma LXA4, RvD1, PD1, and SYNTAX score. Moreover, both univariate and multivariate binary logistic regression analyses identified plasma LXA4, RvD1, and PD1 as protective factors against medium/high-risk SYNTAX score categorization. In the poor prognosis group, plasma PD1 was reduced at short-term follow-up, and the ratios LXA4/IL-6, RvD1/IL-6, PD1/IL-6 were reduced at long-term follow-up. Plasma LXA4, RvD1, and PD1 demonstrated negative correlations with CHD complexity and potentially served as protective factors against CHD. Plasma PD1 provided predictive value for short-term prognosis, while the ratios LXA4/IL-6, RvD1/IL-6, PD1/IL-6 were indicative for long-term prognosis.

The impact of clinical phenotypes of coronary artery disease on outcomes in patients with atrial fibrillation: A post-hoc analysis of GLORIA-AF registry

BACKGROUND

Coronary artery disease (CAD) and atrial fibrillation (AF) often coexist, but the impact of clinical phenotypes of CAD on outcomes in AF patients in the non-vitamin K antagonist oral anticoagulant drugs (NOACs) era is less well understood.

METHODS

This was a post-hoc of the GLORIA-AF registry, a global, multicenter, prospective AF registry study. Patients were divided into three groups: prior history of myocardial infarction (MI)/unstable angina group (Group 1); stable angina group (Group 2); and a control group without stable angina or history of MI/unstable angina. The primary endpoint was the composite of all-cause death or stroke, and the safety endpoint was major bleeding.

RESULTS

A total of 24,827 patients were included in this analysis (median age was 71 (IQR, 64-78) years; 55% male) and 5394 (21.7%) had CAD. During a follow-up of 2 years, the incidence of the primary endpoint was 5.99 (95% CI, 5.33, 6.71) per 100 patient-years in Group 1, 4.04 (95% CI, 3.55, 4.70) per 100 patient-years in Group 2, and 2.79 (95% CI, 2.62, 2.96) per 100 patient-years in the control group (p < .001). Compared the control group, the adjusted hazard ratio of the primary composite endpoint in Groups 1 and 2 were 1.58 (95% CI, 1.37, 1.83, p < .001) and 1.22 (95% CI, 1.04, 1.43, p = .012), respectively. Among anticoagulated patients with AF and CAD, NOACs were associated with a reduced risk of the primary composite endpoint and major bleeding, compared with vitamin K antagonists (VKA).

CONCLUSIONS

CAD was prevalent in patients with AF, and clinical phenotypes of CAD influenced outcomes in patients with AF, with a history of MI/unstable angina being associated with a significantly increased risk of CV events, compared to stable angina. NOACs were superior to VKA in terms of the effectiveness and safety outcomes in patients with AF and concomitant CAD.

The Influence of Risk Factor Modification on Atrial Fibrillation Outcomes and Their Impact on the Success of Catheter Ablation

The global prevalence of atrial fibrillation (AF) is growing with a significant increase in AF burden. The pathophysiology of AF is complex and exhibits a strong relationship with modifiable lifestyle AF risk factors, such as physical inactivity, smoking, obesity, and alcohol consumption, as well as co-morbidities, such as hypertension, diabetes mellitus, and cardiovascular disease. Current evidence suggests that cardiac rehabilitation and lifestyle risk factor modification can potentially lower the overall AF burden. Additionally, AF ablation can be an effective treatment for a rhythm control strategy, but reducing AF recurrences post-catheter ablation is paramount. Thus, addressing these modifiable lifestyle risk factors and co-morbidities is critical, as the recent 2024 European Society of Cardiology AF guidance update highlights. A comprehensive approach to treating these risk factors is essential, especially given the rising prevalence of AF. This article provides a state-of-the-art update on the evidence of addressing AF-related risk factors and co-morbidities, particularly in patients undergoing AF ablation.

Smoking, Alcohol Consumption, and Atrial Fibrillation: Mendelian Randomization Study

Smoking, secondhand smoke exposure, and alcohol consumption are significant risk factors that contribute to an increased global burden of cardiovascular diseases. However, the casual relationship between smoking, passive smoking, alcohol consumption, and atrial fibrillation (AF) remains uncertain. Conventional observational studies are difficult to draw conclusion on high-quality causality. To elucidate the association between smoking, secondhand smoke exposure, alcohol consumption, and AF, we conducted this two-sample Mendelian randomization (MR) analysis. Smoking encompasses current tobacco smoking, ever-smoked, and light smokers, with light smokers being defined as at least 100 smokes in lifetime, as well as secondhand smoke exposure, which is characterized by workplace had a lot of cigarette smoke from other people smoking: Often. Alcohol consumption encompasses diagnoses-secondary ICD10: Z72.1 Alcohol use and the frequency of alcohol intake. Genetic variants associated with smoking and alcohol consumption were obtained from the IEU Open GWAS project and subsequently selected as instrumental variables (IVs). The corresponding variants associated with AF were also retrieved from the IEU Open GWAS project. The primary MR method utilized was the inverse-variance weighted (IVW). To assess the robustness of our results, multiple supplementary methods were utilized, including the weighted median (WM), MR-Egger regression, MR-PRESSO, MR-Egger intercept test, and the leave-one-out method. A reverse MR analysis was also conducted to determine the potential existence of reverse causality. Genetic predictions indicate a causal relationship between active smoking (current tobacco smoking, P-val = 0.019, OR: 1.413, 95% CI = 1.058-1.888; ever smoked, P-val = 0.049, OR: 1.355, 95% CI = 1.001-1.834; light smokers, P-val = 0.001, OR: 1.444, 95% CI = 1.154-1.806) and AF. No causal association was found between secondhand smoke exposure, alcohol consumption phenotypes, and AF. Additionally, the reverse MR analysis did not reveal any evidence of reverse causality from AF to active smoking. This study provides MR evidence supporting a causal association between active smoking and AF. The significance of smoking cessation is underscored by its potential to prevent or mitigate the risk of AF. Furthermore, the impact of secondhand smoke exposure and alcohol consumption on AF, as well as the causality among these factors, warrants further investigation.

Association of single and multiple cardiometabolic diseases with atrial fibrillation: a prospective cohort study

BACKGROUND

Individual cardiometabolic diseases (CMDs) increase atrial fibrillation (AF) risk; however, whether multiple CMDs exert a cumulative effect on AF risk remains unclear. Our objective was to examine the link between coexisting CMDs and AF, as well as their cumulative impact.

METHODS

This UK Biobank-based prospective cohort study included data from participants with information related to CMDs and AF. The assessment of CMDs and AF was based on participants' self-reported medical histories and electronic health records. Cox proportional hazard regression models were employed to analyse the link between the number of CMDs and AF and to determine the cumulative effect of multiple CMDs. Further, we performed stratified analyses and adjusted for confounding factors.

RESULTS

The study included 308 916 participants. The risk of AF was substantially associated with varying numbers of CMDs after multivariable adjustment in comparison to the reference group (all p<0.001). In the fully adjusted model, participants with 1, 2 and ≥3 CMDs exhibited elevated risks of 54% (HR: 1.54, 95% CI 1.48 to 1.59), 104% (HR: 2.04, 95% CI 1.94 to 2.15) and 212% (HR: 3.12, 95% CI 2.87 to 3.38), respectively. A significant cumulative dose-response relationship was noted between the number of CMDs and AF risk (HR: 1.45, 95% CI 1.42 to 1.48, p<0.001). A consistent dose-dependent cumulative relationship was observed in both stratified and sensitivity analyses.

CONCLUSIONS

Multiple CMDs increased AF risk and exhibited a significant cumulative effect based on the number of CMDs.

Atrial Fibrillation as an Independent Predictor of Myocardial Ischemia

Background and Objectives: Atrial fibrillation (AF) and coronary artery disease (CAD) are highly prevalent cardiovascular conditions. This study investigated the role of AF in myocardial ischemia, as assessed with myocardial perfusion imaging (MPI), in patients with suspected stable CAD. Materials and Methods: Our retrospective study included 259 individuals with a negative medical history of CAD who underwent 99mTc tetrofosmin MPI-single-photon emission computed tomography (SPECT)-for nonspecific symptoms to rule out stable CAD. Results: Of the enrolled patients, 90 MPIs were from patients with AF and 169 MPIs were from patients without AF. Semi-quantitative assessments of the extent and severity of perfusion abnormalities according to the summed stress score (SSS) and summed difference score (SDS) were conducted. It was found that patients with a history of AF, compared to patients without AF, were older (p < 0.001), of the male gender (p < 0.001), and had dyslipidemia (p = 0.019). History of AF was associated with increased SSS ≥ 4 (OR 5.12, p < 0.001) and SDS ≥ 2 (OR 2.66, p < 0.001). After adjustment for other risk factors, AF remained an independent predictor of myocardial ischemia on MPI-SPECT. Conclusions: In the current study, an association of AF with extensive perfusion defects in MPI-SPECT studies was found in patients with clinically suspected CAD independently of common cardiovascular risk factors.

Heart failure and microvascular dysfunction: an in-depth review of mechanisms, diagnostic strategies, and innovative therapies

Microvascular dysfunction (MVD) is increasingly recognized as a critical contributor to the pathogenesis of heart failure (HF), particularly in heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF). Coronary microvascular dysfunction (CMD) significantly impacts HFpEF by reducing coronary flow reserve and myocardial perfusion reserve, leading to adverse outcomes such as myocardial ischemia, diastolic dysfunction, and increased risk of major cardiovascular events, including atrial fibrillation. In HFrEF, microvascular impairment is linked to heightened oxidative stress, reduced nitric oxide production, and activation of the renin-angiotensin-aldosterone system, further driving disease progression and contributing to poor prognosis. Advancements in diagnostic techniques, such as positron emission tomography, cardiac magnetic resonance imaging, and biomarker analysis, improve our ability to assess CMD in heart failure patients, enabling earlier diagnosis and risk stratification. Emerging therapies, including sodium-glucose cotransporter-2 inhibitors, angiotensin receptor-neprilysin inhibitors, and endothelial-targeted interventions, enhance microvascular function and improve patient outcomes. The role of personalized medicine is becoming increasingly important, as individualized therapeutic approaches tailored to patient-specific microvascular abnormalities are essential for optimizing treatment effectiveness. This review underscores the pivotal role of MVD in HF. It highlights the urgent need for innovative therapeutic strategies and diagnostic tools to address this complex condition and improve clinical outcomes for HF patients.

Metabolic disorders after traumatic brain injury: a narrative review of systemic consequences

Traumatic brain injury (TBI) is characterized as a heterogeneous and pathological remodeling of brain physiology because of various external mechanisms, including blows, falls, and rapid acceleration and deceleration of the skull. Its pathophysiology consists of two distinct moments, beginning with a primary lesion resulting from the impact that evolves into a secondary lesion as biochemical and molecular mechanisms are activated. The severity and prognosis after TBI vary widely, depending on factors such as the site of the injury, the patient's premorbid history, and the severity of the injury, and can result in long-term sequelae impacting multiple organs and systems, with a reduction in the life expectancy of these individuals. A relevant point to be investigated is the correlation between metabolic syndrome (MS), defined as the combination of glucose intolerance, dyslipidemia, systemic arterial hypertension (SAH), and acute or chronic coronary heart disease, and the prognosis of these individuals after a TBI. Therefore, this review seeks to verify the correlation between the occurrence of MS in patients who have suffered TBI as a pre-existing comorbidity and whether it develops later, looking for evidence in studies based on animal models and cohort follow-ups of individuals who have suffered TBI in the short and long term to assess the prognosis presented.

The effect of integrated medical care on the daily life of patients with coronary heart disease

This study aims to explore the impact of comprehensive medical care on the daily life of patients with coronary heart disease (CHD) and to evaluate its effectiveness in improving quality of life, alleviating symptoms, and reducing the risk of cardiac events. A new comprehensive medical care scheme combining Traditional Chinese Medicine nursing differentiation, collaborative nursing interventions, and specialized community care was proposed. Patients with CHD were recruited as study subjects. Data were collected via questionnaires and interviews to assess the real-world impact of comprehensive medical care on the daily lives of patients. Significant improvements were observed in the observation group across multiple metrics. Baseline characteristics between the 2 groups showed no significant differences initially. Post-intervention, the observation group demonstrated significant improvements in left ventricular ejection fraction and self-assessment of stress (SAS), with left ventricular ejection fraction values increasing to 53.8% compared to 47.2% in the control group, and SAS scores decreasing markedly (P < .05). Additionally, the Disease Severity Index (DSI) indicated a significant reduction in disease severity in the observation group compared to a nonsignificant change in the control group (P > .05). Quality of life, assessed via MacNew and activities of daily living scores, also improved significantly post-intervention in the observation group compared to the control group (P < .05). Furthermore, the observation group exhibited a lower incidence of myocardial ischemia, myocardial infarction, and thrombosis over a 3-year period, with patient satisfaction significantly higher in the observation group (90% reported perfect contentment) compared to the control group (70% reported perfect contentment; P < .001). These findings suggest that the comprehensive nursing care approach significantly enhances cardiac function, quality of life, and patient satisfaction in CHD patients.

Pathophysiology, Diagnosis, and Management of Coronary Artery Disease in the Setting of Atrial Fibrillation

Atrial fibrillation (AF) and coronary artery disease are frequently associated and, when so, lead to a grim prognosis. Recent studies suggest the presence of interconnected pathophysiological pathways between the 2 conditions that can promote and aggravate each other, igniting a vicious cycle. Notwithstanding, in contrast with the attention dedicated to the management of antithrombotic treatment, research on other aspects of coronary artery disease in AF is only recently gaining traction. The clinical impact of correct assessment of coronary artery stenosis in AF is especially high, due to the antithrombotic therapy imposed by both AF and coronary stenting. Until recently, an in-depth characterization of coronary microcirculation in AF was lacking. However, contemporary studies indicate that coronary microvascular dysfunction is a frequent encounter in AF, possibly explaining the ischemic symptoms even in the absence of obstructive coronary artery disease and interfering with the use of pressure-based indices to evaluate the hemodynamic significance of coronary artery stenosis. This comprehensive review addresses our current knowledge on coronary physiology in AF and its repercussion on the invasive management of coronary artery disease in this setting.

Sex differences in patients with atrial fibrillation and acute coronary syndrome or undergoing PCI: a real-world study

BACKGROUND

In patients with acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI), female patients have a worse short-term prognosis than male patients has been consistently concluded in many studies. However, the impact of sex differences on long-term prognosis remains uncertain. Additionally, women are underrepresented in clinical trials exploring optimal antithrombotic strategies in patients with atrial fibrillation (AF) and ACS or PCI. To bridge this gap, this study aimed to investigate sex differences in clinical characteristics, treatment, and long-term clinical outcomes in patients with AF and ACS or PCI.

PATIENTS AND METHODS

This study included a total of 1237 patients with AF and ACS and 539 patients with AF and stable coronary artery disease (SCAD) who underwent PCI at the Fuwai Hospital of the Chinese Academy of Medical Sciences from January 2017 to December 2019. Patients were followed up until the end of 2021 to observe the occurrence of major adverse cardiovascular events (MACE). The relationship between sex and MACE was evaluated using Cox regression models and Kaplan-Meier's survival curves.

RESULTS

In patients with AF and ACS, multivariable COX regression analysis revealed that female patients were independently associated with a higher risk of MACE (HR = 1.45, 95% CI 1.11-1.89, p = .006). However, in AF patients with SCAD who underwent PCI, the analysis showed that female patients were not independently associated with MACE risk (HR = 1.12, 95% CI 0.62-2.03, p = .717).

CONCLUSIONS

In patients with AF and ACS, females have a significantly higher risk of long-term MACE compared to males. However, among patients with AF and SCAD who underwent PCI, there was no significant difference in long-term MACE risk between males and females.

A dynamic nomogram for predicting in-hospital major adverse cardiovascular and cerebrovascular events in patients with both coronary artery disease and atrial fibrillation: a multicenter retrospective study

BACKGROUND AND OBJECTIVE

Patients with both coronary artery disease (CAD) and atrial fibrillation (AF) are at a high risk of major adverse cardiovascular and cerebrovascular events (MACCE) during hospitalization. Accurate prediction of MACCE can help identify high-risk patients and guide treatment decisions. This study was to elaborate and validate a dynamic nomogram for predicting the occurrence of MACCE during hospitalization in Patients with CAD combined with AF.

METHODS

A total of 3550 patients with AF and CAD were collected. They were randomly assigned to a training group and a validation group in a ratio of 7 : 3. Univariate and multivariate analyses were utilized to identify risk factors ( P  < 0.05). To avoid multicollinearity and overfit of the model, the least absolute shrinkage and selection operator was conducted to further screen the risk factors. Calibration curves, receiver operating characteristic curves, and decision curve analyses are employed to assess the nomogram. For external validation, a cohort consisting of 249 patients was utilized from the Medical Information Mart for Intensive Care IV Clinical Database, version 2.2.

RESULTS

Eight indicators with statistical differences were screened by univariate analysis, multivariate analysis, and the least absolute shrinkage and selection operator method ( P  < 0.05). The prediction model based on eight risk factors demonstrated good prediction performance in the training group, with an area under the curve (AUC) of 0.838. This performance was also maintained in the internal validation group (AUC = 0.835) and the external validation group (AUC = 0.806). Meanwhile, the calibration curve indicates that the nomogram was well-calibrated, and decision curve analysis revealed that the nomogram exhibited good clinical utility.

CONCLUSION

The nomogram we constructed may aid in stratifying the risk and predicting the prognosis for patients with CAD and AF.

Correlation among anxiety and depression, fear of disease progression, and social support in coronary heart disease

BACKGROUND

The mental well-being of individuals with coronary heart disease (CHD) during the intensive care unit (ICU) transition period is a multifaceted and significant concern. In this phase, the individuals might encounter psychological challenges like anxiety and depression, which can impede their recuperation and potentially have lasting effects on their health.

AIM

To investigate the correlation among psychological factors in CHD patients in the ICU transition period.

METHODS

A questionnaire survey was conducted with 119 patients admitted to the ICU after coronary artery bypass grafting between March and December 2023. Variations in Hamilton Anxiety Scale (HAMA) and Hamilton Depression Scale (HAMD), Fear of Progression Questionnaire-Short Form (Fop-Q-SF), and Social Support Rating Scale (SSRS) were collected and analyzed among diverse populations. We used Pearson's correlation analysis to examine the correlation. Multiple linear regression analysis was used to explore whether these indicators influenced depression and anxiety in the patients.

RESULTS

The total scores for anxiety, depression, fear of disease progression, and social support were (7.50 ± 1.41) points, (8.38 ± 1.62) points, (35.19 ± 8.14) points, and (36.34 ± 7.08) points, respectively (P < 0.05). Multivariate regression analysis showed that both the level of disease progression and social support affected the level of postoperative depression and anxiety in patients.

CONCLUSION

The anxiety and depression levels were positively related to each dimension of phobia disease progression and negatively related to each dimension of social support among patients with CHD.

Integrated untargeted/targeted metabolomics identifies a putative oxylipin signature in patients with atrial fibrillation and coronary heart disease

Background and Objective

Atrial fibrillation (AF) and coronary heart disease (CHD) are closely related to metabolic dysregulation. However, the metabolic characteristics of AF patients with concomitant CHD remain unclear. The aims of this study were to elucidate the metabolic profiles of patients with AF and CHD to seek new therapeutic targets and related factors of AF combined with CHD.

Methods

Untargeted metabolomics and targeted oxylipins profiling were performed to characterize the serum metabolome landscape of patients with AF, CHD, and AF comorbid CHD.

Results

The serum metabolic fingerprints of patients with AF comorbid CHD were significantly differentiated from normal controls (NC) and individuals with AF or CHD alone, and the differentiated metabolites dominated by a variety of lipid alterations in the phospholipid and fatty acid metabolism. Furthermore, the targeted profiles of oxylipins demonstrated that the levels of arachidonic acid derivatives including prostaglandins, leukotrienes, hydroxy-docosahexaenoic acids, hydroxy-eicostetraenoic acids and hydroxy-eicosatrienoic acids in patients with AF and CHD were significantly different from those in the NC, AF, and CHD groups. Several prostaglandins were positively associated with echocardiographic indicators of myocardial remodeling.

Conclusions

This study updates metabolic insights of AF and CHD and provides potential therapeutic targets for preventing or treating AF comorbid CHD.

Association of Angina, Myocardial Infarction and Atrial Fibrillation-A Bidirectional Mendelian Randomization Study

Aims/Background Coronary heart disease (CHD) and atrial fibrillation (AF) exhibit a close relationship, yet the existing body of research predominantly relies on observational study methodologies, posing challenges in establishing causal relationships. The objective of our study is to investigate the causal linkages between coronary atherosclerosis (CAAs), angina pectoris, myocardial infarction (MI), and AF. Methods This study utilizes a two-sample Mendelian randomization (TSMR) methodology, leveraging genetic variation as a means of evaluating causality. Mendelian randomization is grounded in three primary assumptions: (1) the genetic variant is linked to the exposure, (2) the genetic variant is independent of confounding factors, and (3) the genetic variant influences the outcome solely through the exposure. Results The results of our study suggest a genetic predisposition in which CAAs, angina, and MI may enhance susceptibility to AF, while AF may reciprocally elevate the risk of CAAs. Conclusion In light of these findings, it is recommended that patients with CHD undergo regular cardiac rhythm monitoring, and that patients with AF receive anticoagulant and antiplatelet therapy whenever feasible. This study posits a practical implication for clinical practice.

Role of Gut Microbial Metabolites in Cardiovascular Diseases-Current Insights and the Road Ahead

Cardiovascular diseases (CVDs) are the leading cause of premature morbidity and mortality globally. The identification of novel risk factors contributing to CVD onset and progression has enabled an improved understanding of CVD pathophysiology. In addition to the conventional risk factors like high blood pressure, diabetes, obesity and smoking, the role of gut microbiome and intestinal microbe-derived metabolites in maintaining cardiovascular health has gained recent attention in the field of CVD pathophysiology. The human gastrointestinal tract caters to a highly diverse spectrum of microbes recognized as the gut microbiota, which are central to several physiologically significant cascades such as metabolism, nutrient absorption, and energy balance. The manipulation of the gut microbial subtleties potentially contributes to CVD, inflammation, neurodegeneration, obesity, and diabetic onset. The existing paradigm of studies suggests that the disruption of the gut microbial dynamics contributes towards CVD incidence. However, the exact mechanistic understanding of such a correlation from a signaling perspective remains elusive. This review has focused upon an in-depth characterization of gut microbial metabolites and their role in varied pathophysiological conditions, and highlights the potential molecular and signaling mechanisms governing the gut microbial metabolites in CVDs. In addition, it summarizes the existing courses of therapy in modulating the gut microbiome and its metabolites, limitations and scientific gaps in our current understanding, as well as future directions of studies involving the modulation of the gut microbiome and its metabolites, which can be undertaken to develop CVD-associated treatment options. Clarity in the understanding of the molecular interaction(s) and associations governing the gut microbiome and CVD shall potentially enable the development of novel druggable targets to ameliorate CVD in the years to come.

Association of Diagonal Earlobe Crease with Risk of Atrial Fibrillation in Stable Patients with Coronary Artery Disease

Background: Diagonal earlobe crease (DELC) is a proposed visible predictor of coronary artery disease (CAD). However, studies on the association between atrial fibrillation (AF) and DELC are lacking. This study evaluated the association between DELC and the incidence of AF in patients with CAD. Methods: A total of 669 participants aged <65 years (mean, 53.8 ± 7.5 years) diagnosed with CAD and without AF were evaluated for the presence of DELC. The study outcome was the incidence of AF based on the presence of DELC. The study period was planned for 60 months with a minimum follow-up period of 12 months. Results: Herein, the incidence of DELC was 10.8%. During the follow-up period (44.6 ± 14.9 months), the incidences of AF development were 16.4% and 8.4% in DELC and non-DELC groups, respectively. Kaplan-Meier analysis revealed that the occurrence of AF was significantly higher in the DELC group than in the non-DELC group (log-rank test, p = 0.02). Compared with patients without DELC, patients with DELC had a high risk of AF development (adjusted hazard ratio = 1.88, 95% confidence interval = 1.01-3.53). Conclusions: DELC is associated with an increased risk of AF in patients with CAD. These findings may aid in the detection of AF in patients with CAD.

Outcomes of newly diagnosed atrial fibrillation in patients with acute coronary syndromes

BACKGROUND

Acute coronary syndrome (ACS) is frequently accompanied by newly diagnosed atrial fibrillation (AF).

AIMS

We aimed to compare the risk of major adverse cardiovascular events (MACE) in ACS patients presenting with known, newly diagnosed, or no AF.

METHODS

In our multicentre, prospective registry study, we included patients with confirmed ACS. Patients are classified as having known, newly diagnosed or no AF. Newly diagnosed AF is subdivided according to the duration of the episode, time of onset, post-coronary artery bypass graft (CABG) or spontaneous occurrence, and treatment with oral anticoagulants (OAC). The primary endpoint is MACE at 1 year. Key secondary endpoints include ischaemic stroke and bleeding complications.

RESULTS

Amongst 4,433 patients with confirmed ACS, 3,598 (81.2%) had no AF, 438 (9.9%) had newly diagnosed AF, and 397 (9.0%) had known AF. The rates of OAC treatment at discharge were 53.4% in patients with newly diagnosed AF and 89.2% in patients with known AF. After adjusting for baseline imbalances, only new AF was independently associated with increased rates of MACE, whereas known AF was not (hazard ratio [HR] 1.52, 95% confidence interval [CI]: 1.19-1.90 and HR 0.93, 95% CI: 0.70-1.23). For ACS patients with newly diagnosed AF, episodes lasting >24 hours were associated with a higher risk of MACE compared to episodes <24 hours (HR 1.99, 95% CI: 1.36-2.93). Episodes of new AF occurring post-CABG had more favourable outcomes compared to spontaneously occurring new AF (HR for MACE 0.52, 95% CI: 0.31-0.86). OAC treatment rates were higher in the new AF subcategories with higher rates of MACE and ischaemic stroke.

CONCLUSIONS

Newly diagnosed AF in ACS patients was associated with higher rates of MACE and ischaemic stroke compared to ACS patients without or with known AF. Among the ACS patients with new AF, an episode lasting >24 hours was associated with worse outcomes than shorter episodes, while post-CABG occurrence of AF showed relatively better outcomes compared to spontaneously occurring AF. Only 53% of new AF patients were discharged on OAC therapy versus 89% with known AF.

The effect of antiarrhythmic medications on the risk of cardiovascular outcomes in patients with atrial fibrillation and coronary artery disease

BACKGROUND

While current guidelines recommend amiodarone and dronedarone for rhythm control in patients with atrial fibrillation (AF) and coronary artery disease (CAD), there was no comparative study of antiarrhythmic drugs (AADs) on the cardiovascular outcomes in general practice.

METHODS

This study included patients with AF and CAD who received their first prescription of amiodarone, class Ic AADs (flecainide, propafenone), dronedarone or sotalol between January 2016 and December 2020. The primary outcome was a composite of hospitalization for heart failure (HHF), stroke, acute myocardial infarction (AMI), and cardiovascular death. We used Cox proportional regression models, including with inverse probability of treatment weighting (IPTW), to estimate the relationship between AADs and cardiovascular outcomes.

RESULTS

Among the AF cohort consisting of 8752 patients, 1996 individuals had CAD, including 477 who took dronedarone and 1519 who took other AADs. After a median follow-up of 38 months, 46.3% of patients who took dronedarone and 54.4% of patients who took other AADs experienced cardiovascular events. Compared to dronedarone, the use of other AADs was associated with increased cardiovascular events after adjusting for covariates (hazard ratio [HR] 1.531, 95% confidence interval [CI] 1.112-2.141, p = 0.023) and IPTW (HR 1.491, 95% CI 1.174-1.992, p = 0.012). The secondary analysis showed that amiodarone and class Ic drugs were associated with an increased risk of HHF. The low number of subjects in the sotalol group limits data interpretation.

CONCLUSION

For patients with AF and CAD, dronedarone was associated with better cardiovascular outcomes than other AADs. Amiodarone and class Ic AADs were associated with a higher risk of cardiovascular events, particularly HHF.

Rate control or rhythm control in patients with atrial fibrillation and acute coronary syndrome or percutaneous coronary intervention

Background

Restoring and maintaining sinus rhythm in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI) has been studied in clinical trials to reduce symptoms and improve quality of life. Limited data exist on the effectiveness of rate or rhythm control therapy in these patients.

Methods

Consecutive patients with AF and ACS or referred for PCI were prospectively recruited in Fuwai Hospital during 2017-2020. The primary endpoints were all-cause death and major adverse cardiovascular and cerebrovascular events (MACCEs), including cardiovascular mortality, myocardial infarction, ischemic stroke, non-central nervous system embolism and ischemia-driven revascularization. Kaplan-Meier curves and Cox regressions were performed to evaluate the association between rhythm/rate control and subsequent outcomes. For the primary endpoints, we used the Benjamini-Hochberg correction for multiple comparisons.

Results

A total of 1499 patients with AF and ACS or undergoing PCI were included, with a median follow-up of 34.7 months. Compared to non-rate control, rate control strategy reduced the risk of subsequent MACCEs (adjusted HR, 0.320; 95 % CI 0.220-0.466; p <0.001; *p <0.002) and all-cause death (adjusted HR, 0.148; 95 % CI 0.093-0.236; p <0.001; *p <0.002). Similar trends were observed across all predefined subgroups (p <0.001). In the final multivariate model, rhythm control was not associated with a lower subsequent MACCEs but significantly improved all-cause mortality compared to non-rhythm control (adjusted HR, 0.546; 95 % CI 0.313-0.951; p =0.033; *p =0.044).

Conclusions

In this real-world study, rate control strategy was associated with lower risk of MACCEs and all-cause death in AF and ACS or undergoing PCI. Besides, management with rhythm control strategy may improve all-cause mortality.

Identification of potential biomarkers for atrial fibrillation and stable coronary artery disease based on WGCNA and machine algorithms

BACKGROUND

Patients with atrial fibrillation (AF) often have coronary artery disease (CAD), but the biological link between them remains unclear. This study aims to explore the common pathogenesis of AF and CAD and identify common biomarkers.

METHODS

Gene expression profiles for AF and stable CAD were downloaded from the Gene Expression Omnibus database. Overlapping genes related to both diseases were identified using weighted gene co-expression network analysis (WGCNA), followed by functional enrichment analysis. Hub genes were then identified using the machine learning algorithm. Immune cell infiltration and correlations with hub genes were explored, followed by drug predictions. Hub gene expression in AF and CAD patients was validated by real-time qPCR.

RESULTS

We obtained 28 common overlapping genes in AF and stable CAD, mainly enriched in the PI3K-Akt, ECM-receptor interaction, and relaxin signaling pathway. Two hub genes, COL6A3 and FKBP10, were positively correlated with the abundance of MDSC, plasmacytoid dendritic cells, and regulatory T cells in AF and negatively correlated with the abundance of CD56dim natural killer cells in CAD. The AUCs of COL6A3 and FKBP10 were all above or close to 0.7. Drug prediction suggested that collagenase clostridium histolyticum and ocriplasmin, which target COL6A3, may be potential drugs for AF and stable CAD. Additionally, COL6A3 and FKBP10 were upregulated in patients with AF and CAD.

CONCLUSION

COL6A3 and FKBP10 may be key biomarkers for AF and CAD, providing new insights into the diagnosis and treatment of this disease.

Burden of cardiometabolic disorders and lifetime risk of new-onset atrial fibrillation among men and women: the Rotterdam Study

AIMS

To examine the association between the burden of cardiometabolic disorders with new-onset atrial fibrillation (AF) and lifetime risk of AF incidence among men and women.

METHODS AND RESULTS

Four thousand one hundred and one men and 5421 women free of AF at baseline (1996-2008) from the population-based Rotterdam Study were included. Sex-specific Cox proportional-hazards regression models were used to assess the association between the burden of cardiometabolic disorders and risk of new-onset AF. The remaining lifetime risk for AF was estimated at index ages of 55, 65, and 75 years up to age 108. Mean age at baseline was 65.5 ± 9.4 years. Median follow-up time was 12.8 years. In the fully adjusted model, a stronger association was found between a larger burden of cardiometabolic disorders and incident AF among women [hazard ratio (HR): 1.33% and 95% conference interval (CI): 1.22-1.46], compared to men [1.18 (1.08-1.29)] (P for sex-interaction <0.05). The lifetime risk for AF significantly increased with the number of cardiometabolic disorders among both sexes. At an index age of 55 years, the lifetime risks (95% CIs) for AF were 27.1% (20.8-33.4), 26.5% (22.8-30.5), 29.9% (26.7-33.2), 30.8% (25.7-35.8), and 33.3% (23.1-43.6) among men, for 0, 1, 2, 3, and ≥4 comorbid cardiometabolic disorders. Corresponding risks were 15.8% (10.5-21.2), 23.0% (19.8-26.2), 29.7% (26.8-32.6), 26.2% (20.8-31.6), and 34.2% (17.3-51.1) among women.

CONCLUSION

We observed a significant combined impact of cardiometabolic disorders on AF risk, in particular among women. Participants with cardiometabolic multimorbidity had a significantly higher lifetime risk of AF, especially at a young index age.

Network pharmacology analysis and experimental verification of the antithrombotic active compounds of trichosanthis pericarpium (Gualoupi) in treating coronary heart disease

ETHNOPHARMACOLOGICAL RELEVANCE

Trichosanthis pericarpium (TP; Gualoupi, pericarps of Trichosanthes kirilowii Maxim) has been used in traditional Chinese medicine (TCM) to reduce heat, resolve phlegm, promote Qi, and clear chest congestion. It is also an essential herbal ingredient in the "Gualou Xiebai" formula first recorded by Zhang Zhongjing (from the Eastern Han Dynasty) in the famous TCM classic "Jin-Guì-Yào-Lüe" for treating chest impediments. According to its traditional description, Gualou Xiebai is indicated for symptoms of chest impediments, which correspond to coronary heart diseases (CHD).

AIM OF THE STUDY

This study aimed to identify the antithrombotic compounds in Gualoupi for the treatment of CHD.

MATERIALS AND METHODS

A CHD rat model was established with a combination of high-fat diet and isoproterenol hydrochloride (ISO) administration via subcutaneous multi-point injection in the back of the neck. This model was used to evaluate the antithrombotic effect of two mainstream cultivars of TP ("HaiShi GuaLou" and "WanLou") by analyzing the main components and their effects. Network pharmacology, molecular docking-based studies, and a zebrafish (Danio rerio) thrombosis model induced by phenylhydrazine was used to validate the antithrombosis components of TP.

RESULTS

TP significantly reduced the body weight of the CHD rats, improved myocardial ischemia, and reduced collagen deposition and fibrosis around the infarcted tissue. It reduced thrombosis in a dose-dependent manner and significantly reduced inflammation and oxidative stress damage. Cynaroside, isoquercitrin, rutin, citrulline, and arginine were identified as candidate active TP compounds with antithrombotic effects. The key potential targets of TP in thrombosis treatment were initially identified by molecular docking-based analysis, which showed that the candidate active compounds have a strong binding affinity to the potential targets (protein kinase C alpha type [PKCα], protein kinase C beta type [PKCβ], von Willebrand factor [vWF], and prostaglandin-endoperoxide synthase 1 [PTGS1], fibrinogen alpha [Fga], fibrinogen beta [Fgb], fibrinogen gamma [Fgg], coagulation factor II [F2], and coagulation factor VII [F7]). In addition, the candidate active compounds reduced thrombosis, improved oxidative stress damage, and down-regulated the expression of thrombosis-related genes (PKCα, PKCβ, vWF, PTGS1, Fga, Fgb, Fgg, F2, and F7) in the zebrafish model.

CONCLUSION

Cynaroside, isoquercitrin, rutin, citrulline, and arginine were identified as the active antithrombotic compounds of TP used to treat CHD. Mechanistically, the active compounds were found to be involved in oxidative stress injury, platelet activation pathway, and complement and coagulation cascade pathways.

Effect of care bundles based on importance degree analysis on postoperative comorbid state, coping style and disease management ability of patients with coronary heart disease

Coronary heart disease (CHD) is a significant global health concern, particularly among the elderly. While care bundles present a comprehensive strategy for clinical disorders, their application in CHD rehabilitation remains understudied. This research addresses this gap by investigating the effectiveness of care bundles in CHD patients. By analyzing important performance degrees, we aim to contribute valuable insights to bridge existing knowledge deficiencies. Our study strives to establish a theoretical foundation for the broader implementation of care bundles, potentially improving the quality of care and patient outcomes in CHD rehabilitation. This is a retrospective study. 360 patients with CHD who were admitted to our hospital from January 2019 to October 2022 were enrolled in this retrospective study and divided into the observation group (n = 180) and control group (n = 180) according to the different care that they received. All cases were given routine nursing after CHD operation, and the observation group was given care bundles on the basis of the analysis of important performance degrees. The perioperative indexes, self-management ability score, depression, anxiety, stress scale (DASS), coping styles, medical compliance and the incidence of complications were compared between the 2 groups. Aftercare, the time of hospitalization and getting out-of-bed in the observation group was notably shorter (P < .05). Aftercare, the scores of self-management ability and related dimensions in the observation group were notably higher (P < .05). After care, the score of depression (P < .001), anxiety (P = .003) and stress (P = .017) of the observation group were notably lower. Aftercare, the observation group face score was significantly higher than the control group (P = .005), while the observation group avoidance score (P = .028) and yield score (P < .001) were significantly lower than the control group scores. Aftercare, the compliance behavior of patients in the observation group was notably better (P = .013). Aftercare, the incidence of complications in the observation group was notably lower (P = .039). Care bundles based on the degree of importance analysis can play a positive role in postoperative comorbid state, coping styles and self-management ability of patients with CHD, which can improve the rehabilitation effects on patients.

Prevalence and characteristics of patent foramen ovale in a sample of Egyptian population: a computed tomography study

BACKGROUND

The reported prevalence of patent foramen ovale (PFO) in the general population is variable. It ranges between 8.6 and 42% according to the population studied and the imaging technique used. We aim to prospectively assess the prevalence and characteristics of PFO and interatrial septum (IAS) abnormalities as well as the related clinical manifestations in a sample of Egyptian population.

RESULTS

This study comprised 1000 patients who were referred for CT coronary angiography (CTCA). Mean age was 52.5 ± 10.9 years. The prevalence of PFO among the studied population was 16.3%; closed PFO (grade I) 44.2%, open PFO (grade II) 50.9%, and open PFO with jet (grade III) 4.9%. Anatomical high-risk PFO features-defined as the presence of at least 2 or more of the following (diameter ≥ 2 mm, length ≥ 10 mm, septal aneurysm "ASA", or redundant septum)-were found in 51.5% of PFOs' population. Other IAS abnormalities as redundant septum (8.6%), ASA (5.3%), Bachmann's bundle (4.5%), microaneurysm (2.6%), and atrial septal defect (ASD) (0.4%) were detected. There was a lower rate of coexistence of ASA with PFO (p = 0.031). Syncope was significantly higher in patients with PFO compared to those without PFO (6.7% vs. 1.6%, p = 0.001). Stroke, transient ischaemic attacks (TIA), and dizziness were similar in both groups. TIA, dizziness, and syncope were significantly higher in patients with IAS abnormalities including PFO compared to those without IAS abnormalities. Syncope was also significantly higher in PFO with high-risk anatomical features compared to those with non-high-risk PFO population (p = 0.02).

CONCLUSION

The prevalence of PFO in our study was approximately 16.3%, almost half of them showed anatomical high-risk features for stroke. Dizziness, syncope and TIA were significantly higher in patients with IAS abnormalities including PFO.

Associations of lipids and lipid-modifying drug target genes with atrial fibrillation risk based on genomic data

BACKGROUND

The causal associations of lipids and the drug target genes with atrial fibrillation (AF) risk remain obscure. We aimed to investigate the causal associations using genetic evidence.

METHODS

Mendelian randomization (MR) analyses were conducted using summary-level genome-wide association studies (GWASs) in European and East Asian populations. Lipid profiles (low-density lipoprotein cholesterol, triglyceride, and lipoprotein[a]) and lipid-modifying drug target genes (3-hydroxy-3-methylglutaryl-CoA reductase, proprotein convertase subtilisin/kexin type 9, NPC1-like intracellular cholesterol transporter 1, apolipoprotein C3, angiopoietin-like 3, and lipoprotein[a]) were used as exposures. AF was used as an outcome. The inverse variance weighted method was applied as the primary method. Summary-data-based Mendelian randomization analyses were performed for further validation using expression quantitative trait loci data. Mediation analyses were conducted to explore the indirect effect of coronary heart disease.

RESULTS

In the European population, MR analyses demonstrated that elevated levels of lipoprotein(a) increased AF risk. Moreover, analyses focusing on drug targets revealed that the genetically proxied target gene LPA, which simulates the effects of drug intervention by reducing lipoprotein(a), exhibited an association with AF risk. This association was validated in independent datasets. There were no consistent and significant associations observed for other traits when analyzed in different datasets. This finding was also corroborated by Summary-data-based Mendelian randomization analyses between LPA and AF. Mediation analyses revealed that coronary heart disease plays a mediating role in this association. However, in the East Asian population, no statistically significant evidence was observed to support these associations.

CONCLUSIONS

This study provided genetic evidence that Lp(a) may be a causal factor for AF and that LPA may represent a promising pharmacological target for preventing AF in the European population.

Association Between Remnant Cholesterol and Risk of Incident Atrial Fibrillation: Population-Based Evidence From a Large-Scale Prospective Cohort Study

BACKGROUND

Evidence for the relationship between remnant cholesterol (RC) and incident atrial fibrillation (AF) risk remains sparse and limited.

METHODS AND RESULTS

Participants were enrolled between 2006 and 2010 and followed up to 2021. The multivariable Cox proportional hazards model was used to examine the relationship between RC quartiles and risk of incident AF. Subgroup analyses and sensitivity analyses were performed to explore the potential modification of the association and the robustness of the main findings. A total of 422 316 participants (mean age, 56 years; 54% women) were included for analyses. During a median follow-up of 11.9 years (first quartile-third quartile, 11.6-13.2 years), there were 24 774 AF events documented with an incidence of 4.92 events per 1000 person-years (95% CI, 4.86-4.98). Participants in higher RC quartiles had a lower risk of incident AF than those in the lowest quartile (first quartile): hazard ratio (HR)=0.96 (95% CI, 0.91-1.00) for second quartile; HR=0.92 (95% CI, 0.88-0.96) for third quartile; and HR=0.85 (95% CI, 0.81-0.89) for fourth quartile (P for trend <0.001). The association between RC quartiles and risk of incident AF was stronger in participants aged ≥65 years, in men, and in participants without history of diabetes when compared with control groups (P<0.001 for interaction).

CONCLUSIONS

On the basis of data from this large-scale prospective cohort study, elevated RC was associated with a lower risk of incident AF.

Identification of necroptosis-related diagnostic biomarkers in coronary heart disease

Background

The implication of necroptosis in cardiovascular disease was already recognized. However, the molecular mechanism of necroptosis has not been extensively studied in coronary heart disease (CHD).

Methods

The differentially expressed genes (DEGs) between CHD and control samples were acquired in the GSE20681 dataset downloaded from the GEO database. Key necroptosis-related DEGs were captured and ascertained by bioinformatics analysis techniques, including weighted gene co-expression network analysis (WGCNA) and two machine learning algorithms, while single-gene gene set enrichment analysis (GSEA) revealed their molecular mechanisms. The diagnostic biomarkers were selected via receiver operating characteristic (ROC) analysis. Moreover, an analysis of immune elements infiltration degree was carried out. Authentication of pivotal gene expression at the mRNA level was investigated in vitro utilizing quantitative real-time PCR (qRT-PCR).

Results

A total of 94 DE-NRGs were recognized here, among which, FAM166B, NEFL, POLDIP3, PRSS37, and ZNF594 were authenticated as necroptosis-related biomarkers, and the linear regression model based on them presented an acceptable ability to different sample types. Following regulatory analysis, the ascertained biomarkers were markedly abundant in functions pertinent to blood circulation, calcium ion homeostasis, and the MAPK/cAMP/Ras signaling pathway. Single-sample GSEA exhibited that APC co-stimulation and CCR were more abundant, and aDCs and B cells were relatively scarce in CHD patients. Consistent findings from bioinformatics and qRT-PCR analyses confirmed the upregulation of NEFL and the downregulation of FAM166B, POLDIP3, and PRSS37 in CHD.

Conclusion

Our current investigation identified 5 necroptosis-related genes that could be diagnostic markers for CHD and brought a novel comprehension of the latent molecular mechanisms of necroptosis in CHD.

New-onset atrial fibrillation following arteriovenous fistula increases adverse clinical events in dialysis patients with end-stage renal disease

Background

End-stage renal disease (ESRD) patients have a high potential cardiovascular burden, and cardiovascular disease (CVD) is the leading cause of death in maintenance haemodialysis (MHD) patients. Arteriovenous fistula (AVF) is the preferred vascular access for MHD patients, but AVF significantly affects the haemodynamics of the cardiovascular system, leading to or exacerbating CVD, including atrial fibrillation (AF). This study aimed to evaluate the impact of AVF on cardiac function, especially of the left atrium (LA), in patients with ESRD and to further explore the relationship between AVF establishment and the occurrence of AF.

Methods

We selected 1,107 ESRD patients on haemodialysis using AVF and 550 patients with tunneled-cuffed catheters (TCC) admitted between January 2016 and December 2022 for follow-up to compare the rate of AF between the two groups. A total of 153 patients in the AVF group with complete information (clinical data, echocardiographic and biochemical indices, and other data) were enrolled and retrospectively analysed for risk factors for the development of AF and were followed up for adverse clinical outcomes (including all-cause death, cardiac death, readmission due to heart failure, and stroke).

Results

The incidence of new-onset AF was higher in the AVF group than the TCC group after dialysis access was established (16.30% vs. 5.08%, P < 0.001). Echocardiography showed that the LA anteroposterior diameter increased (P < 0.001) and the incidence of AF increased from 11.76% to 26.14% (P = 0.001) after AVF establishment. Multivariate logistic regression analysis showed that age and LA enlargement were independent risk factors for new-onset AF after AVF establishment (P < 0.05). Adverse clinical outcomes were more common in patients with AF than in patients without AF (P < 0.001). Multivariate Cox risk regression analysis suggested that new-onset AF (HR = 4.08, 95% CI: 2.00-8.34, P < 0.001) and left ventricular systolic dysfunction (HR = 2.42, 95% CI: 1.20-4.88, P = 0.01) after AVF establishment were independent risk factors for adverse clinical outcomes.

Conclusion

LA enlargement after AVF establishment is associated with a significant increase in the incidence of AF, in addition, AF which is as an important influential factor in patients with MHD combined other systemic diseases might increase adverse clinical events.

Clinical Trial Registration

(NCT06199609).

Coronary events in elderly patients with non-valvular atrial fibrillation: a prespecified sub-analysis of the ANAFIE registry

Real-world data on coronary events (CE) in elderly patients with atrial fibrillation (AF) are lacking in the direct oral anticoagulant era. This prespecified sub-analysis of the ANAFIE Registry, a prospective observational study in > 30,000 Japanese patients aged ≥ 75 years with non-valvular AF (NVAF), investigated CE incidence and risk factors. The incidence and risk factors for new-onset CE (a composite of myocardial infarction [MI] and cardiac intervention for coronary heart diseases other than MI), MI, and cardiac intervention for coronary heart diseases other than MI during the 2-year follow-up were assessed. Bleeding events in CE patients were also examined. Among 32,275 patients, the incidence rate per 100 patient-years was 0.48 (95% confidence interval (CI): 0.42-0.53) for CE during the 2-year follow-up, 0.20 (0.16-0.23) for MI, and 0.29 (0.25-0.33) for cardiac intervention for coronary heart diseases other than MI; that of stroke/systemic embolism was 1.62 (1.52-1.73). Patients with CE (n = 287) likely had lower creatinine clearance (CrCL) and higher CHADS2 and HAS-BLED scores than patients without CE (n = 31,988). Significant risk factors associated with new-onset CE were male sex, systolic blood pressure of ≥ 130 mmHg, diabetes mellitus (glycated hemoglobin ≥ 6.0%), CE history, antiplatelet agent use, and CrCL < 50 mL/min. Major bleeding incidence was significantly higher in patients with new-onset CE vs without CE (odds ratio [95% CI], 3.35 [2.06-5.43]). In elderly patients with NVAF, CE incidence was lower than stroke/systemic embolism incidence. New-onset CE (vs no CE) was associated with a higher incidence of major bleeding.Trial registration: UMIN000024006.

The Intersection of Atrial Fibrillation and Coronary Artery Disease in Middle Eastern Patients. Analysis from the Jordan Atrial Fibrillation Study

Background

There is a scarcity of clinical studies which evaluate the association of atrial fibrillation (AF) and coronary artery disease (CAD) in the Middle East. The aim of this study was to evaluate the impact of CAD on baseline clinical profiles and one-year outcomes in a Middle Eastern cohort with AF.

Methods

Consecutive AF patients evaluated in 29 hospitals and cardiology clinics were enrolled in the Jordan AF Study (May 2019-December 2020). Clinical and echocardiographic features, use of medications and one-year outcomes in patients with AF/CAD were compared to AF/no CAD patients.

Results

Of 2020 AF patients enrolled, 216 (10.7%) had CAD. Patients with AF/CAD were more likely to be men and had significantly higher prevalence of hypertension, diabetes, dyslipidemia, heart failure and chronic kidney disease compared to the AF/no CAD patients. They also had lower mean left ventricular ejection fraction and larger left atrial size. Mean CHA2DS2 VASc and HAS-BLED scores were higher in AF/CAD patients than those with AF/no CAD (4.3 ± 1.7 vs. 3.6 ± 1.8, p < 0.0001) and (2.0 ± 1.1 vs. 1.6 ± 1.1, p < 0.0001), respectively. Oral anticoagulant agents were used in similar rates in the two groups (83.8% vs. 82.9%, p = 0.81), but more patients with AF/CAD were prescribed additional antiplatelet agents compared to patients with AF/no CAD (73.7% vs. 41.5%, p < 0.0001). At one year, AF/CAD patients, compared to AF/no CAD patients had significantly higher hospitalization rate (39.4% vs. 29.2%, p = 0.003), more acute coronary syndrome and coronary revascularization (6.9% vs. 2.4%, p = 0.004), and higher all-cause mortality (18.5% vs. 10.9%, p = 0.002).

Conclusions

In this cohort of Middle Eastern patients with AF, one in 10 patients had CAD. The coexistence of AF and CAD was associated with a worse baseline clinical profile and one-year outcomes. Clinical study registration: the study is registered on clinicaltrials.gov (unique identifier number NCT03917992).

CT-Assessment of Epicardial Fat Identifies Increased Inflammation at the Level of the Left Coronary Circulation in Patients with Atrial Fibrillation

Background: Atrial fibrillation (AF) can often be triggered by an inflammatory substrate. Perivascular inflammation may be assessed nowadays using coronary computed tomography angiography (CCTA) imaging. The new pericoronary fat attenuation index (FAI HU) and the FAI Score have prognostic value for predicting future cardiovascular events. Our purpose was to investigate the correlation between pericoronary fat inflammation and the presence of AF among patients with coronary artery disease. Patients and methods: Eighty-one patients (mean age 64.75 ± 7.84 years) who underwent 128-slice CCTA were included in this study and divided into two groups: group 1 comprised thirty-six patients with documented AF and group 2 comprised forty-five patients without a known history of AF. Results: There were no significant differences in the absolute value of fat attenuation between the study groups (p > 0.05). However, the mean FAI Score was significantly higher in patients with AF (15.53 ± 10.29 vs. 11.09 ± 6.70, p < 0.05). Regional analysis of coronary inflammation indicated a higher level of this process, especially at the level of the left anterior descending artery (13.17 ± 7.91 in group 1 vs. 8.80 ± 4.75 in group 2, p = 0.008). Conclusions: Patients with AF present a higher level of perivascular inflammation, especially in the region of the left coronary circulation, and this seems to be associated with a higher risk of AF development.

Impact of missense TSBP1 variants on the susceptibility to coronary heart disease

BACKGROUND

A genome-wide association study has recognized C6orf10-BTNL2 polymorphism in coronary artery disease. The goal of this study was to explore the potential correlation of nine missense TSBP1 variants with coronary heart disease (CHD) risk in the Chinese Han population.

METHODS

Nine TSBP1 missense single nucleotide polymorphisms (SNPs) were selected for genotyping by the Agena MassARRAY platform. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to analyze the contribution of TSBP1 SNPs to CHD predisposition by logistic regression models adjusted by age, sex, drinking, and smoking. The correlation of TSBP1 variants with clinical data in CHD patients was examined by Kruskal-Wallis test.

RESULTS

rs9268368-C (p = 0.039, OR = 1.18, 95 % CI: 1.01-1.38) was related to an increased risk of CHD, while rs3749966-C (p = 0.032, OR = 0.49, 95 % CI: 0.25-0.96) and rs3129941-A (p = 0.011, OR = 0.74, 95 % CI: 0.59-0.93) might be protective factors against CHD occurrence in the Chinese Han population. We also observed the effects of demographic characteristics (age, sex, alcohol consumption, and smoking) and complications (hypertension and diabetes) on the interactive association of TSBP1 polymorphisms with CHD susceptibility. rs139993810 was related to the levels of high-density lipoprotein cholesterol (HDL-C, p = 0.030).

CONCLUSIONS

Our findings determined the association of TSBP1 rs9268368, rs3749966, and rs3129941 with CHD occurrence in the Chinese Han population, and highlighted the influence of demographic characteristics and complications on the interactive association of TSBP1 polymorphisms with CHD risk.

A proteomic analysis of atrial fibrillation in a prospective longitudinal cohort (AGES-Reykjavik study)

AIMS

Atrial fibrillation (AF) is associated with high risk of comorbidities and mortality. Our aim was to examine causal and predictive relationships between 4137 serum proteins and incident AF in the prospective population-based Age, Gene/Environment Susceptibility-Reykjavik (AGES-Reykjavik) study.

METHODS AND RESULTS

The study included 4765 participants, of whom 1172 developed AF. Cox proportional hazards regression models were fitted for 4137 baseline protein measurements adjusting for known risk factors. Protein associations were tested for replication in the Cardiovascular Health Study (CHS). Causal relationships were examined in a bidirectional, two-sample Mendelian randomization analysis. The time-dependent area under the receiver operating characteristic curve (AUC)-statistic was examined as protein levels and an AF-polygenic risk score (PRS) were added to clinical risk models. The proteomic signature of incident AF consisted of 76 proteins, of which 63 (83%) were novel and 29 (38%) were replicated in CHS. The signature included both N-terminal prohormone of brain natriuretic peptide (NT-proBNP)-dependent (e.g. CHST15, ATP1B1, and SVEP1) and independent components (e.g. ASPN, AKR1B, and LAMA1/LAMB1/LAMC1). Nine causal candidates were identified (TAGLN, WARS, CHST15, CHMP3, COL15A1, DUSP13, MANBA, QSOX2, and SRL). The reverse causal analysis suggested that most AF-associated proteins were affected by the genetic liability to AF. N-terminal prohormone of brain natriuretic peptide improved the prediction of incident AF events close to baseline with further improvements gained by the AF-PRS at all time points.

CONCLUSION

The AF proteomic signature includes biologically relevant proteins, some of which may be causal. It mainly reflects an NT-proBNP-dependent consequence of the genetic liability to AF. N-terminal prohormone of brain natriuretic peptide is a promising marker for incident AF in the short term, but risk assessment incorporating a PRS may improve long-term risk assessment.

Nanotechnology in coronary heart disease

Coronary heart disease (CHD) is one of the major causes of death and disability worldwide, especially in low- and middle-income countries and among older populations. Conventional diagnostic and therapeutic approaches have limitations such as low sensitivity, high cost and side effects. Nanotechnology offers promising alternative strategies for the diagnosis and treatment of CHD by exploiting the unique properties of nanomaterials. In this review, we use bibliometric analysis to identify research hotspots in the application of nanotechnology in CHD and provide a comprehensive overview of the current state of the art. Nanomaterials with enhanced imaging and biosensing capabilities can improve the early detection of CHD through advanced contrast agents and high-resolution imaging techniques. Moreover, nanomaterials can facilitate targeted drug delivery, tissue engineering and modulation of inflammation and oxidative stress, thus addressing multiple aspects of CHD pathophysiology. We discuss the application of nanotechnology in CHD diagnosis (imaging and sensors) and treatment (regulation of macrophages, cardiac repair, anti-oxidative stress), and provide insights into future research directions and clinical translation. This review serves as a valuable resource for researchers and clinicians seeking to harness the potential of nanotechnology in the management of CHD. STATEMENT OF SIGNIFICANCE: Coronary heart disease (CHD) is the one of leading cause of death and disability worldwide. Nanotechnology offers new strategies for diagnosing and treating CHD by exploiting the unique properties of nanomaterials. This review uses bibliometric analysis to uncover research trends in the use of nanotechnology for CHD. We discuss the potential of nanomaterials for early CHD detection through advanced imaging and biosensing, targeted drug delivery, tissue engineering, and modulation of inflammation and oxidative stress. We also offer insights into future research directions and potential clinical applications. This work aims to guide researchers and clinicians in leveraging nanotechnology to improve CHD patient outcomes and quality of life.

A Novel Catheter Shape-Sensing Method Based on Deep Learning with a Multi-Core Optical Fiber

In this paper, we propose a novel shape-sensing method based on deep learning with a multi-core optical fiber for the accurate shape-sensing of catheters and guidewires. Firstly, we designed a catheter with embedded multi-core fiber containing three sensing outer cores and one temperature compensation middle core. Then, we analyzed the relationship between the central wavelength shift, the curvature of the multi-core Fiber Bragg Grating (FBG), and temperature compensation methods to establish a Particle Swarm Optimization (PSO) BP neural network-based catheter shape sensing method. Finally, experiments were conducted in both constant and variable temperature environments to validate the method. The average and maximum distance errors of the PSO-BP neural network were 0.57 and 1.33 mm, respectively, under constant temperature conditions, and 0.36 and 0.96 mm, respectively, under variable temperature conditions. This well-sensed catheter shape demonstrates the effectiveness of the shape-sensing method proposed in this paper and its potential applications in real surgical catheters and guidewire.

Management and Anticoagulation Treatment of Non-Valvular Atrial Fibrillation in Elderly Patients: The Dali Study

Background

Non-valvular atrial fibrillation (NVAF) is associated with increased stroke in elderly populations, yet anticoagulant therapy is underutilized. We analyzed clinical characteristics and anticoagulation treatment rates of elderly NVAF patients hospitalized in Dali, China, to identify potential contributing factors.

Methods

We collected data for 155 elderly patients with NVAF aged ≥60 years, from July 01, 2020, to December 31, 2021. We analyzed the awareness rate, clinical characteristics, and anticoagulant treatment rate of atrial fibrillation (AF), and identified factors influencing treatment. Patients were followed up one year after discharge to assess vital status, cardiovascular events, and anticoagulation therapy status.

Results

Among 155 patients, 52.26% were female, and the average age was 75.77 years. The awareness rate of AF was 47.74% at admission, and only 21.94% received anticoagulant therapy. After discharge, the rate of anticoagulant therapy significantly increased to 70.97%, and 89.09% used new oral anticoagulants. Thromboembolic history and persistent AF predicted anticoagulant therapy at discharge, while male gender, previous bleeding history, and antiplatelet therapy predicted non-anticoagulant therapy. Out of 133 patients who completed a one-year follow-up, 23.31% died, 3.01% had strokes, and 3.01% experienced bleeding. Anticoagulant therapy decreased to 51.96% during the follow-up year.

Conclusion

Our findings highlight the low awareness rate and anticoagulant treatment rate, and high mortality among elderly NVAF patients in Dali. The development of comprehensive intervention strategies is critical to standardize AF management and improve prognosis.

The causal effects of genetically determined human blood metabolites on the risk of atrial fibrillation

Background

Blood metabolites have been found related to atrial fibrillation (AF), but the causal role is still unclear. Mendel randomization (MR) can give information about the causality between blood metabolites and AF.

Methods

Two-sample MR analysis was used to evaluate the causality between 486 blood metabolites and AF. Firstly, the genome-wide association study (GWAS) data for AF (from Nielsen et al.) was analyzed and some metabolites were identified. Then another GWAS data for AF (from Roselli et al.) was repeatedly analyzed to verify the results. Inverse variance weighted method was mainly used to determine the causality, and MR-egger, Weighted Median, and MR-PRESSO models were used as supplements of MR. Cochran's Q test was used to assess heterogeneity. And MR-Egger intercept and MR-PRESSO global test were performed to measure pleiotropy.

Results

The study used Bonferroni's corrected P value (P < 1.03 × 10-4) as the significance threshold. After MR analysis and replication analysis, we found two overlapped metabolites. Among which tryptophan betaine was the most significant causal metabolite in both AF GWAS data (from Nielsen et al.) (odds ratio (OR) = 0.83, 95% confidence interval (CI) = 0.76-0.90, P = 9.37 × 10-6) and AF GWAS data (from Roselli et al.) (OR = 0.82, 95% CI = 0.76-0.88, P = 2.00 × 10-7), while uridine was nominally significant metabolites in both AF GWAS data (from Nielsen et al.) (OR = 0.58, 95% CI = 0.40-0.84, P = 0.004) and AF GWAS data (from Roselli et al.) (OR = 0.56, 95% CI = 0.35-0.88, P = 0.01). And the results of sensitivity analysis showed that none of them had obvious heterogeneity or pleiotropy.

Conclusion

The study identified several blood metabolites that were causally related to AF, which may provide new perspectives on the pathogenesis of AF.

Effects of traditional Chinese exercise on physiological indicators and quality of life in patients with coronary heart disease: A systematic review and meta-analysis

BACKGROUND

The efficacy of traditional Chinese exercise (TCE)-based intervention in the improvement of physiological indicators and quality of life in patients with coronary heart disease (CHD) is controversial.

METHOD

Five databases were systematically searched for relevant articles published from inception to February 2023. Controlled trials examining TCE intervention in patients with CHD. The treatment effects were estimated using a random-effect meta-analysis model with standardized mean differences (Hedges g). The categorical and continuous variables were used to conduct moderator analyses. Two investigators independently screened abstracts and full-text articles and graded the certainty of evidence based on the Grading of Recommendations Assessment, Development and Evaluation approach. This review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (identifier CRD42023401934).

RESULT

Ten studies involving a total of 718 participants were included in the final analysis. In the physiological indicators outcomes, the meta-analytic findings revealed large and significant improvements in systolic blood pressure (g = 0.78, 95% confidence interval [CI] = 0.51-1.05, P = .00, I2 = 98%), diastolic blood pressure (g = 0.90, 95% CI = 0.61-1.20, P = .00, I2 = 98%) and body mass index (g = 1.05, 95% CI = 0.75-1.34, P = .00, I2 = 99%), small and significant improvements in heart rate (g = 0.28, 95% CI = 0.01-0.54, P = .04, I2 = 98%) and ventilatory equivalents/carbon dioxide (g = -1.10, 95% CI = -1.47 to -0.74, P = .00, I2 = 96%).In the quality of life outcomes, the findings revealed small and significant improvements in physical functioning (g = -3.01, 95% CI = -3.45 to -2.57, P = .00, I2 = 96%), bodily pain (g = -2.16, 95% CI = -2.57 to -1.74, P = .00, I2 = 98%), vitality (g = -3.67, 95% CI = -4.16 to -3.16, P = .00, I2 = 97%) and mental health (g = -1.23, 95% CI = -1.771 to -0.692, P = .00, I2 = 99%). The moderator shows that the effects of TCE on physiological indicators and quality of life were moderated by PEDro score, type of exercise, exercise frequency, exercise duration, and number of sessions.

CONCLUSION

TCE intervention is a beneficial nonpharmacological approach to improving physiological indicators in patients with CHD, especially in systolic blood pressure, diastolic blood pressure, and body mass index. However, there was no significant effect on quality of life. Our findings require broader clinical trials and higher-quality study designs to strengthen the evidence.

Atrial Fibrillation and Chronic Coronary Ischemia: A Challenging Vicious Circle

Atrial fibrillation, the most frequent arrhythmia in clinical practice and chronic coronary syndrome, is one of the forms of coronary ischemia to have a strong dual relationship. Atrial fibrillation may accelerate atherosclerosis and may increase oxygen consumption in the myocardium, creating a mismatch between supply and demand, thus promoting the development or worsening of coronary ischemia. Chronic coronary syndrome alters the structure and function of gap junction proteins, affecting the conduction of action potential and leading to ischemic necrosis of cardiomyocytes and their replacement with fibrous tissue, in this way sustaining the focal ectopic activity in atrial myocardium. They have many risk factors in common, such as hypertension, obesity, type 2 diabetes mellitus, and dyslipidemia. It is vital for the prognosis of patients to break this vicious circle by controlling risk factors, drug therapies, of which antithrombotic therapy may sometimes be challenging in terms of prothrombotic and bleeding risk, and interventional therapies (revascularization and catheter ablation).

Epidemiology, Trends, Utilization Disparities, and Outcomes of Catheter Ablation and Its Association With Coronary Vasospasm Amongst Patients With Non-valvular Atrial Fibrillation: A Nationwide Burden of Last Decade

BACKGROUND

Catheter ablation (CA) is an important curative treatment for non-valvular atrial fibrillation (NVAF), however, nationwide data on its utilization and disparities is limited. Coronary vasospasm is a rare, life-threatening, peri-operative complication of CA with limited literature in Caucasians.

METHODS

We performed a retrospective study on adult hospitalizations in the USA from 2007 to 2017 by obtaining the data from National Inpatient Sample. The primary endpoints of our study were to identify the utilization rate of CA, disparities in utilization, and study the outcomes associated with CA. The secondary endpoints of the study were to identify the incidence of coronary vasospasm amongst patients who underwent CA, evaluate their association, and identify the predictors of coronary vasospasm.

RESULTS

From 35,906,946 patients with NVAF, 343641 (0.96%) underwent CA. Its utilization decreased from 1% in 2007 to 0.71% in 2017. Patients who underwent CA, compared to those without CA, fared better in terms of hospital length of stay, mortality rate, disability rate, and discharge to the non-home facility. Patients in the 50-75 years age group, Native Americans, those with private insurance, and median household income of 76-100th percentile were associated with higher odds of CA utilization. Urban teaching hospitals and large-bedded hospitals performed more ablations, while the Mid-West region fared lower than the South, the West, and the Northeast. The prevalence of coronary vasospasm was higher amongst CA in comparison without CA, however, in regression analysis, no significant association was demonstrated between CA and coronary vasospasm.

CONCLUSION

CA is an important treatment modality that is associated with improved clinical outcomes. Identification of factors associated with lower utilization of CA and its disparities will help to mitigate the burden associated with NVAF.

Atrial fibrillation and coronary artery disease: An integrative review focusing on therapeutic implications of this relationship

The incidence of both atrial fibrillation (AF) and coronary artery disease (CAD) increases with advancing age. They share common risk factors and very often coexist. Evidence points to an intricate relationship between atrial tissue excitability and neuronal remodeling with ischemia at the microcirculatory level. In this review, we delineated this complex relationship, identified a common theme between the two, and discussed how the knowledge of this relationship translates into a positive and meaningful impact in patient management. Recent research indicates a high prevalence of CAD among AF patients undergoing coronary angiography. Further, the incidence of AF is much higher in those suffering from CAD compared to age-matched adults without CAD underlying this reciprocal relationship. CAD adversely affects AF by promoting progression via re-entry and increasing excitability of atrial tissue as a result of ischemia and electrical inhomogeneity. AF in turn accelerates atherosclerosis via endothelial dysfunctional and inflammation and together with enhanced thrombogenicity and hypercoagulability contribute to micro and macrothrombi throughout cardiovascular system. In a nutshell, the two form a vicious cycle wherein one disease promotes the other. Most AF recommendations focuses on rate/rhythm control and prevention of thromboembolism. Very few studies have discussed the importance of unmasking coexistent CAD and how the treatment of underlying ischemia will impact the burden of AF in these patients. Inflammation and endothelial dysfunction remain central to both disease processes and form a handsome therapeutic target in the management of the two diseases. The relationship between AF and CAD is complex and much more than mere coincidence. The two diseases share common risk factor and pathophysiology. Hence, it is impractical to treat them in isolation. Accordingly, we share the implications of managing underlying ischemia and inflammation to positively impact and improve quality of life among AF patients.

Mechanisms of Atrial Fibrillation: How Our Knowledge Affects Clinical Practice

Atrial fibrillation (AF) is a very common arrhythmia that mainly affects older individuals. The mechanism of atrial fibrillation is complex and is related to the pathogenesis of trigger activation and the perpetuation of arrhythmia. The pulmonary veins in the left atrium arei confirm that onfirm the most common triggers due to their distinct anatomical and electrophysiological properties. As a result, their electrical isolation by ablation is the cornerstone of invasive AF treatment. Multiple factors and comorbidities affect the atrial tissue and lead to myocardial stretch. Several neurohormonal and structural changes occur, leading to inflammation and oxidative stress and, consequently, a fibrotic substrate created by myofibroblasts, which encourages AF perpetuation. Several mechanisms are implemented into daily clinical practice in both interventions in and the medical treatment of atrial fibrillation.

An evidence map of systematic reviews on models of outpatient care for patients with chronic heart diseases

BACKGROUND

Chronic heart disease affects millions of people worldwide and the prevalence is increasing. By now, there is an extensive literature on outpatient care of people with chronic heart disease. We aimed to systematically identify and map models of outpatient care for people with chronic heart disease in terms of the interventions included and the outcomes measured and reported to determine areas in need of further research.

METHODS

We created an evidence map of published systematic reviews. PubMed, Cochrane Library (Wiley), Web of Science, and Scopus were searched to identify all relevant articles from January 2000 to June 2021 published in English or German language. From each included systematic review, we abstracted search dates, number and type of included studies, objectives, populations, interventions, and outcomes. Models of care were categorised into six approaches: cardiac rehabilitation, chronic disease management, home-based care, outpatient clinic, telemedicine, and transitional care. Intervention categories were developed inductively. Outcomes were mapped onto the taxonomy developed by the COMET initiative.

RESULTS

The systematic literature search identified 8043 potentially relevant publications on models of outpatient care for patients with chronic heart diseases. Finally, 47 systematic reviews met the inclusion criteria, covering 1206 primary studies (including double counting). We identified six different models of care and described which interventions were used and what outcomes were included to measure their effectiveness. Education-related and telemedicine interventions were described in more than 50% of the models of outpatient care. The most frequently used outcome domains were death and life impact.

CONCLUSION

Evidence on outpatient care for people with chronic heart diseases is broad. However, comparability is limited due to differences in interventions and outcome measures. Outpatient care for people with coronary heart disease and atrial fibrillation is a less well-studied area compared to heart failure. Our evidence mapping demonstrates the need for a core outcome set and further studies to examine the effects of models of outpatient care or different interventions with adjusted outcome parameters.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (CRD42020166330).

Combining Mendelian randomization and network deconvolution for inference of causal networks with GWAS summary data

Mendelian randomization (MR) has been increasingly applied for causal inference with observational data by using genetic variants as instrumental variables (IVs). However, the current practice of MR has been largely restricted to investigating the total causal effect between two traits, while it would be useful to infer the direct causal effect between any two of many traits (by accounting for indirect or mediating effects through other traits). For this purpose we propose a two-step approach: we first apply an extended MR method to infer (i.e. both estimate and test) a causal network of total effects among multiple traits, then we modify a graph deconvolution algorithm to infer the corresponding network of direct effects. Simulation studies showed much better performance of our proposed method than existing ones. We applied the method to 17 large-scale GWAS summary datasets (with median N = 256879 and median #IVs = 48) to infer the causal networks of both total and direct effects among 11 common cardiometabolic risk factors, 4 cardiometabolic diseases (coronary artery disease, stroke, type 2 diabetes, atrial fibrillation), Alzheimer's disease and asthma, identifying some interesting causal pathways. We also provide an R Shiny app (https://zhaotongl.shinyapps.io/cMLgraph/) for users to explore any subset of the 17 traits of interest.