The cardiovascular disease continuum validated: clinical evidence of improved patient outcomes: part I: Pathophysiology and clinical trial evidence (risk factors through stable coronary artery disease)

Long working hours at midlife and arterial stiffness at older age in a 24-year prospective cohort

BACKGROUNDS

This study aims to examine whether long working hours, repeatedly assessed at midlife, is associated with higher arterial stiffness at older age in a 24-year prospective study of white-collar workers in Quebec City, Canada.

METHODS

This study relied on a prospective cohort, initiated in 1991-1993 (T1) with two follow-ups after 8 years (T2, 1999-2001) and 24 years (T3, 2015-2018). Participants (N = 1,629, 51.3% women, mean age 37 ± 6.4 at T1) were randomly selected for arterial stiffness measurement at T3 using carotid-femoral pulse wave velocity (PWV). Long working hours (> 40 h/week) were assessed at T1 and T2. Mean differences in PWV were estimated using generalized linear models, accounting for sociodemographic factors, lifestyle-related risk factors, clinical factors and psychosocial stressors at work.

RESULTS

Among participants who remained actively employed over the study period (age range: 21-59 at T1), long working hours at T1 were associated with a + 0.54 m/s (95% CI: 0.05; 1.02) increase in PWV, while repeated exposure at T1 and T2 was associated with a + 1.50 m/s (95% CI: 0.78; 2.21) increase. No association was observed among participants who retired between T2 and T3.

CONCLUSION

The present study suggests that exposure to long working hours during midlife is associated with higher arterial stiffness, among aging workers. Workplace preventive strategies reducing long working hours may be effective to mitigate long-term arterial stiffening.

Potential Effects of Sacubitril/Valsartan on the Cardio-ankle Vascular Index in Hypertensive Patients

Objective Angiotensin receptor-neprilysin inhibitors (ARNIs) have been widely used as a treatment for heart failure. However, they have only been approved for the treatment of hypertension in a limited number of countries. We investigated the effect of ARNIs on arterial stiffness using the cardio-ankle vascular index (CAVI) in patients with hypertension to reveal the mechanism underlying cardiovascular interaction. Methods We investigated the utility of ARNIs in patients in whom arterial stiffness was assessed using the CAVI before and after ARNI administration. Patients In this retrospective observational study, we enrolled 50 patients with hypertension treated with ARNIs between January 2021 and 2023. Forty-eight of the 50 patients (96%) were switched from angiotensin II receptor blockers due to inadequate antihypertensive control. Results The systolic blood pressure (BP), diastolic BP, and CAVI were significantly decreased by ARNI administration [systolic BP: 145 (135, 162) to 131 (123, 143) mmHg (p=0.000); diastolic BP: 92 (78, 100) to 82 (74, 89) mmHg (p=0.000); and CAVI: 9.9 (9.1, 10.5) to 9.5 (8.8, 10.2) (p=0.005), respectively]. Conclusion Hypertension treatment with ARNIs may improve not only the blood pressure but also the CAVI, reducing the afterload on the heart.

Mitochondrial Dysfunction and Atherosclerosis: The Problem and the Search for Its Solution

Background/Objectives: This review has been prepared to promote interest in the interdisciplinary study of mitochondrial dysfunction (MD) and atherosclerosis. This review aims to describe the state of this problem and indicate the direction for further implementation of this knowledge in clinical medicine. Methods: Extensive research of the literature was implemented to elucidate the role of the molecular mechanisms of MD in the pathogenesis of atherosclerosis. Results: A view on the pathogenesis of atherosclerosis through the prism of knowledge about MD is presented. MD is the cause and primary mechanism of the onset and progression of atherosclerosis. It is proposed that this problem be considered in the context of a continuum. Conclusions: MD and atherosclerosis are united by common molecular mechanisms of pathogenesis. Knowledge of MD should be used to argue for a healthy lifestyle as the primary way to prevent atherosclerosis. The development of new approaches to diagnosing and treating MD in atherosclerosis is an urgent task and challenge for modern science.

Thiol/Disulfide Homeostasis in Pericardial Fluid and Plasma of Patients Undergoing Coronary Artery Bypass Surgery

INTRODUCTION

On-pump coronary artery bypass grafting (CABG) method affect almost allbiochemicalreactions by disrupting the patient's redox homeostasis. Detection of systemic redox hemostasis in the patient is critical for the CABG method's success and the prognosis of the disease. In this study, thiol/disulfide parameters, which are indicators of redox homeostasis, and ischemia-modified albumin levels in the plasma and pericardial fluid of patients who underwent CABG were investigated.

METHODS

Sixty patients who underwent an on-pump CABG operation with the cardiopulmonary bypass method were included in this study. Blood samples were taken from the patients before and after cardiopulmonary bypass. Pericardia fluid samples were taken before cardiopulmonary bypass. Then, thiol/disulfide homeostasis, albumin, and ischemia-modified albumin levels in the pericardial fluid and the patients' plasma levels were compared.

RESULTS

Albumin and ischemia-modified albumin levels were significantly higher in the postoperative period compared to the preoperative one (P<0.001). Thiol/disulfide parameters were higher and statistically significant in preoperative than in postoperative examinations (P<0.001). A negative correlation was found between pericardial fluid ischemia-modified albumin and thiol-disulfide parameters (P<0.001).

CONCLUSION

Changes in thiol/disulfide homeostasis, albumin, and ischemia-modified albumin levels at different times during the on-pump CABG may be caused by foreign non-endothelial surfaces, filters, the reperfusion process, and pharmacological effects in the extracorporeal circulation. Thiol/disulfide homeostasis, albumin, and ischemia-modified albumin levels should be monitored during the on-pump CABG and should be intervened with appropriate therapeutic strategies. In this way, secondary pathologies can be avoided by preventing cellular damage and excessive inflammatory responses.

Urate Levels as a Predictor of the Prevalence and Level of Cardiovascular Risk Factors: An Identificación de La PoBlación Española de Riesgo Cardiovascular y Renal Study

(1) Background: Urate levels lower than the classical cut-off point for defining hyperuricemia can increase cardiovascular risks. The aim of this study is to determine if there is a relationship between different urate levels and classic cardiovascular risk factors (CVRFs). (2) Methods: A cross-sectional study of the inclusion visits of the patients recruited to the IBERICAN study was conducted. The patients were classified into quartiles according to their distribution of urate levels and separated by sex; the three lower points corresponded to normal levels of urate, and the highest quartile was determined according to the classical definition of HU. Multivariate analysis models, adjusted for epidemiological variables, were used to analyze the association of urate levels with CVRFs. (3) Results: The presence of CVRFs was higher across the quartiles of urate, with a continuous increase along the quartiles in both sexes in accordance with body mass index (p < 0.01), waist circumference (p < 0.01), blood pressure (p < 0.01), and LDL cholesterol (p < 0.01). The CV risk estimated by SCORE was associated with an increase along the quartiles in women (p = 0.02). (4) Conclusions: A progressive increase in the frequency of CVRFs, as well as in their levels, was observed across the quartiles of uricemia, which reflects an increase in the CVRs associated with uricemia.

Mitochondrial Dysfunction and Risk Factors for Noncommunicable Diseases: From Basic Concepts to Future Prospective

BACKGROUND/OBJECTIVES

Noncommunicable diseases (NCDs) are a very important medical problem. The key role of mitochondrial dysfunction (MD) in the occurrence and progression of NCDs has been proven. However, the etiology and pathogenesis of MD itself in many NCDs has not yet been clarified, which makes it one of the most serious medical problems in the modern world, according to many scientists.

METHODS

An extensive research in the literature was implemented in order to elucidate the role of MD and NCDs' risk factors in the pathogenesis of NCDs.

RESULTS

The authors propose to take a broader look at the problem of the pathogenesis of NCDs. It is important to understand exactly how NCD risk factors lead to MD. The review is structured in such a way as to answer this question. Based on a systematic analysis of scientific data, a theoretical concept of modern views on the occurrence of MD under the influence of risk factors for the occurrence of NCDs is presented. This was done in order to update MD issues in clinical medicine. MD and NCDs progress throughout a patient's life. Based on this, the review raised the question of the existence of an NCDs continuum.

CONCLUSIONS

MD is a universal mechanism that causes organ dysfunction and comorbidity of NCDs. Prevention of MD involves diagnosing and eliminating the factors that cause it. Mitochondria are an important therapeutic target.

Assessing the association between e-cigarette use and cardiovascular disease: A meta-analysis of exclusive and dual use with combustible cigarettes

BACKGROUND

Growing evidence highlights the impact of e-cigarette use on cardiovascular health, prompting a crucial examination of its association with cardiovascular disease (CVD) in both exclusive e-cigarette and dual use scenarios with combustible cigarettes. This meta-analysis assessed the association between e-cigarette use and CVD by synthesizing the existing literature.

METHODS

Pertinent observational studies were identified using multiple electronic databases, from August 22nd, 2006, to April 10th, 2024. A meta-analysis was conducted using random-effect models. Risk of bias was assessed using the National Institutes of Health (NIH) Study Quality Assessment Tools.

FINDINGS

A total of 20 observational studies involving 8,499,444 participants were included in the meta-analysis. Dual use (e-cigarettes and combustible cigarette) increased the odds of CVD by 2.56 times (95 % CI: 2.11, 3.11) compared to never use of both. Current e-cigarette use combined with former combustible cigarette increased the odds of CVD by 2.02 times (95 % CI: 1.58, 2.58) compared to never use of either. Exclusive current e-cigarette use did not show a statistically significant association with CVD odds compared to never use of either (OR = 1.24, 95 % CI: 0.93, 1.67).

CONCLUSIONS

Dual use of e-cigarettes and combustible cigarettes was significantly associated with CVD, but results failed to show a significant association between exclusive e-cigarette use and CVD. Robust and longitudinal studies are needed to understand the long-term implications of e-cigarette use and CVD. Public health efforts should focus on awareness, smoking cessation, and regulating both e-cigarettes and combustible cigarettes.

High free sugars, insulin resistance, and low socioeconomic indicators: the hubs in the complex network of non-communicable diseases in adolescents

BACKGROUND

Noncommunicable diseases (NCDs) predominantly affect adults, but pathophysiological changes begin decades earlier, as a continuum, with initial events apparent in adolescence. Hence, early identification and intervention are crucial for the prevention and management of NCDs. We investigated the complex network of socioeconomic, behavioral, and metabolic factors associated with the presence of NCD in Brazilian adolescents.

METHODS

We conducted a cross-sectional study nested within the São Luís segment of the Ribeirão Preto, Pelotas, and São Luís (RPS) cohort's consortium, focusing on 18-19-year-olds (n = 2515). Data were collected prospectively, from which we constructed a complex network with NCD-related factors/indicators as nodes and their co-occurrences as edges. General and sex-based models analyzed: socioeconomic status, behavioral (smoking, alcohol, and other drugs use, unhealthy diet, poor sleep, physical inactivity), and metabolic factors (overweight/obesity, elevated blood pressure, poor lipid profile). We also looked for NCDs in adolescence like asthma, abnormal spirometry, depression, suicide risk, and poor oral health. The network was characterized by degree, betweenness, eigenvector, local transitivity, Shannon entropy, and cluster coefficient.

RESULTS

The adolescents had an average age of 18.3 years, 52.3% were female and 47.7% male. 99.8% of them have a diet rich in free sugars, 15% are overweight/obese and 72.3% had an elevated TyG index. High free sugar emerged as the central hub, followed by high TyG index (an early marker of insulin resistance) and low socioeconomic class. In males, low fiber intake and a high triglycerides/HDL ratio highlighted cardiometabolic concerns; in females, sedentary behavior and poor sleep marked metabolic and psychological challenges, along with caries in both sexes.

CONCLUSIONS

Our findings provide insights into central health challenges during adolescence, such as high free sugars, insulin resistance, and low socioeconomic indicators, suggesting that interventions targeted at these central hubs could have a significant impact on their NCD network.

Sex and population differences in the cardiometabolic continuum: a machine learning study using the UK Biobank and ELSA-Brasil cohorts

BACKGROUND

The temporal relationships across cardiometabolic diseases (CMDs) were recently conceptualized as the cardiometabolic continuum (CMC), sequence of cardiovascular events that stem from gene-environmental interactions, unhealthy lifestyle influences, and metabolic diseases such as diabetes, and hypertension. While the physiological pathways linking metabolic and cardiovascular diseases have been investigated, the study of the sex and population differences in the CMC have still not been described.

METHODS

We present a machine learning approach to model the CMC and investigate sex and population differences in two distinct cohorts: the UK Biobank (17,700 participants) and the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) (7162 participants). We consider the following CMDs: hypertension (Hyp), diabetes (DM), heart diseases (HD: angina, myocardial infarction, or heart failure), and stroke (STK). For the identification of the CMC patterns, individual trajectories with the time of disease occurrence were clustered using k-means. Based on clinical, sociodemographic, and lifestyle characteristics, we built multiclass random forest classifiers and used the SHAP methodology to evaluate feature importance.

RESULTS

Five CMC patterns were identified across both sexes and cohorts: EarlyHyp, FirstDM, FirstHD, Healthy, and LateHyp, named according to prevalence and disease occurrence time that depicted around 95%, 78%, 75%, 88% and 99% of individuals, respectively. Within the UK Biobank, more women were classified in the Healthy cluster and more men in all others. In the EarlyHyp and LateHyp clusters, isolated hypertension occurred earlier among women. Smoking habits and education had high importance and clear directionality for both sexes. For ELSA-Brasil, more men were classified in the Healthy cluster and more women in the FirstDM. The diabetes occurrence time when followed by hypertension was lower among women. Education and ethnicity had high importance and clear directionality for women, while for men these features were smoking, alcohol, and coffee consumption.

CONCLUSIONS

There are clear sex differences in the CMC that varied across the UK and Brazilian cohorts. In particular, disadvantages regarding incidence and the time to onset of diseases were more pronounced in Brazil, against woman. The results show the need to strengthen public health policies to prevent and control the time course of CMD, with an emphasis on women.

How should we assess the cardiovascular system in patients presenting with bothersome nocturia? ICI-RS 2023

AIMS

The link between nocturia and cardiovascular disease (CVD) is frequently discussed in literature, yet the precise nature of this relationship remains poorly characterized. The existing literature was reviewed in order to address issues concerning the origin, diagnosis, management, and implications of the co-occurrence of CVD and nocturia.

METHODS

This review summarizes literature and recommendations regarding the link between CVD and nocturia discussed during a think-tank meeting held at the 2023 International Consultation on Incontinence-Research Society.

RESULTS

Cardiovascular disorders are often underestimated contributors to nocturia, with various potential mechanisms influencing nighttime urination, such as impact on fluid retention, atrial natriuretic peptide, and glomerular filtration rate. The redistribution of fluid from leg edema in supine position can lead nocturnal polyuria (NP). Additionally, sleep disturbances due to nocturia in itself may lead to CVD through an increase in blood pressure, insulin resistance, and inflammation. Disrupted circadian rhythms (e.g., in sleep pattern and urine production) were identified as critical factors in most etiologies of nocturia, and their contribution is deemed imperative in future research and treatment approaches, particularly in the aging population. NP can be detected through a simple bladder diary and can even be used to distinguish cardiac from noncardiac causes of nocturia. For the treatment of NP, desmopressin can be effective in select patients, however, caution and close monitoring is warranted for those with CVD due to increased risk of side effects.

CONCLUSIONS

Gaps were identified in the available evidence and clear cut recommendations were put forth for future research. It is essential to gain a deeper understanding of the mechanisms linking nocturia and CVD to develop optimal management strategies.

Updates on the Renin-Angiotensin-Aldosterone System and the Cardiovascular Continuum

The cardiovascular continuum describes how several cardiovascular risk factors contribute to the development of atherothrombosis, ischemic heart disease, and peripheral arteriopathy, leading to cardiac and renal failure and ultimately death. Due to its multiple valences, the renin-angiotensin-aldosterone system plays an important role in all stages of the cardiovascular continuum, starting from a cluster of cardiovascular risk factors, and continuing with the development of atherosclerosis thorough various mechanisms, and culminating with heart failure. Therefore, this article aims to analyze how certain components of the renin-angiotensin-aldosterone system (converting enzymes, angiotensin, angiotensin receptors, and aldosterone) are involved in the underlying pathophysiology of the cardiovascular continuum and the possible arrest of its progression.

Correlations of Serum Lipid Parameters and Atherogenic Indices With Left Ventricular Diastolic Dysfunction Among Apparently Healthy Patients With Type 2 Diabetes Mellitus: A Multicenter In-Hospital Cross-Sectional Study

Background: In adolescents with Type 1 diabetes, lipid ratios are predictors of left ventricular diastolic dysfunction (LVDD). However, whether this also applies to adults with Type 2 Diabetes Mellitus (T2DM) is unclear. This study is aimed at assessing the correlations of serum lipid parameters and atherogenic indices with LVDD in patients with T2DM. Methods: This cross-sectional study included 203 patients with T2DM aged 59.9 ± 13.6 years (111 males, sex ratio: 1 : 2 in favor of males) from eight randomly selected urban hospitals. Demographic information was collected, an anthropometric assessment was performed, and blood pressure was measured. Fasting blood samples were obtained to assess total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglycerides (TGs), glucose, and glycated hemoglobin. The atherogenic index of plasma (AIP), Castelli Risk Index I (CRI-I), Castelli Risk Index II (CRI-II), atherogenic coefficient, and non-HDL-C were determined using specific formulas. Diastolic function was assessed using echocardiography as per the 2016 updated guidelines of the American Society of Echocardiography (ASE) and the European Association of Cardiovascular Imaging (EACVI). Results: Approximately 47.8% of the participants had LVDD. Compared with participants with normal diastolic function, those with LVDD were more likely to be older than 55 years (p < 0.001), tended to have obesity (p = 0.045), had a higher risk of developing dyslipidemia (p = 0.041), and higher AIP and CRI-II (p < 0.05) levels while having similar low HDL-C and hypertriglyceridemia frequencies. In the multivariate model adjusting for age, high AIP (adjusted odds ratio [aOR], 3.37; 95% confidence interval [CI], 1.22-5.34) and high CRI-II (aOR: 3.80; 95% CI: 2.25-6.35) were independent determinants of LVDD. Conclusions: These results highlight the importance of considering atherogenic indices, primarily AIP and CRI-II in the management of T2DM patients. High AIP and high CRI-II could serve as surrogate markers of LVDD, an early cardiovascular manifestation in patients with T2DM.

Achievement of LDL-Cholesterol Goals in Patients Receiving LLT in Primary Care: TERESA-AP Study: LDL-Cholesterol Goals in Primary Care

Background and Aim: Since 2019, LDL-cholesterol (LDL-C) is the risk factor with the strictest goals and the most difficult to reach, due to its role in the development of atherosclerotic plaque and, therefore, cardiovascular risk. The objective of the TERESA-AP study is to analyze the degree of LDL-C control in patients followed up in primary care with lipid-lowering drug treatment (LLT). Methods: Observational, multicenter, cross-sectional, nationwide study was conducted, in which 50 PC physicians recruited 929 patients who were receiving LLT during at least the preceding 6 months. The variables required to estimate the patients' cardiovascular risk and LDL control were recorded. Results: Nearly half of sample was women (50.5%), and the mean age was 67.8 (10.4) years. High blood pressure (65.3%) and sedentary lifestyle (59.7%) were the most frequent risk factors. Recommended goals were reached in 26.0% (95% CI: 23.3%-29.0%) of patients, with a slightly higher percentage in patients with cardiovascular disease (CVD) (26.7%), diabetes mellitus (DM) (35.5%), and a lower one in patients with chronic kidney disease (CKD) (12.1%). The most frequent drug treatments were statin monotherapy (69.0%) and statin with ezetimibe combination (27.6%), with moderate-intensity statins being the most commonly used in both groups. Conclusions: On average, only a quarter of the patients followed up in PC and who receive drug treatment reach their therapeutic targets. This percentage is slightly higher if the patients have CVD and DM and lower if they have CKD. The most commonly used therapeutic strategy is moderate-intensity statins, both in monotherapy and in combination with ezetimibe.

Prospective associations between systolic blood pressure, serum cholesterol, and physical activity behaviour and the development of cardiovascular disease

AIMS

To systematically appraise and summarise meta-analyses of longitudinal studies to determine the effect size, and quality and certainty of the evidence summaries for systolic blood pressure (SBP), serum cholesterol, and physical activity behaviour in developing cardiovascular disease (CVD).

METHODS AND RESULTS

An umbrella review was conducted by searching MEDLINE, Embase, and Scopus databases. Eligible meta-analyses were longitudinal studies investigating the association between SBP, serum cholesterol, or physical activity behaviour on CVD development. Summary risk estimates were extracted. Quality and certainty of the evidence summaries of included records were performed using AMSTAR 2 and GRADE, respectively. Forty-one eligible records were found of which thirteen related to SBP, five to cholesterol, and twenty-three to physical activity behaviour. The quality and certainty of the evidence summaries were variable, with most studies rating 'low'. Reported risk estimates for the risk of developing CVD ranged from: no change to a 68% decreased risk for lower SBP; a 21% increased risk to a 44% decreased risk for lower cholesterol; and a 1% decreased risk to a 56% decreased risk for higher physical activity levels.

CONCLUSIONS

There were strong associations with CVD risk at the meta-analysis level for all three exposures, with a proportionally greater number of meta-analyses and primary studies for physical activity than SBP or serum cholesterol. Given the number of meta-analyses and similar CVD risk reductions and certainty of evidence associated with physical activity behaviour, there is a strong case for its routine assessment alongside SBP and serum cholesterol in primary CVD prevention.

Aerobic exercise attenuates dysautonomia, cardiac diastolic dysfunctions, and hemodynamic overload in female mice with atherosclerosis

Cardiovascular risk increases during the aging process in women with atherosclerosis and exercise training is a strategy for management of cardiac risks in at-risk populations. Therefore, the aims of this study were to evaluate: (1) the influence of the aging process on cardiac function, hemodynamics, cardiovascular autonomic modulation, and baroreflex sensitivity in females with atherosclerosis at the onset of reproductive senescence; and (2) the impact of exercise training on age-related dysfunctions in this model. Eighteen Apolipoprotein-E knockout female mice were divided equally into young (Y), middle-aged (MA), and trained middle-aged (MAT). Echocardiographic exams were performed to verify cardiac morphology and function. Cannulation for direct recording of blood pressure and heart rate, and analysis of cardiovascular autonomic modulation, baroreflex sensitivity were performed. The MA had lower cardiac diastolic function (E'/A' ratio), and higher aortic thickness, heart rate and mean arterial pressure, lower heart rate variability and baroreflex sensitivity compared with Y. There were no differences between Y and MAT in these parameters. Positive correlation coefficients were found between aortic wall thickness with hemodynamics data. The aging process causes a series of deleterious effects such as hemodynamic overload and dysautonomia in female with atherosclerosis. Exercise training was effective in mitigating aged-related dysfunctions.

Comorbidity of patients with noncommunicable diseases in general practice. Eurasian guidelines

Создание руководства поддержано Советом по терапевтическим наукам отделения клинической медицины Российской академии наук.

Association between ischemic heart disease and dietary intake of lycopene: a case-control study

Aim

The effect of dietary lycopene on ischemic heart disease (IHD) is not clear. Hence, this study aimed to determine the association between dietary lycopene and IHD.

Methods

This case-control study was conducted on 443 patients with physician confirmed diagnosis of IHD as the case group and 443 healthy individuals as the control group. Data on demographic, medical history, anthropometric, and physical activity of the participants were collected. Food intake was evaluated using a 237-item semi-quantitative food frequency questionnaire (FFQ). The dietary intake of lycopene was assessed using Nutritionist IV software.

Results

A negative association was found between IHD and lycopene (OR: 0.98, CI 95%: 0.963-0.996, p = 0.02). The results remained significant after adjustment for age and sex, additional adjustment for dietary intake of calorie and fat, further adjustments for BMI, and additional adjustment for smoking, drinking alcohol, and physical activity. The risk of IHD in people with the highest quartile of dietary intake of lycopene was significantly lower than those with the lowest quartile (OR = 0.67, CI 95%: 0.46-0.97, p = 0.036).

Conclusion

There was a significant inverse relationship between intake of lycopene and IHD. Further prospective studies in different populations are required to elucidate the roles of lycopene against IHD.

Blood Homocysteine Levels Mediate the Association Between Blood Lead Levels and Cardiovascular Mortality

Lead is a heavy, toxic metal and its exposure to humans can lead to increased risk of cardiovascular disease development and mortality. Lead exposure has been shown to induce hyperhomocysteinemia (HHCy) which may be a major pathogenic risk for the risk of CVDs. The aim of this study was to investigate whether homocysteine (Hcy) mediates the effect of lead on cardiovascular mortality. A total of 17,915 adults aged ≥ 20 who participated in the National Health and Nutrition Examination Survey (1999 to 2006). Information on mortality was ascertained via probabilistic matching to the death certificates from the National Death Index recorded up to December 31, 2015. Cox proportional hazards regression was performed to assess the association between blood lead levels and mortality. Mediation via Hcy was examined using a logit model. During a mean follow-up of 11.6 years, the incidences of CVD mortality were 0.73, 2.18, 3.03 and 4.94 per 1000 person-years across quarterlies of blood lead levels from low to high. Following multivariable adjustment, blood lead levels were strongly associated with CVD mortality in all mortality models (p-trend < 0.001). This association remained statistically significant after further adjusting for quartiles of homocysteine (model 3; HR 1.38 (95% CI 1.01-1.89) p-trend < 0.001). Furthermore, blood lead levels increased the odds of CVD mortality via homocysteine (indirect effect) (OR 1.42 (95% CI 1.30-1.55)), demonstrating the mediatory effect of homocysteine. This the first study that demonstrates that increased homocysteine mediates nearly half of CVD mortality related to blood lead levels.

A Retrospective Observational Real-Word Analysis of the Adherence, Healthcare Resource Consumption and Costs in Patients Treated with Bisoprolol/Perindopril as Single-Pill or Free Combination

INTRODUCTION

The present real-world analysis aims to compare the drug utilization, hospitalizations and direct healthcare costs related to the use of single-pill combination (SPC) or free-equivalent combination (FEC) of perindopril and bisoprolol (PER/BIS) in a large Italian population.

METHODS

This observational retrospective analysis was based on administrative databases covering approximately 7 million subjects across Italy. All adult subjects receiving PER/BIS as SPC or FEC between January 2017-June 2020 were included. Subjects were followed for 1 year after the first prescription of PER/BIS as FEC (± 1 month) or SPC. Before comparing the SPC and FEC cohorts, propensity score matching (PSM) was applied to balance the baseline characteristics. Drug utilization was investigated as adherence (defined by the proportion of days covered, PDC) and persistence (evaluated by Kaplan-Meier curves). Hospitalizations and mean annual direct healthcare costs (due to drug prescriptions, hospitalizations and use of outpatient services) were analyzed during follow-up.

RESULTS

The original cohort included 11,440 and 6521 patients taking the SPC and FEC PER/BIS combination, respectively. After PSM, two balanced SPC and FEC cohorts of 4688 patients were obtained (mean age 70 years, approximately 50% male, 24% in secondary prevention). The proportion of adherent patients (PDC ≥ 80%) was higher for those on SPC (45.5%) than those on FEC (38.6%), p < 0.001. The PER/BIS combination was discontinued by 35.8% of patients in the SPC cohort and 41.7% in the FEC cohort (p < 0.001). The SPC cohort had fewer cardiovascular (CV) hospitalizations (5.3%) than the free-combination cohort (7.4%), p < 0.001. Mean annual total healthcare costs were lower in the SPC (1999€) than in the FEC (2359€) cohort (p < 0.001).

CONCLUSION

In a real-world setting, patients treated with PER/BIS SPC showed higher adherence, lower risk of drug discontinuation, reduced risk of CV hospitalization, and lower healthcare costs than those on FEC of the same drugs.

Association of meal-specific protein intake and cardiometabolic risk factors: a cross-sectional study

We aimed to investigate the association of main meals' specific protein intake with cardiometabolic risk factors, including general and abdominal obesity, serum lipid profile, and blood pressure (BP). This cross-sectional study was conducted on 850 subjects aged 20-59 years. Dietary intakes were assessed by completing three 24-h recalls, and the protein intake of each meal was extracted. Anthropometric measures, lipid profile, fasting blood sugar and BP were measured. Multivariate logistic regression controlling for age, physical activity, sex, marital status, smoking status, BMI and energy intake was applied to obtain OR and CI. The mean age was 42 years, and the mean BMI of the participants was 27·2. The mean protein intake for breakfast, lunch and dinner was 12·5, 22·2 and 18·7 g/d, respectively. After adjustment for confounders, higher protein intake was not associated with any of the cardiometabolic risk factors, including LDL-cholesterol, HDL-cholesterol, total cholesterol (TC), TAG, body weight, BP and fasting plasma glucose, in any of the three main meals consumed within a day. Adherence to a higher protein intake at each meal was not associated with cardiometabolic risk factors in Iranian adults. Further prospective studies are needed to justify our findings.

Progress on Physical Field-Regulated Micro/Nanomotors for Cardiovascular and Cerebrovascular Disease Treatment

Cardiovascular and cerebrovascular diseases (CCVDs) are two major vasculature-related diseases that seriously affect public health worldwide, which can cause serious death and disability. Lack of targeting effect of the traditional CCVD treatment drugs may damage other tissues and organs, thus more specific methods are needed to solve this dilemma. Micro/nanomotors are new materials that can convert external energy into driving force for autonomous movement, which can not only enhance the penetration depth and retention rates, but also increase the contact areas with the lesion sites (such as thrombus and inflammation sites of blood vessels). Physical field-regulated micro/nanomotors using the physical energy sources with deep tissue penetration and controllable performance, such as magnetic field, light, and ultrasound, etc. are considered as the emerging patient-friendly and effective therapeutic tools to overcome the limitations of conventional CCVD treatments. Recent efforts have suggested that physical field-regulated micro/nanomotors on CCVD treatments could simultaneously provide efficient therapeutic effect and intelligent control. In this review, various physical field-driven micro/nanomotors are mainly introduced and their latest advances for CCVDs are highlighted. Last, the remaining challenges and future perspectives regarding the physical field-regulated micro/nanomotors for CCVD treatments are discussed and outlined.

Knowledge, awareness, and attitude among pharmacists regarding the risk estimation of cardiovascular disease in Jordan: Immersion of lipid-lowering agents

The Risk Estimation of Cardiovascular Disease (CVD) is an important factor for predicting the incidence of cardiovascular events in a given population. This study aimed to assess the knowledge, awareness, and attitude of pharmacists in Jordan regarding the risk estimation of CVD and the use of lipid-lowering agents. The study is particularly interested in investigating the extent to which pharmacists are immersed in this area of practice, which can significantly impact patient health outcomes. The study employed a cross-sectional design, with a sample of pharmacists drawn from various regions in Jordan. Data were collected through a self-administered questionnaire, which was designed to explore pharmacists' knowledge of CVD risk estimation tools and their awareness of lipid-lowering agents' efficacy and side effects. The questionnaire also assessed pharmacists' attitudes towards the use of these agents in practice and their perceptions of the barriers to implementing CVD risk estimation tools. The study's findings shed light on the suboptimal levels of overall knowledge score of pharmacists in Jordan regarding CVD risk estimation and lipid-lowering agents' use. The results provided insights into the gaps that exist in pharmacists' knowledge and practice and help to identify areas for improvement. Ultimately, the present findings inform strategies to enhance pharmacists' engagement in CVD risk estimation and improve patient outcomes in Jordan and highlight the urgent need for ongoing education and training for pharmacists to improve their knowledge and skills in managing patients with dyslipidemia.

Spatial and temporal trends of overweight/obesity and tobacco use in East Africa: subnational insights into cardiovascular disease risk factors

BACKGROUND

Cardiovascular disease (CVD) is increasing in Sub-Saharan Africa (SSA). Overweight/obesity and tobacco use are modifiable CVD risk factors, however literature about the spatiotemporal dynamics of these risk factors in the region at subnational or local scales is lacking. We describe the spatiotemporal trends of overweight/obesity and tobacco use at subnational levels over a 13-year period (2003 to 2016) in five East African nations.

METHODS

Cross-sectional, nationally representative Demographic and Health Surveys (DHS) were used to explore the subnational spatiotemporal patterns of overweight/obesity and tobacco use in Burundi, Kenya, Rwanda, Tanzania, and Uganda, five East African Community (EAC) nations with unique cultural landscapes influencing CVD risk factors. Adaptive kernel density estimation and logistic regression were used to determine the spatial distribution and change over time of CVD risk factors on a subnational and subpopulation (rural/urban) scale.

RESULTS

Subnational analysis shows that regional and national level analysis masks important trends in CVD risk factor prevalence. Overweight/obesity and tobacco use trends were not similar: overweight/obesity prevalence increased across most nations included in the study and the inverse was true for tobacco use prevalence. Urban populations in each nation were more likely to be overweight/obese than rural populations, but the magnitude of difference varied widely between nations. Spatial analysis revealed that although the prevalence of overweight/obesity increased over time in both urban and rural populations, the rate of change differed between urban and rural areas. Rural populations were more likely to use tobacco than urban populations, though the likelihood of use varied substantially between nations. Additionally, spatial analysis showed that tobacco use was not evenly distributed across the landscape: tobacco use increased in and around major cities and urban centers but declined in rural areas.

CONCLUSIONS

We highlight the importance of de-homogenizing CVD risk factor research in SSA. Studies of national or regional prevalence trends mask important information about subpopulation and place-specific behavior and drivers of risk factor prevalence. Spatially explicit studies should be considered as a vital tool to understand local drivers of health, disease, and associated risk factor trends, especially in highly diverse yet low-resourced, marginalized, and often homogenized regions.

Non-Conventional Risk Factors: "Fact" or "Fake" in Cardiovascular Disease Prevention?

Cardiovascular diseases (CVDs), such as arterial hypertension, myocardial infarction, stroke, heart failure, atrial fibrillation, etc., still represent the main cause of morbidity and mortality worldwide. They significantly modify the patients' quality of life with a tremendous economic impact. It is well established that cardiovascular risk factors increase the probability of fatal and non-fatal cardiac events. These risk factors are classified into modifiable (smoking, arterial hypertension, hypercholesterolemia, low HDL cholesterol, diabetes, excessive alcohol consumption, high-fat and high-calorie diet, reduced physical activity) and non-modifiable (sex, age, family history, of previous cardiovascular disease). Hence, CVD prevention is based on early identification and management of modifiable risk factors whose impact on the CV outcome is now performed by the use of CV risk assessment models, such as the Framingham Risk Score, Pooled Cohort Equations, or the SCORE2. However, in recent years, emerging, non-traditional factors (metabolic and non-metabolic) seem to significantly affect this assessment. In this article, we aim at defining these emerging factors and describe the potential mechanisms by which they might contribute to the development of CVD.

Genetic Deletion of the LINC00520 Homolog in Mouse Aggravates Angiotensin II-Induced Hypertension

(1) Background: Hypertension is a complex, multifactorial disease that is caused by genetic and environmental factors. Apart from genetic predisposition, the mechanisms involved in this disease have yet to be fully understood. We previously reported that LEENE (lncRNA enhancing endothelial nitric oxide expression, transcribed from LINC00520 in the human genome) regulates endothelial cell (EC) function by promoting the expression of endothelial nitric oxide synthase (eNOS) and vascular growth factor receptor 2 (VEGFR2). Mice with genetic deletion of the LEENE/LINC00520 homologous region exhibited impaired angiogenesis and tissue regeneration in a diabetic hindlimb ischemia model. However, the role of LEENE in blood pressure regulation is unknown. (2) Methods: We subjected mice with genetic ablation of leene and wild-type littermates to Angiotensin II (AngII) and monitored their blood pressure and examined their hearts and kidneys. We used RNA-sequencing to identify potential leene-regulated molecular pathways in ECs that contributed to the observed phenotype. We further performed in vitro experiments with murine and human ECs and ex vivo experiments with murine aortic rings to validate the select mechanism. (3) Results: We identified an exacerbated hypertensive phenotype of leene-KO mice in the AngII model, evidenced by higher systolic and diastolic blood pressure. At the organ level, we observed aggravated hypertrophy and fibrosis in the heart and kidney. Moreover, the overexpression of human LEENE RNA, in part, restored the signaling pathways impaired by leene deletion in murine ECs. Additionally, Axitinib, a tyrosine kinase inhibitor that selectively inhibits VEGFR suppresses LEENE in human ECs. (4) Conclusions: Our study suggests LEENE as a potential regulator in blood pressure control, possibly through its function in ECs.

Optimization of the pharmacological therapy in patients with poly-vascular disease: A multidisciplinary approach

The recent shift of the concept of cardiovascular disease as a chronic progressive condition, potentially involving multiple districts, has driven attention to the optimal management of patients with concomitant coronary and peripheral artery disease, representing a subset of patients with an increased risk of events and impaired survival. Recent pharmacological achievements in terms of antithrombotic therapy and lipid-lowering drugs allow multiple therapeutical combinations, thus requiring optimizing the treatment in a tailored fashion according to patients’ risk profiles. Nevertheless, data dedicated to this specific subset of patients are still modest. We summarize currently available strategies and indications for the management of antithrombotic and lipid-lowering drugs in patients with the poly-vascular disease.

Evaluation of cadmium and mercury on cardiovascular and neurological systems: Effects on humans and fish

Chemicals are at the top of public health concerns and metals have received much attention in terms of toxicological studies. Cadmium (Cd) and mercury (Hg) are among the most toxic heavy metals and are widely distributed in the environment. They are considered important factors involved in several organ disturbances. Heart and brain tissues are not among the first exposure sites to Cd and Hg but they are directly affected and may manifest intoxication reactions leading to death. Many cases of human intoxication with Cd and Hg showed that these metals have potential cardiotoxic and neurotoxic effects. Human exposure to heavy metals is through fish consumption which is considered as an excellent source of human nutrients. In the current review, we will summarize the most known cases of human intoxication with Cd and Hg, highlight their toxic effects on fish, and investigate the common signal pathways of both Cd and Hg to affect heart and brain tissues. Also, we will present the most common biomarkers used in the assessment of cardiotoxicity and neurotoxicity using Zebrafish model.

Genetic outline of the hermeneutics of the diseases connection phenomenon in human

The structure of diseases in humans is heterogeneous, which is manifested by various combinations of diseases, including comorbidities associated with a common pathogenetic mechanism, as well as diseases that rarely manifest together. Recently, there has been a growing interest in studying the patterns of development of not individual diseases, but entire families associated with common pathogenetic mechanisms and common genes involved in their development. Studies of this problem make it possible to isolate an essential genetic component that controls the formation of disease conglomerates in a complex way through functionally interacting modules of individual genes in gene networks. An analytical review of studies on the problems of various aspects of the combination of diseases is the purpose of this study. The review uses the metaphor of a hermeneutic circle to understand the structure of regular relationships between diseases, and provides a conceptual framework related to the study of multiple diseases in an individual. The existing terminology is considered in relation to them, including multimorbidity, polypathies, comorbidity, conglomerates, families, "second diseases", syntropy and others. Here we summarize the key results that are extremely useful, primarily for describing the genetic architecture of diseases of a multifactorial nature. Summaries of the research problem of the disease connection phenomenon allow us to approach the systematization and natural classification of diseases. From practical healthcare perspective, the description of the disease connection phenomenon is crucial for expanding the clinician's interpretive horizon and moving beyond narrow, disease-specific therapeutic decisions.

Contemporary aetiology of acute heart failure in a teaching hospital in Ghana

BACKGROUND

Heart failure (HF) is recognized as a global public health disease associated with high morbidity and mortality. It is suggested that the main underlying causes of HF in developing countries differ from those identified in well-resourced countries. This study therefore presents the cardiovascular risk factors and the underlying aetiology of HF among admitted patients in a teaching Hospital in Ghana.

METHOD

The study prospectively recruited 140 consecutive patients admitted for heart failure at the Medical department of the Korle-Bu Teaching Hospital from March to October, 2014. The study evaluated the cardiovascular risk factors and the aetiologies of heart failure, and compared the risk factors and aetiologies with patient's age and gender.

RESULTS

The mean age of the study participants was 51.3 ± 16.8 years. The commonest cardiovascular risk factors observed were hypertension (46.5%), history of previous HF (40.7%), excessive alcohol use (38.6%), and family history of heart disease (29.3%); predominantly hypertension (68.3%). The major underlying aetiology of HF were dilated cardiomyopathy (38.6%), hypertensive heart disease (21.4%), ischaemic heart disease (13.6%) and valvular heart disease (12.9%). These underlying aetiology of HF were more common in patients aged 40 years and above (p = 0.004) and those presenting with multiple risk factors (p = 0.001).

CONCLUSION

The major underlying aetiology of heart failure in adults were dilated cardiomyopathy, hypertensive heart disease, ischaemic heart disease and valvular heart disease, which were significantly high among patients aged 40 years and above and those presenting multiple risk factors. Hypertension, excessive alcohol use, family history of heart disease and personal history of previous heart failure diagnosis are noted as the main cardiovascular risk factors among heart failure patients.

Development of risk prediction model for cognitive impairment in patients with coronary heart disease: A study protocol for a prospective, cross-sectional analysis

Background

Ischemic heart disease and degenerative encephalopathy are two main sources of disease burden for the global elderly population. Coronary heart disease (CHD) and cognitive impairment, as representative diseases, are prevalent and serious illnesses in the elderly. According to recent research, patients with CHD are more likely to experience cognitive impairment and their cognitive ability declines more quickly. Vascular risk factors have been associated with differences in cognitive performance in epidemiological studies, but evidence in patients with CHD is more limited. Inextricably linked between the heart and the brain. Considering the unique characteristics of recurrent cognitive impairment in patients with CHD, we will further study the related risk factors. We tried to investigate the potential predictors of cognitive impairment in patients with CHD through a prospective, cross-sectional study.

Methods

The cross-sectional study design will recruit 378 patients with CHD (≥65 years) from Xiyuan Hospital of China Academy of Chinese Medical Sciences. The subjects' cognitive function is evaluated with MoCA scale, and they are divided into cognitive impairment group and normal cognitive function group according to the score results. Demographic data, disease characteristics (results of coronary CT/ angiography, number of stents implanted, status of diseased vessels), laboratory tests (biochemistry, coagulation, serum iron levels, pulse wave velocity), metabolites (blood samples and intestinal metabolites), and lifestyle (smoking, alcohol consumption, sleep, physical activity) will be assessed as outcome indicators. Compare the two groups and the correlation analysis will be performed on the development of mild cognitive impairment. Mann-Whitney U or X² test was selected to describe and evaluate the variation, and logistics regression analysis was employed to fit the prediction model. After that, do the calibration curve and decision curve to evaluate the model. The prediction model will be validated by a validation set.

Discussion

To explore the risk factors related to mild cognitive impairment (MCI) in patients with CHD, a new predictive model is established, which can achieve advanced intervention in the occurrence of MCI after CHD. Owing to its cross-sectional study design, the study has some limitations, but it will be further studied by increasing the observation period, adding follow-up data collection or prospective cohort study. The study has been registered with the China Clinical Trials Registry (ChiCTR2200063255) to conduct clinical trials.

Insulin resistance phenotype is associated with vascular risk phenotype at the end of the second decade of life: a population-based study

We hypothesize that early events of diabetes and cardiovascular disease continuums would be ongoing and associated in adolescents. We investigated the association between the Insulin Resistance Phenotype and the Vascular Risk Phenotype at the end of the second decade of life and indirect pathways from social vulnerability, alcohol consumption, and body fat mass. It is a population-based study in the RPS cohort of 18-19 years (n = 2,515), São Luís, Brazil. The theoretical model analyzed the association between Insulin Resistance Phenotype and Vascular Risk Phenotype by sex, using structural equation modeling (SEM). The Insulin Resistance Phenotype was a latent variable deduced from the correlations of Triglyceride to HDL ratio, Triglyceride Glycemic index, and VLDL; the Vascular Risk Phenotype was deduced from Systolic Blood Pressure, Diastolic Blood Pressure, and Pulse Wave Velocity. The Insulin Resistance Phenotype was directly associated with the Vascular Risk Phenotype in males (standardized coefficient SC = 0.183; p < 0.001) and females (SC = 0.152; p < 0.001). The Insulin Resistance Phenotype was an indirect pathway in the association of alcohol consumption and higher values of fat mass index with the Vascular Risk Phenotype. VLDL presented the highest factor loading, appearing as a marker of insulin resistance linked to cardiovascular risk in young people. Lower values of socioeconomic status, harmful use of alcohol, and high body fat values were also associated with higher values of the two phenotypes. The association of the Insulin Resistance Phenotype with the Vascular Risk Phenotype suggests common pathophysiological mechanisms present in early events in the continuums of diabetes and cardiovascular disease in adolescence.

Bioconversion of lovastatin to simvastatin by Streptomyces carpaticus toward the inhibition of HMG-CoA activity

The aim of this study was the modification of lovastatin by microbes to improve its potential. Actinobacteria exhibit staggering diversity in terms of their biosynthetic capability for specialized metabolites which has been traced back to the presence of specialized gene clusters. The objective of the study is to exploit the potential of Actinobacteria strain(s), which can biotransform lovastatin to simvastatin, which might be a more potent therapeutic agent than lovastatin. We have screened 40 Actinobacteria strains and assessed their biotransformation potential primarily through thin layer chromatography (TLC) analysis, followed by high performance thin layer chromatography and high performance liquid chromatography analysis. One strain C7 (CTL S12) has been identified as a potential Actinobacteria that favored the simvastatin biotransformation. The morphological and biochemical analysis together with 16S rRNA sequencing coupled with phylogenetic analysis confirmed the ideal strain (C7) as Streptomyces carpaticus. Successively, the purified simvastatin from S. carpaticus was characterized by liquid chromatography-mass spectrometry (LC-MS), infrared spectrometry, nuclear magnetic resonance, and HMG-CoA assay. In the LC-MS analysis, a peak at 419.24 m/z confirmed the elemental composition of simvastatin (C₂₅ H₃₉ O₅ ). In HMG-CoA assay, the IC50 of simvastatin was 50 μg/ml, and the inhibitory potential was 1.36 times higher compared to that of lovastatin. Thus, the biotransformation of simvastatin from lovastatin by S. carpaticus is reported for the first time.

Development of a diet pattern assessment tool for coronary heart disease risk reduction

Objective

Existing diet indices have gaps including neglect of the patterns of intake known to affect the final metabolic impact and use of measurement units prone to reporting error, and have applicability that is limited to specific populations. This study sought to develop a tool for diet-pattern assessment (Prudent Approach to Cardiovascular Epidemic, for Indians – Diet Quality Index (iPACE-DQI)) to reduce diet-related coronary-heart-disease (CHD) risk.

Study design

The iPACE-DQI was developed on a 0–100 points scale (higher numeric value healthier). A proof-of-concept analysis was done to examine its construct validity and relation with risk-markers.

Methods

Development of iPACE-DQI was partly guided by ‘prudent diet’ principles, with assessment focus on quality, quantity, and the pattern of intake. In the second part of the study, construct validity was evaluated by association of iPACE-DQI score with nutrients. Further, relationship of the score with risk-markers high-sensitivity C-reactive protein(hs-CRP), body-mass-index(BMI) and body-fat-percent was examined at single-point-in-time (baseline), and predictive ability of score change on hs-CRP change was evaluated in a proof-of-concept 12-weeks pre-post intervention, among free-living Indians (25–44years,n = 55) in an urban setting.

Results

The iPACE-DQI consists of eight main components. Associations of iPACE-DQI score with mean daily intake of key nutrients were robust and in expected direction [total-dietary-fiber (r = 0.5, p < 0.001), crude-fiber (r = 0.6, p < 0.001), protein (r = 0.5, p < 0.001), total-fat (r = −0.4, p = 0.002), vitamin-C (r = 0.5, p < 0.001), total-carbohydrate (r = 0.3, p = 0.017)]. Trends of hs-CRP, BMI and body-fat-percent across increasing diet-pattern score showed highest degree of abnormality in lowest tertile (≤35). Logistic regression model indicated higher likelihood for hs-CRP reduction (OR: 1.6, 95% CI 0.5–4.9) among those with ≥20% increase in iPACE-DQI score as compared with <20% increase or no-increase over 12-weeks

Conclusion

The iPACE-DQI is a 100-point scale that assesses diet-pattern with respect to CHD-risk. The proposed tool could be useful for researchers/health practitioners to track diet-pattern change and concomitant CHD-risk reduction.

Cardio-Vascular Interaction Evaluated by Speckle-Tracking Echocardiography and Cardio-Ankle Vascular Index in Hypertensive Patients

Hypertension increases arterial stiffness, leading to dysfunction and structural changes in the left atrium (LA) and left ventricle (LV). However, the effects of hypertension on the right atrium (RA) and the right ventricle are still not fully understood. The purpose of this study was to clarify whether there is an interaction not only in the left ventricular system but also in the right ventricular system in hypertensive patients with preserved LV ejection fraction. The current retrospective observational study included patients (n = 858) with some risk of metabolic abnormalities (hypertension, diabetes, and dyslipidemia) who had visited our hospital and undergone echocardiography between 2015 and 2018. Among them, we retrospectively studied 165 consecutive hypertensive patients with preserved LV ejection fraction who had echocardiography performed on the same day as a cardio-ankle vascular index (CAVI) in our hospital. The phasic function of both atria was evaluated by two-dimensional speckle-tracking echocardiography. CAVI was measured using Vasela 1500 (Fukuda Denshi^®). In the univariate analysis, CAVI was significantly correlated with LA and RA conduit function (LA conduit function, r = -0.448, p = 0.0001; RA conduit function, r = -0.231, p = 0.003). A multivariate regression analysis revealed that LA and RA conduit function was independently associated with CAVI (LA, t = -5.418, p = 0.0001; RA, t = -2.113, p = 0.036). CAVI showed a possibility that the association between heart and vessels are contained from not only LA phasic function but also RA phasic function in hypertensive patients.

Telomere length is associated with intima-media thickness in pediatric liver transplant patients: A prospective cohort study

Leukocyte telomere length (LTL) is a marker for biological age. Pediatric liver transplant recipients show a high rate of subclinical atherosclerosis, indicated by elevated intima-media thickness (IMT). We hypothesized that atherosclerosis is associated with biological age in these patients and investigated the course of LTL over time. We measured LTL from peripheral blood leukocytes by quantitative polymerase chain reaction and IMT from 97 pediatric patients after liver transplantation in a prospective cohort study. Of the patients, 71% (n = 69) had two or more assessments (total, 228 observations; median follow-up, 1.1 years). Lower LTL was associated with higher IMT (β = -0.701, p = 0.01) and higher aspartate aminotransferase (β = -0.001, p = 0.02), adjusted for age, sex, and age at transplantation. Of the patients, 45% showed decreasing LTL over time, whereas 55% exhibited stable LTL. Patients with stable LTL showed a decrease in IMT (median, -0.02 mm/year) and a decrease of tacrolimus trough levels (median, -0.08 μg/L/year). LTL is associated with IMT independent of age in pediatric liver transplant patients, suggesting that early aging contributes to the high burden of subclinical cardiovascular damage and may furthermore negatively affect the graft.

Impact of hypoglycemia at the time of hospitalization for heart failure from emergency department on major adverse cardiovascular events in patients with and without type 2 diabetes

Background

Few studies have examined the association between hypoglycemic episodes among people with type 2 diabetes (T2DM) at the time of hospitalization for heart failure (HF) and cardiovascular outcomes.

Methods

From March 2016 to June 2018, we conducted a retrospective cohort study to investigate hypoglycemia during HF hospitalization in the emergency department, three-point major adverse cardiovascular events (3P-MACE), and all-cause mortality; these were followed up through June 2021. HF hospitalization was defined according to American Heart Association criteria. Hypoglycemia was defined as a glucose level < 3.9 mmol/L at the time of HF hospitalization. We classified the enrolled patients into three groups (reference group, those without T2DM or hypoglycemia; those diagnosed with T2DM without hypoglycemia; and those with hypoglycemia and T2DM). We used Cox proportional hazard regression analysis to investigate the association between the three groups and the development of the first occurrence of 3P-MACE and all-cause mortality.

Results

During a median of 25 months of follow-up, a total of 783 patients admitted due to HF were analyzed. In total, 159 (20.3%) cases of 3P-MACE were identified, and the mortality rate was 20.2% (n = 158). The median age of patients was 76.0 (65.0–82.0) years, and 49.0% were men. Patients with 3P-MACE had a lower body mass index (22.6 [20.4–25.1] vs. 23.8 [21.3–26.7]), higher frequency of previous history of HF (24.5% vs. 15.7%), T2DM (64.2% vs. 47.3%), higher rates of hypoglycemia at the time of HF hospitalization (19.5% vs. 7.7%), and lower eGFR levels (61.1 [36.0–80.7] mL/min/1.73 m² vs. 69.2 [45.8–89.5] mL/min/1.73 m²) than those without 3P-MACE. The multivariable adjusted HR of 3P-MACE was as follows: group with hypoglycemia and T2DM: HR, 2.29; 95% CI: 1.04–5.06; group with T2DM without hypoglycemia: HR: 1.42; 95% CI: 0.86–2.33; and all-cause mortality group with hypoglycemia and T2DM: HR: 2.58; 95% CI: 1.26–5.31, group with T2DM without hypoglycemia: HR: 1.32; 95% CI: 0.81–2.16; compared to the reference group (group without T2DM or hypoglycemia).

Conclusions

T2DM and hypoglycemia are independent risk factors for 3P-MACE and all-cause mortality compared to those without hypoglycemia during HF hospitalization.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01651-0.

Intersection of the Ubiquitin–Proteasome System with Oxidative Stress in Cardiovascular Disease

Cardiovascular diseases (CVDs) present a major social problem worldwide due to their high incidence and mortality rate. Many pathophysiological mechanisms are involved in CVDs, and oxidative stress plays a vital mediating role in most of these mechanisms. The ubiquitin–proteasome system (UPS) is the main machinery responsible for degrading cytosolic proteins in the repair system, which interacts with the mechanisms regulating endoplasmic reticulum homeostasis. Recent evidence also points to the role of UPS dysfunction in the development of CVDs. The UPS has been associated with oxidative stress and regulates reduction–oxidation homeostasis. However, the mechanisms underlying UPS-mediated oxidative stress’s contribution to CVDs are unclear, especially the role of these interactions at different disease stages. This review highlights the recent research progress on the roles of the UPS and oxidative stress, individually and in combination, in CVDs, focusing on the pathophysiology of key CVDs, including atherosclerosis, ischemia–reperfusion injury, cardiomyopathy, and heart failure. This synthesis provides new insight for continued research on the UPS–oxidative stress interaction, in turn suggesting novel targets for the treatment and prevention of CVDs.

Vascular Aging and Arterial Stiffness

O envelhecimento biológico é reflexo da interação entre genética, idade cronológica e fatores externos; é a base para novos conceitos em envelhecimento vascular, cuja progressão é determinada pela diferença entre idade biológica e cronológica. Do ponto de vista estrutural, os efeitos do envelhecimento vascular são mais evidentes na camada média das grandes artérias elásticas e resultam em aumento da rigidez arterial, da dilatação do lúmen e da espessura da parede. Esses efeitos são descritos no continuum de envelhecimento cardiovascular (proposto por Dzau em 2010) em que as etapas progressivas de lesões da microvasculatura de coração, rins e cérebro, têm início a partir do processo de envelhecimento. O aumento da rigidez arterial pode ser verificado de forma não invasiva por vários métodos. Os eventos cardiovasculares têm sido tradicionalmente previstos utilizando escores que combinam fatores de risco convencionais para aterosclerose. No continuum cardiovascular clássico (Dzau, 2006), é desafiador avaliar o peso exato da contribuição de cada fator de risco; entretanto, por refletir o dano precoce e cumulativo desses fatores de riscos cardiovascular, a rigidez arterial reflete o verdadeiro dano à parede arterial. Este artigo fornece uma visão geral dos mecanismos da fisiopatogenia, alterações estruturais das artérias e consequências hemodinâmicas do envelhecimento arterial; métodos não invasivos para a avaliação da rigidez arterial e da medida central da pressão arterial; o continuum de envelhecimento cardiovascular, e aplicação do conceito de rigidez arterial na estratificação de risco cardiovascular.

Cardiovascular Benefits of Empagliflozin Are Associated With Gut Microbiota and Plasma Metabolites in Type 2 Diabetes

CONTEXT

Cardiovascular benefits of empagliflozin in patients with type 2 diabetes mellitus (T2DM) have been reported; however, the underlying mechanism remains unknown.

OBJECTIVE

We hypothesized that the cardiovascular benefits of empagliflozin are associated with altered gut microbiota and plasma metabolites, and that empagliflozin may be used as an initial treatment for patients with T2DM at risk of cardiovascular diseases (CVDs).

METHODS

This randomized, open-label, 3-month, 2-arm clinical trial included 76 treatment-naïve patients with T2DM and risk factors for CVD who were treated with either empagliflozin (10 mg/d, n = 40) or metformin (1700 mg/d, n = 36). We investigated changes in clinical parameters related to glucose metabolism and CVD risk factors, gut microbiota using 16S rRNA gene sequencing, and plasma metabolites using LC-MS.

RESULTS

We found significant and similar reduction in HbA1c levels and alleviation of glucose metabolism in both groups. However, only empagliflozin improved CVD risk factors. Empagliflozin significantly reshaped the gut microbiota after 1 month of treatment; this alteration was maintained until the end of the trial. Empagliflozin increased the levels of plasma metabolites such as sphingomyelin, but reduced glycochenodeoxycholate, cis-aconitate, and uric acid levels. Concurrently, empagliflozin elevated levels of short-chain fatty acid-producing bacteria such as species from Roseburia, Eubacterium, and Faecalibacterium, and reduced those of several harmful bacteria including Escherichia-Shigella, Bilophila, and Hungatella.

CONCLUSION

Empagliflozin may be a superior initial therapy for patients with T2DM at risk of CVDs; its cardiovascular benefits may be associated with shifts in gut microbiota and plasma metabolites.

Cholecalciferol supplementation lowers leptin and TMAO but increases NO and VEGF-A levels in obese vitamin D deficient patients: Is it one of the potential cardioprotective mechanisms of vitamin D?

Background

Vitamin D deficiency is one of the most common health issues in developed countries. Obese patients are most at risk of having serum 25-hydroxyvitamin D₃ (25(OH)D₃) levels that are too low due to the accumulation of vitamin D in adipose tissue. While the effects of a deficiency on the skeletal or immune system are known, the effects on the cardiovascular system are not yet clear. Our study investigates the effect of cholecalciferol supplementation in obese patients on selected biomarkers associated with cardiovascular diseases (CVDs).

Methods

The study enrolled 33 obese patients with insufficient 25(OH)D₃ levels. For three months, the subjects supplemented with cholecalciferol at a dose of 2000 IU/day. Concentrations of nitric oxide (NO), vascular endothelial growth factor A (VEGF-A), leptin, trimethylamine N-oxide (TMAO) and soluble suppression of tumorigenicity 2 (sST2) were measured in baseline samples using ELISA (BioTek EPOCH). 25(OH)D₃ levels measured on Beckman Coulter DXI 800 by chemiluminescence method.

Results

After supplementation, 25(OH)D₃ levels increased significantly. Normal levels were achieved in most patients. A statistically significant reduction leptin and TMAO levels was observed. At the same time, NO and VEGF-A levels increased statistically significantly.

Conclusion

This study indicates that restoring normal 25(OH)D₃ levels in obese people reduces the concentration of pro-inflammatory factors associated with cardiovascular diseases. Reducing inflammation and the potential impact on vascular reactivity leads to the conclusion that cholecalciferol supplementation in obese patients may benefit the cardiovascular system.

Serum potassium variability as a predictor of clinical outcomes in patients with cardiorenal disease or diabetes: a retrospective UK database study

Background

Hyperkalaemia is an electrolyte abnormality associated with adverse clinical outcomes; however, few studies have investigated the relationship with patterns of hyperkalaemia over time. This study explored the impact of time spent in a hyperkalaemic state and variability of serum potassium (sK+) on major adverse cardiovascular events (MACE) and all-cause mortality in patients with chronic kidney disease (CKD), resistant hypertension, heart failure and diabetes.

Methods

Cohorts comprised adult patients diagnosed with CKD stage 3+, resistant hypertension, heart failure or diabetes, and/or renin-angiotensin-aldosterone system inhibitor prescription, between 1 January 2003 and 30 June 2018, from the UK Clinical Practice Research Datalink. Associations between percentage of follow-up spent in a hyperkalaemic state (sK+ ≥5.0 mmol/L, ≥5.5 mmol/L, ≥6.0 mmol/L) or sK+ variability (standard deviation above or below median standard deviation) and all-cause mortality or MACE were investigated.

Results

For sK+ ≥5.0 mmol/L, time spent in a hyperkalaemic state was associated with reduced risk of all-cause mortality across all cohorts. For higher sK+ thresholds, this trend was attenuated or reversed; for time spent in a hyperkalaemic state at sK+ ≥6.0 mmol/L, an increased risk of mortality was seen in the overall cohort and for patients with diabetes, resistant hypertension or prescribed renin-angiotensin-aldosterone system inhibitors, with no consistent association seen for patients with CKD or heart failure. Risk of MACE in the overall cohort and in patients with CKD, diabetes or resistant hypertension increased with time spent in a hyperkalaemic state at all sK+ thresholds; however, no correlation was seen in patients with heart failure or those receiving dialysis. High sK+ variability was associated with a higher risk of MACE compared with low sK+ variability across most sK+ categories in the overall population and in all disease cohorts, except patients on dialysis; however, no association between sK+ variability and all-cause mortality was observed.

Conclusions

Patterns of hyperkalaemia, including time spent in hyperkalaemia and sK+ variability, are associated with adverse clinical outcomes. Regular monitoring of sK+ in high-risk populations in broader community, primary care and outpatient settings may enable guideline-recommended management of hyperkalaemia and help avoid adverse events.

Pathways in the association between added sugar consumption, obesity in mother-child dyads, and chronic oral disease burden in early childhood

In this study, we modeled the pathways in the association of socioeconomic status, frequency of added sugar consumption, and obesity in mother-child dyads with chronic oral disease burden in early childhood using structural equation modeling. A population-based study was conducted on preschoolers from public daycare centers in São Luís, Brazil (n = 674) and their mothers. Chronic oral disease burden in early childhood was a latent variable, representing the shared variance of the following indicators: visible plaque index, gingivitis, and dental caries. A higher consumption frequency of added sugars by children [standardized regression coefficient (SC) = 0.219] explained the chronic oral disease burden. A higher consumption frequency of added sugars by mothers was associated with greater consumption of sugar by children (SC = 0.236), and indirectly with a greater chronic oral disease burden (SC = 0.052). Maternal obesity was associated with obesity in the offspring (SC = 0.130). The chronic oral disease burden is already present in early childhood and can be explained by the higher consumption of added sugars by the mother-child dyad. Approaches to preventing chronic oral diseases should focus on common risk factors, start early in life, and promote family involvement in this process.

Retinal microvasculature impairments in patients with coronary artery disease: An optical coherence tomography angiography study

PURPOSE

To investigate the association between retinal microvasculature and the presence and severity of coronary artery disease (CAD) using optical coherence tomography angiography (OCTA).

METHODS

The cross-sectional study was conducted in Guangdong Provincial People's Hospital, China. Retinal microvasculature parameters were measured by OCTA of the optic disc, including the vessel density (VD) and retinal nerve fibre thickness of the radial peripapillary capillary. In terms of the entire macula, VD of the superficial capillary plexus (SCP), deep capillary plexus (DCP) and foveal density (FD-300) were included. The Gensini score was used to evaluate the severity of coronary artery obstructive lesions in CAD patients.

RESULTS

A total of 410 participants (270 CAD patients and 140 controls) were included. Overall, participants showed significantly greater odds of having CAD in the lower versus higher VD for mean SCP, OR = 2.33 (95% CI 1.49-3.65); in the parafoveal SCP, OR = 2.68 (95% CI 1.70-4.23); and in the perifoveal SCP, OR = 2.36 (95% CI 1.49-3.72). Additionally, participants showed significantly greater odds of having CAD in the lower versus higher VD for mean DCP, OR = 4.04 (95% CI 2.53-6.45); in the parafoveal DCP, OR = 4.08 (95% CI 2.54-6.55); and in the perifoveal DCP, OR = 3.88 (95% CI 2.43-6.19). Among CAD patients, lower VD of DCP was associated with significantly greater adjusted Gensini scores (p = 0.004 for mean DCP; p = 0.035 for parafoveal DCP; p = 0.006 for perifoveal DCP).

CONCLUSIONS

SCP and DCP were found to be associated with the presence of CAD among the whole population, while DCP was found to be associated with Gensini scores in CAD patients. Retinal microvasculature was associated with the presence and severity of coronary artery stenosis in CAD patients.

Morphology and specifics of morphometry of lungs and myocardium of heart ventricles of cattle, sheep and horses

Respiratory organs and cardiovascular system are interconnected and perform extremely vital functions of the organism, the main goals being performing gas exchange with the environment and emitting carbon dioxide produced in the organism into the environment. Therefore, we carried out comparative histo- and cytomorphometric evaluation of morphological structures of the heart and lungs of cattle, sheep and horses. Using complex methods of research, we determined specifics of microscopic structure and histometric parameters of parenchyma of the lungs and myocardium of the ventricles of the hearts of clinically healthy animals in species aspect – cattle, sheep and horses. The studies revealed that the histoarchitectonics of the studied animals were similar in structure, characteristic of other species of agricultural mammals, and distinct morphometric peculiarities of their histostructures. The study indicated that the respiratory zone of the lungs is most developed in horses. This parameter was lower in ruminants – cattle and sheep. Connective tissue septum of parenchyma of lungs was better expressed in cattle and sheep, and less in horses. At the same time, mean volume of lung alveoli in clinically healthy animals varied: being highest in horses – 699 ± 106 thou µm3, then cattle – 337 ± 43 thou µm3 and sheep – 158 ± 37 thou µm3. Such variation in histometric parameters of parenchyma of the lungs in experimental animals indicates adaptive specifics of the organism of animals in terms of living conditions. Therefore, the respiratory zone was most developed in the lungs of horses, animals that experience significant physical and physiological load on corresponding organs and systems. As a result of histometric studies of myocardium, we determined patterns of sizes of thickness of its cardiomyocytes and volume of their nuclei. We determined that in myocardium of the heart ventricles, in the same microscope field of view, cardiomyocytes of varying thicknesses occur. At the same time, thickness of cardiomyocytes, their mean volume of nuclei in the ventricle myocardium were expressed the most in cattle, then in horses and sheep, and their histometric parameters in myocardium of the left ventricle of the heart in the experimental animals were higher than in the right one. Therefore, thickness of cardiomyocytes of the left ventricle in cattle equaled 14.06 ± 0.41 µm, and volume of nuclei of cardiomyocytes respectively 124.55 ± 7.99 µm3. Similar changes in such parameters of histometry were found in sheep and horses. We attribute such varying histometric parameters of the thickness of cardiomyocytes and volume of their nuclei in myocardium of the left ventricle of the heart in experimental animals, compared with such parameters in the right ventricle, to the activities of the ventricles (the left one generally functions as a pump, right one – as a volumetric) and functional specifics of this myocardium tissue, which is capable of spontaneous rhythmic contractions, resulting in blood flow in the vessels: cardiomyocytes of the left ventricle carry greater load, promoting blood flow in vessels of greater (somatic) blood circulation, respectively cardiomyocytes of the right ventricle – less load, promoting blood flow in vessels of lesser (pulmonary) blood circulation.

Oral GLP-1 analogue: perspectives and impact on atherosclerosis in type 2 diabetic patients

Cardiovascular events related to atherosclerosis are responsible for high morbidity and mortality among patients with type 2 diabetes. Improvement in care, especially in early stages, is crucial. Oral semaglutide, a glucagon-like peptide 1 analogue, controls blood glucose and results in significant body weight loss in patients with type 2 diabetes. Beyond these well-known effects, an interesting aspect of this drug is its antiatherogenic activity, which should be further explored in clinical practice. This paper reviews the evidence related to oral semaglutide decreasing cardiovascular risk in patients with type 2 diabetes, focusing on the drug's antiatherosclerotic properties. The glucagon-like peptide 1 analogue restores endothelial dysfunction, induces vasodilatation, and reduces plasma lipids. Oral semaglutide showed cardiovascular safety profile, with significant reduced risk of death from cardiovascular events. Based on current data, clinicians should consider oral semaglutide for type 2 diabetes management.

Soluble angiotensin-converting enzyme levels in heart failure or acute coronary syndrome: revisiting its modulation and prognosis value

The main objective was to compare the meaning of soluble angiotensin-converting enzyme-2 (sACE2) plasma levels modulation on the prognosis of two cohorts of heart failure (HF) and acute coronary syndrome (ACS). We conducted an observational clinical study where sACE2 was measured in two cohorts of HF or ACS (102 patients each), matched by age and gender. The primary endpoint (cardiac death) and the secondary endpoints (non-fatal myocardial infarction or HF readmission) were registered during a 5-year follow-up period. Association with pharmacotherapy was studied, and the effects of cardiovascular drugs on ACE isoforms expression were analysed in human umbilical vein endothelial cells (HUVEC) in vitro. The levels of sACE2 were significantly higher in the HF than ACS cohort. sACE2 was inversely related with the leukocytes number and directly with urea levels. In the ACS cohort, sACE2 was associated with age and glycaemic parameters, but in the HF cohort, the association was with N-terminal pro-B-type natriuretic peptide. The levels of sACE2 were related to long-term prognosis and confirmed as a non-independent predictor in the HF cohort. Soluble ACE2 was higher in patients treated with angiotensin receptors blockers and β-blockers, accordingly with losartan and metoprolol upregulation of ACE1 and ACE2 in HUVECs. Plasma levels of sACE2 were higher in HF than in ACS, independently of age and gender, and were related to long-term cardiac death in the HF cohort. Losartan and metoprolol, but not enalapril, upregulated ACE expression in endothelial cells, accordingly with higher levels of sACE2 in patients using these drugs.

Reciprocal organ interactions during heart failure: a position paper from the ESC Working Group on Myocardial Function

Heart failure-either with reduced or preserved ejection fraction (HFrEF/HFpEF)-is a clinical syndrome of multifactorial and gender-dependent aetiology, indicating the insufficiency of the heart to pump blood adequately to maintain blood flow to meet the body's needs. Typical symptoms commonly include shortness of breath, excessive fatigue with impaired exercise capacity, and peripheral oedema, thereby alluding to the fact that heart failure is a syndrome that affects multiple organ systems. Patients suffering from progressed heart failure have a very limited life expectancy, lower than that of numerous cancer types. In this position paper, we provide an overview regarding interactions between the heart and other organ systems, the clinical evidence, underlying mechanisms, potential available or yet-to-establish animal models to study such interactions and finally discuss potential new drug interventions to be developed in the future. Our working group suggests that more experimental research is required to understand the individual molecular mechanisms underlying heart failure and reinforces the urgency for tailored therapeutic interventions that target not only the heart but also other related affected organ systems to effectively treat heart failure as a clinical syndrome that affects and involves multiple organs.

Monitoring of risk factors of cardiovascular diseases in adult men

The study aims to evaluate the monitoring of risk factors of cardiovascular diseases in the young population, which significantly contribute to the origin and development of cardiovascular diseases, such as peripheral artery diseases, atherosclerosis, stroke, and others. We focused on a group of young adult men (n = 110) in the age range of 30 to 50 years, which we selected from the database of 800 patients hospitalized in the Cardio Center in Nitra during 2010 – 2020. When evaluating the influence of meat products consumption frequency on biochemical parameters and BMI, we recorded a statistically significant effect at the level of p <0.05 in the evaluation of meat products such as salami, brawn, and sausages. When consuming sausages, BMI values also increased with increasing frequency of consumption. The effect on BMI was also observed when eating salami, between consuming 1 – 2 times a week and not at all. We recorded a statistically significant effect (p <0.05) in frequent consumption of brawn (1 – 2 weeks) on the level of HDL cholesterol. The most frequent fish consumption was 1 – 2 times a month for freshwater (51.8%) and marine fish (56.3%). Daily consumption of fruit was reported in 64.6% of men, while daily consumption of vegetables was recorded in only 44.6% of men. In the lifestyle assessment, we focused on probands' time spent on physical activity. Only 35.5% of men stated that they spend more than an hour a day on physical activity. 40% of men from the surveyed respondents were active smokers. Another risk factor for cardiovascular diseases is stress, which significantly affected up to 42.7% of respondents. Nutrition and lifestyle play an important role in the prevention of cardiovascular diseases, which significantly affect blood lipid parameters, vascular endothelial elasticity, and factors determining the etiopathogenesis of cardiovascular diseases.

Evaluating the thermal performance of a balloon-based renal sympathetic denervation system with array electrodes: a finite element study

Renal denervation transmits radiofrequency (RF) energy through an electrode to treat resistant hypertension (RH), applying ablation in the renal artery. Several experimental studies have shown that this treatment has been used effectively to treat RH. The aim of this paper is to investigate the effect of ablation parameters (i.e., electrode length, applied voltage, ablation time, and blood flow) on the temperature distribution using a balloon-based array electrodes system. A simplified three-dimensional model including four electrodes and a balloon was established. The balloon diameter was 3 mm and placed in a 5 mm diameter renal artery for forming intra-arterial occlusion. Four electrodes were mounted on the balloon and distributed in the same plane to mimic circumferential RF ablation. Computer simulations were conducted to investigate the thermal performances of the device by setting different electrode configurations, treatment protocols, and physiological factors. The thermal performances including the thermal distribution, maximum lesion depth, length, and area were analyzed. The lesion shape of the array RF electrodes was approximately a sphere with a 100% circumference coverage rate of the renal artery. The lesion depth and length increase with each factor except for blood velocity. Increasing the electrode length from 2 to 4 mm or 2 to 6 mm, the lesion depth increases by 1.15 mm and 0.54 mm at 60 s. The corresponding lesion length increases by 2.65 mm and 2.34 mm, respectively. The range of effective lesion depth is 1.90-4.90 mm, at a voltage of 15-30 V. But the peak temperature at the arterial outer wall exceeded 100 °C when the voltage is above 25 V. In tissue, the degree of thermal injury in the 2 mm area reached 100%, but in blood was not more than 5%. There was no significant difference at different flow conditions because the difference value in lesion depth was not exceeded 0.5 mm. The results showed that the balloon-based four electrodes system is expected to overcome the difficulty of incomplete ablation. In clinical application, 2 mm-electrode is recommended to avoid long wall damage as much as possible and control the voltage below 25 V. This treatment has little thermal injury on the blood, which means it may avoid coagulation formation. Moreover, the application of this device does not need to consider the difference in individual blood velocity.