Six-Year Changes in Physical Activity and the Risk of Incident Heart Failure: ARIC Study

Alcohol Consumption and Progression of Heart Failure in Those at Risk for or With Pre-heart Failure

BACKGROUND

This study aimed to understand the dose-response relationship between alcohol consumption, progression of left ventricular dysfunction (LVD) and/or symptomatic heart failure (HF) in an older European population at risk for HF (stage A) or with pre-HF (stage B).

METHODS

This longitudinal, observational, secondary analysis of the STOP-HF (St Vincent's Screening TO-Prevent Heart Failure) trial follow-up study excluded former alcohol drinkers and included patients with documented alcohol intake and echocardiography at baseline and follow-up ≥ 18 months. It evaluated the relationship between alcohol intake and progression of LVD/symptomatic (stage C) HF in those at risk for or with pre-HF.

RESULTS

Of 744 patients (mean age 66.5 [SD 9.8] years), 395 (53.1%) were female, and 260 (34.9%) had pre-HF at baseline. Overall, 201 (27.0%) patients reported no alcohol usage, 356 (47.8%) reported ≤70 g/week (low) alcohol intake, and 187 (25.1%) reported > 70g/week (moderate-high). Over a median follow-up of 5.44 (IQR 4.33;6.73) years, 84 (11.3%) patients experienced progression of LVD/symptomatic HF. Alcohol usage of > 70g/week was associated with an adjusted 4.9-fold (95% CI 1.7-15.1; P < 0.01) increased risk of HF progression among those with pre-HF at baseline. The adverse relationship remained significant when adjusting for age, sex, diabetes, hypertension, body mass index, as well as further models with baseline liver function and alcohol dehydrogenase 1B gene variant rs1229984 status. The association remained when excluding those with high (> 140 g) weekly alcohol intake. In patients at risk for HF, there was no association of alcohol usage with progression of LVD/symptomatic HF. No protective associations of low alcohol usage (≤70 g/week) on progression of HF were found.

CONCLUSION

Moderate to high alcohol (> 70 g/week) usage appears to be associated with progression of LVD/symptomatic HF in those with pre-HF, and we did not observe protective benefits of low alcohol usage.

Effects of lifestyle factors on leukocytes in cardiovascular health and disease

Exercise, stress, sleep and diet are four distinct but intertwined lifestyle factors that influence the cardiovascular system. Abundant epidemiological, clinical and preclinical studies have underscored the importance of managing stress, having good sleep hygiene and responsible eating habits and exercising regularly. We are born with a genetic blueprint that can protect us against or predispose us to a particular disease. However, lifestyle factors build upon and profoundly influence those predispositions. Studies in the past 10 years have shown that the immune system in general and leukocytes in particular are particularly susceptible to environmental perturbations. Lifestyle factors such as stress, sleep, diet and exercise affect leukocyte behaviour and function and thus the immune system at large. In this Review, we explore the various mechanisms by which lifestyle factors modulate haematopoiesis and leukocyte migration and function in the context of cardiovascular health. We pay particular attention to the role of the nervous system as the key executor that connects environmental influences to leukocyte behaviour.

Exploring the Mechanistic Link Between Obesity and Heart Failure

PURPOSE OF REVIEW

Among subtypes of cardiovascular disease, obesity has a potent and unique association with heart failure (HF) that is unexplained by traditional cardiovascular risk mediators. The concomitant rise in the prevalence of obesity and HF necessitates better understanding of their relationship to develop effective prevention and treatment strategies. The purpose of this review is to provide mechanistic insight regarding the link between obesity and HF by elucidating the direct and indirect pathways linking the two conditions.

RECENT FINDINGS

Several direct pathophysiologic mechanisms contribute to HF risk in individuals with excess weight, including hemodynamic alterations, neurohormonal activation, hormonal effects of dysfunctional adipose tissue, ectopic fat deposition with resulting lipotoxicity and microvascular dysfunction. Obesity further predisposes to HF indirectly through causal associations with hypertension, dyslipidemia, and most importantly, diabetes via insulin resistance. Low levels of physical activity and fitness further influence HF risk in the context of obesity. These various processes lead to myocardial injury and cardiac remodeling that are reflected by abnormalities in cardiac biomarkers and cardiac function on myocardial imaging. Understanding and addressing obesity-associated HF is a pressing clinical and public health challenge which can be informed by a deeper understanding of the complex pathways linking these two conditions together.

Preventing new-onset heart failure: Intervening at stage A

Heart failure (HF) prevention is an urgent public health need with national and global implications. Stage A HF patients do not show HF symptoms or structural heart disease but are at risk of HF development. There are no unique recommendations on detecting Stage A patients. Patients in Stage A are heterogeneous; many patients have different combinations of risk factors and, therefore, have markedly different absolute risks for HF. Comprehensive strategies to prevent HF at Stage A include intensive blood pressure lowering, adequate glycemic and lipid management, and heart-healthy behaviors (adopting Life's Essential 8). First and foremost, it is imperative to improve public awareness of HF risk factors and implement healthy lifestyle choices very early. In addition, recognize the HF risk-enhancing factors, which are nontraditional cardiovascular (CV) risk factors that identify individuals at high risk for HF (genetic susceptibility for HF, atrial fibrillation, chronic kidney disease, chronic liver disease, chronic inflammatory disease, sleep-disordered breathing, adverse pregnancy outcomes, radiation therapy, a history of cardiotoxic chemotherapy exposure, and COVID-19). Early use of biomarkers, imaging markers, and echocardiography (noninvasive measures of subclinical systolic and diastolic dysfunction) may enhance risk prediction among individuals without established CV disease and prevent chemotherapy-induced cardiomyopathy. Efforts are needed to address social determinants of HF risk for primordial HF prevention.Central illustrationPolicies developed by organizations such as the American Heart Association, American College of Cardiology, and the American Diabetes Association to reduce CV disease events must go beyond secondary prevention and encompass primordial and primary prevention.

Visceral adiposity index and the risk of heart failure, late-life cardiac structure, and function in ARIC study

BACKGROUND

It is well established that obesity is associated with the risk of heart failure (HF). However, the data about relationship between visceral fat and the risk of HF are limited.

AIMS

We aim to evaluate the association between visceral obesity assessed by visceral adiposity index (VAI) and incident HF and left ventricular (LV) structure and function in Atherosclerosis Risk in Communities (ARIC) study.

METHODS

We included 12 161 participants (aged 54.1 ± 5.8 years) free of history of HF and coronary heart disease at baseline (1987-89) in ARIC study. We used multivariable Cox hazard regression models to assess the association between the VAI and incident HF. We further explored the effects of the VAI on LV geometry and function among 4817 participants with echocardiographic data using multivariable linear regression analysis and multinomial logistic regression.

RESULTS

During a median follow-up of 22.5 years, a total of 1904 (15.7%) participants developed HF. After adjustment for traditional HF risk factors, 1 unit increase in the baseline VAI was associated with an 8% higher risk of incident HF [hazard ratio (HR): 1.08, 95% confidence interval (CI): 1.06-1.11]. Results were similar when participants were categorized by VAI tertiles. Compared with participants in the lowest tertile of VAI, those in the second tertile and third tertile had a greater risk of incident HF [HR (95% CI): 1.19 (1.05-1.34) and 1.42 (1.26-1.61), respectively]. For the analyses of the HF subtypes, the higher VAI was only associated with the risk of HF with preserved ejection fraction, not with HF with reduced ejection fraction. In addition, the greater VAI was associated with worse LV diastolic function and abnormal LV geometry including concentric remodelling, concentric hypertrophy, and eccentric hypertrophy.

CONCLUSION

This study shows that higher VAI was independently associated with the increased risk of incident HF and abnormal LV geometry and LV diastolic dysfunction.

Physical Activity Over the Lifecourse and Cardiovascular Disease

Despite improvements in cardiovascular care in recent decades, cardiovascular disease (CVD) remains a leading cause of death worldwide. At its core, CVD is a largely preventable disease with diligent risk factor management and early detection. As highlighted in the American Heart Association's Life's Essential 8, physical activity plays a central role in CVD prevention at an individual and population level. Despite pervasive knowledge of the numerous cardiovascular and noncardiovascular health benefits of physical activity, physical activity has steadily decreased over time and unfavorable changes in physical activity occur throughout people's lives. Here, we use a lifecourse framework to examine the evidence reporting on the association of physical activity with CVD. From in utero to older adults, we review and discuss the evidence detailing how physical activity may prevent incident CVD and mitigate CVD-related morbidity and death across all life stages.

Heart failure and obesity: The latest pandemic

The marked rise in rates of obesity, which is most prominent among individuals from socio-economically disadvantaged circumstances, has been a powerful contributor to the rising prevalence of heart failure (HF). Obesity has indirect effects on HF through the development of several metabolic risk factors, but also direct adverse effects on the myocardium. Obesity contributes to myocardial dysfunction and HF risk through multiple mechanisms, including hemodynamic changes, neurohormonal activation, endocrine and paracrine effects of adipose tissue, ectopic fat deposition and lipotoxicity. These processes principally result in concentric left ventricular (LV) remodeling and predominant increase in the risk for HF with preserved LV ejection fraction (HFpEF). Despite the excess risk for HF associated with obesity, there is a well described obesity paradox in which individuals with overweight and grade I obesity have better survival than those with normal weight and overweight. Despite the obesity paradox among individuals with prevalent HF, intentional weight loss is associated with improvements in metabolic risk factors, myocardial dysfunction and quality of life, in a dose-response fashion. In matched observational studies of bariatric surgery patients, marked weight loss is associated with decreased risk for developing HF, as well as improved cardiovascular disease (CVD) outcomes in those with existing HF. Ongoing clinical trials using powerful new obesity pharmacotherapies in individuals in with obesity and CVD may provide definitive information regarding the cardiovascular impact of weight loss. Given the powerful contribution of rising obesity prevalence to rates of HF, addressing these intertwined epidemics is a clinical and public health priority.

Improvement of physical activity significantly reduced serum hepatocyte growth factor levels in a general population: 10 year prospective study

Hepatocyte growth factor (HGF) is an adipocytokine elevated in obese subjects. We have previously reported that serum HGF levels were significantly associated with insulin resistance or components of the metabolic syndrome. However, it has been unknown how physical activity (PA) affects HGF levels after a long-term follow-up. Our aim was to clarify the association between PA changes and HGF levels as well as cerebro-cardiovascular disease (CVD) development, during a 10 year follow-up period in a Japanese general population. Of 1320 subjects who received a health check-up examination in Tanushimaru town in 1999, 903 subjects (341 males and 562 females), who received the examination both in 1999 and 2009 were enrolled. We evaluated their PA levels by Baecke questionnaire in 1999 and by a simple questionnaire in 2009. We measured the HGF levels by ELISA method in 1999 and 2009. We divided the subjects into four PA groups, stable low PA, increased PA, decreased PA, and stable high PA. Using these questionnaires, we compared their PA and HGF levels after an interval of 10 years. A significant inverse association was found between PA changes and HGF levels at 10 years, after adjustment for age and sex. The HGF levels of the increased PA group were significantly lower than stable low PA (p = 0.038), and the increased PA group showed reduced CVD development compared to the stable low PA group after adjustment for age and sex (p = 0.012). Our data demonstrated that improvement of PA levels was associated with reduced HGF levels and CVD development.

Changes in physical activity and risk of ischemic stroke: The ARIC study

BACKGROUND

Limited data exist regarding the impact of changes in physical activity (PA) over time on ischemic stroke risk. Exploring this understudied area could help improve stroke prevention strategies and promote PA during the lifespan.

METHODS

We evaluated 11,089 Atherosclerosis Risk in Communities (ARIC) participants recruited in 1987-1989 who completed Visit 3 (1993-1995). We classified PA as meeting recommendations, not meeting recommendations, or no PA. Categories of increased, decreased, stable high, and stable low PA and a continuous PA variable were also evaluated. Crude and adjusted Cox regression models were used to characterize the association of 6-year changes in PA and ischemic stroke risk.

RESULTS

Participants had a mean age of 60 years. During a median of 21 years, 762 ischemic stroke events occurred. Compared to the participants with recommended PA at both visits, those with no PA had 46% higher hazards of ischemic stroke (hazard ratio (HR) = 1.46 (95% confidence interval (CI) = 1.17, 1.82)), and those with recommended PA at Visit 1 and no PA at Visit 3 also had 37% higher hazards (HR = 1.37 (95% CI = 1.02, 1.83)). Participants who increased their PA from Visit 1 to Visit 3 had 23% lower hazard than those with stable low PA at both visits (HR = 0.77 (95% CI = 0.63, 0.94)), while those who decreased their PA had 25% higher hazards compared to those with stable high PA at both visits (HR = 1.25 (95% CI = 1.01, 1.54)).

CONCLUSION

Physical inactivity during midlife increases ischemic stroke risk, while meeting PA recommendations reduces it.

Healthy hearts healthy minds: A randomized trial of online interventions to improve physical activity

INTRODUCTION

Depressed individuals are more likely to die from cardiovascular disease (CVD) than those without depression. People with CVD have higher rates of depression than those without and have higher mortality rates if they have comorbid depression. While physical activity (PA) improves both, few people engage in enough. We compared self-guided internet-based cognitive behavior therapy (CBT) + Fitbit or mindfulness-based cognitive therapy (MBCT) + Fitbit, with Fitbit only to increase daily steps for participants with depression who have low PA.

METHODS

Adult participants (N = 340) were recruited from two online patient-powered research networks and randomized to one of three study interventions for 8 weeks with an additional 8 weeks of follow-up. Using linear mixed effects models, we evaluated the effect of the intervention on average daily steps (NCT03373110).

RESULTS

Average daily steps increased 2.8 steps per day in MBCT+Fitbit, 2.9 steps/day in CBT + Fitbit, but decreased 8.2 steps/day in Fitbit Only. These changes were not statistically different between the MBCT+Fitbit and CBT + Fitbit groups, but were different from Fitbit Only across the initial 8-week period. Group differences were not maintained across follow-up. Exploratory analyses identified comorbid anxiety disorders, self-reported PA, and employment status as moderators.

DISCUSSION

Changes in daily steps over both 8- and 16-week periods-regardless of intervention group-were minimal. The results emphasize the limits of using self-guided web-based psychotherapy with an activity tracker to increase PA in participants with a history of depression and low PA.

Physical activity, cardiorespiratory fitness, and cardiovascular health: A clinical practice statement of the American Society for Preventive Cardiology Part II: Physical activity, cardiorespiratory fitness, minimum and goal intensities for exercise training, prescriptive methods, and special patient populations

The prescription of exercise for individuals with and without cardiovascular disease (CVD) should be scientifically-based yet adapted to the patient. This scientific statement reviews the clinical and physiologic basis for the prescription of exercise, with specific reference to the volume of physical activity (PA) and level of cardiorespiratory fitness (CRF) that confer significant and optimal cardioprotective benefits. Recommendations are provided regarding the appropriate intensity, frequency, and duration of training; the concept of MET-minutes per week; critical components of the exercise session (warm-up, conditioning phase, cool-down); methodologies for establishing the training intensity, including oxygen uptake reserve (V̇O2R), target heart rate derivation and rating perceived exertion; minimum and goal intensities for exercise training; and, types of training activities, including resistance training, adjunctive lifestyle PA, marathon/triathlon training, and high-intensity interval training. In addition, we discuss the rationale for and value of exercise training programs for patients with peripheral artery disease, diabetes mellitus, and heart failure.

Remission of type 2 diabetes and improved diastolic function by combining structured exercise with meal replacement and food reintroduction among young adults: the RESET for REMISSION randomised controlled trial protocol

INTRODUCTION

Type 2 diabetes mellitus (T2DM) onset before 40 years of age has a magnified lifetime risk of cardiovascular disease. Diastolic dysfunction is its earliest cardiac manifestation. Low energy diets incorporating meal replacement products can induce diabetes remission, but do not lead to improved diastolic function, unlike supervised exercise interventions. We are examining the impact of a combined low energy diet and supervised exercise intervention on T2DM remission, with peak early diastolic strain rate, a sensitive MRI-based measure, as a key secondary outcome.

METHODS AND ANALYSIS

This prospective, randomised, two-arm, open-label, blinded-endpoint efficacy trial is being conducted in Montreal, Edmonton and Leicester. We are enrolling 100 persons 18-45 years of age within 6 years' T2DM diagnosis, not on insulin therapy, and with obesity. During the intensive phase (12 weeks), active intervention participants adopt an 800-900 kcal/day low energy diet combining meal replacement products with some food, and receive supervised exercise training (aerobic and resistance), three times weekly. The maintenance phase (12 weeks) focuses on sustaining any weight loss and exercise practices achieved during the intensive phase; products and exercise supervision are tapered but reinstituted, as applicable, with weight regain and/or exercise reduction. The control arm receives standard care. The primary outcome is T2DM remission, (haemoglobin A1c of less than 6.5% at 24 weeks, without use of glucose-lowering medications during maintenance). Analysis of remission will be by intention to treat with stratified Fisher's exact test statistics.

ETHICS AND DISSEMINATION

The trial is approved in Leicester (East Midlands - Nottingham Research Ethics Committee (21/EM/0026)), Montreal (McGill University Health Centre Research Ethics Board (RESET for remission/2021-7148)) and Edmonton (University of Alberta Health Research Ethics Board (Pro00101088). Findings will be shared widely (publications, presentations, press releases, social media platforms) and will inform an effectiveness trial.

TRIAL REGISTRATION NUMBER

ISRCTN15487120.

Clinically Recognized Varicose Veins and Physical Function in Older Individuals: The ARIC Study

BACKGROUND

Although a few studies reported an association between varicose veins and physical function, this potentially bidirectional association has not been systematically evaluated in the general population.

METHOD

In 5 580 participants (aged 71-90 years) from the Atherosclerosis Risk in Communities study, varicose veins were identified in outpatient and inpatient administrative data prior to (prevalent cases) and after (incident cases) visit 5 (2011-2013). Physical function was evaluated by the Short Physical Performance Battery (SPPB, score ranging from 0 to 12). We evaluated (i) cross-sectional association between prevalent varicose veins and physical function, (ii) association of prevalent varicose veins with subsequent changes in physical function from visit 5 to visits 6 (2016-2017) and 7 (2018-2019), and (iii) association of physical function at visit 5 with incident varicose veins during a median follow-up of 3.6 years (105 incident varicose veins among 5 350 participants without prevalent cases at baseline).

RESULTS

At baseline, varicose veins were recognized in 230 (4.1%) participants and cross-sectionally associated with reduced physical function. Longitudinally, prevalent varicose veins were not significantly associated with a decline in SPPB over time. In contrast, a low SPPB ≤6 was associated with a greater incidence of varicose veins compared to SPPB ≥10 (adjusted hazard ratio 2.13 [95% confidence interval = 1.19, 3.81]).

CONCLUSION

In community-dwelling older adults, varicose veins and low physical function were associated cross-sectionally. Longitudinally, low physical function was a risk factor for incident varicose veins, but not vice versa. Our findings suggest an etiological contribution of low physical function to incident varicose veins.

Effects of Exercise on Heart Failure with Preserved Ejection Fraction: An Updated Review of Literature

Heart failure with preserved ejection fraction (HFpEF) represents the most common HF phenotype of patients aged > 65 years, with an incidence and a prevalence that are constantly growing. The HFpEF cardinal symptom is exercise intolerance (EI), defined as the impaired ability to perform physical activity and to reach the predicted age-related level of exercise duration in the absence of symptoms—such as fatigue or dyspnea—and is associated with a poor quality of life, a higher number of hospitalizations, and poor outcomes. The evidence of the protective effect between exercise and adverse cardiovascular outcomes is numerous and long-established. Regular exercise is known to reduce cardiovascular events and overall mortality both in apparently healthy individuals and in patients with established cardiovascular disease, representing a cornerstone in the prevention and treatment of many cardio-metabolic conditions. Several studies have investigated the role of exercise in HFpEF patients. The present review aims to dwell upon the effects of exercise on HFpEF. For this purpose, the relevant data from a literature search (PubMed, EMBASE, and Medline) were reviewed. The analysis of these studies underlines the fact that exercise training programs improve the cardiorespiratory performance of HFpEF patients in terms of the increase in peak oxygen uptake, the 6 min walk test distance, and the ventilatory threshold; on the other hand, diastolic or systolic functions are generally unchanged or only partially modified by exercise, suggesting that multiple mechanisms contribute to the improvement of exercise tolerance in HFpEF patients. In conclusion, considering that exercise training programs are able to improve the cardiorespiratory performance of HFpEF patients, the prescription of exercise training programs should be encouraged in stable HFpEF patients, and further research is needed to better elucidate the pathophysiological mechanisms underpinning the beneficial effects described.

Changes in Patterns of Physical Activity and Risk of Heart Failure in Newly Diagnosed Diabetes Mellitus Patients

BACKGROUND

Exercise is recommended for type 2 diabetes mellitus (T2DM) patients to prevent cardiovascular disease. However, the effects of physical activity (PA) for reducing the risk of heart failure (HF) has yet to be elucidated. We aimed to assess the effect of changes in patterns of PA on incident HF, especially in newly diagnosed diabetic patients.

METHODS

We examined health examination data and claims records of 294,528 participants from the Korean National Health Insurance Service who underwent health examinations between 2009 and 2012 and were newly diagnosed with T2DM. Participants were classified into the four groups according to changes in PA between before and after the diagnosis of T2DM: continuously inactive, inactive to active, active to inactive, and continuously active. The development of HF was analyzed until 2017.

RESULTS

As compared with those who were continuously inactive, those who became physically active after diagnosis showed a reduced risk for HF (adjusted hazard ratio [aHR], 0.79; 95% confidence interval [CI], 0.66 to 0.93). Those who were continuously active had the lowest risk for HF (aHR, 0.77; 95% CI, 0.62 to 0.96). As compared with those who were inactive, those who exercised regularly, either performing vigorous or moderate PA, had a lower HF risk (aHR, 0.79; 95% CI, 0.69 to 0.91).

CONCLUSION

Among individuals with newly diagnosed T2DM, the risk of HF was reduced in those with higher levels of PA after diagnosis was made. Our results suggest either increasing or maintaining the frequency of PA after the diagnosis of T2DM may lower the risk of HF.

Association of physical activity trajectories with major cardiovascular diseases in elderly people

Introduction

Cardiovascular benefits deriving from physical activity are well known, but it is unclear whether physical activity trajectories in late life are associated with different risks of cardiovascular diseases.

Methods

Progetto Veneto Anziani (Pro.V.A.) is a cohort study of 3099 Italians aged ≥65 years with baseline assessment in 1995–1997 and follow-up visits at 4 and 7 years. Surveillance was extended to 2018 by linkage with hospital and mortality records. Prevalent and incident cardiovascular diseases (coronary heart disease, heart failure and stroke) were identified through clinical examination, questionnaire, or hospital records. Moderate to vigorous physical activity was considered as a time-varying variable. Physical activity trajectories were categorised as: stable-low, high-decreasing, low-increasing and stable-high. Exposure was also assessed at 70, 75, 80 and 85 years.

Results

Overall, physical activity was associated with lower rates of incident cardiovascular diseases. A significant risk reduction was present among men and was stronger earlier in late life (70–75 years). Trajectories of stable-high physical activity were associated with a significantly lower risk of cardiovascular outcomes among men (HR 0.48, 95% CI 0.27 to 0.86) compared with those with stable-low trajectories (p for trend 0.002). No significant association was found with stroke. The greatest cardiovascular risk reduction was observed for >20 min/day of physical activity, and was more marked at 70 years.

Conclusion

Increasingly active trajectories of physical activity were associated with lower rates of cardiovascular diseases and overall mortality. Promoting at least 20 min/day of physical activity early in late life seems to provide the greatest cardiovascular benefits.

Growth Differentiation Factor-15 Predicts Death and Stroke Event in Outpatients With Cardiovascular Risk Factors: The J-HOP Study

Background Growth differentiation factor-15 (GDF-15) has emerged as a novel biomarker to predict all-cause death in community-dwelling individuals and patients with cardiovascular disease. We evaluated the prognostic value of GDF-15 in outpatients with cardiovascular risk factors. Methods and Results GDF-15 levels were measured in 3562 outpatients with cardiovascular risk factors in the J-HOP (Japan Morning Surge-Home Blood Pressure) study, a nationwide prospective study. Participants were stratified according to tertiles of GDF-15 and followed up for all-cause death and cardiovascular disease. During a mean follow-up period of 6.6 years, there were 155 all-cause deaths, 81 stroke events including cerebral infarction and intracranial hemorrhage, and 141 cardiac events including cardiac artery disease and heart failure. Patients with higher GDF-15 levels were associated with risks of all-cause death and stroke events (except for cardiac events) after adjustment for traditional risk factors and other prognostic biomarkers (NT-proBNP [N-terminal pro-B-type natriuretic peptide], high-sensitivity troponin T; all-cause death, hazard ratio, 2.38; 95% CI, 1.26-4.48; P=0.007; stroke events, hazard ratio, 2.93; 95% CI, 1.31-6.56, P=0.009; compared with the lowest tertile). Furthermore, incorporating GDF-15 to the predictive models for all-cause death improved discrimination and reclassification significantly. For stroke events, GDF-15 showed similar diagnostic accuracy to NT-proBNP and high-sensitivity troponin T. Conclusions In Japanese outpatients with cardiovascular risk factors, GDF-15 improves risk stratification for all-cause death when compared with NT-proBNP and high-sensitivity troponin T. GDF-15 was associated with increased risks of stroke events beyond conventional risk factors and other prognostic markers; however, the predictive ability for stroke events was equivalent to NT-proBNP and high-sensitivity troponin T. Registration URL: http://www.umin.ac.jp/ctr.; Unique identifier: UMIN000000894.

Physical activity and stroke among women - A non-linear relationship

Studies have identified non-linear inverse relationships between physical activity and the risk of stroke. A U-shaped response has been observed between haemorrhagic stroke and physical activity. The objective of this study was to investigate the associations between physical activities on stroke. We used data from the E3N cohort study, a French prospective study of women initiated in 1990. From the women in the study, we included those without cardiovascular disease or cancer at baseline, resulting in 94,169 women. We assessed total physical activity in 1993, grouped as quartiles. Cox models adjusted for potential confounders were used to assess the relationship with stroke, considering cases until 2008. Splines were used to assess the shape of the response. Similarly, we then considered high and low-intensity physical activity grouped as tertiles. Among the included women, with a mean age of 51.2 ± 6.7 years, 592 cases of stroke were identified over an average follow-up time of 16.2 years. Total physical activity was associated with a lower stroke risk (HR_Q1-Q4 = 0.38 [0.31, 0.49]). An inverse relationship was observed between physical activity and all stroke sub-types. A non-linear (L-shaped) relationship was observed for all-stroke, and ischemic stroke, and a U-shaped response for sub-arachnoid and intracerebral haemorrhage. High-intensity activities were associated with a U-shaped response for haemorrhagic stroke types. Low-intensity activities were associated with a linear response for all stroke types. Our results support other observations that physical activity may reduce stroke risk.

Physical Activity in the Treatment and Prevention of Heart Failure: An Update

ABSTRACT

Heart failure (HF) is a complex clinical syndrome hallmarked by an inability to match cardiac output with metabolic demand, resulting in exercise intolerance. HF is increasingly prevalent in an aging population and accounts for substantial burden of health care costs and morbidity. Because many of the central and peripheral mechanisms of HF respond favorably to exercise training, its role in HF treatment is becoming established. The role of habitual physical activity in the primary prevention of HF is less clear; however, available evidence is supportive. This article reviews recently published studies on exercise training and usual physical activity in HF treatment and prevention, discusses potential mechanisms, and suggests areas where further research is needed.

Associations of Cardiac Mechanics With Exercise Capacity: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Lower exercise capacity, as measured by 6-minute walk distance (6MWD), is associated with incident heart failure (HF). Among those without HF, the associations of measures of cardiac function with 6MWD are unclear, and may provide insight regarding the risk of incident HF.

OBJECTIVES

The purpose of this study was to understand the relationships between cardiac function and exercise capacity.

METHODS

This study evaluated the associations of cardiac mechanics with 6MWD in the sixth examination of the Multi-Ethnic Study of Atherosclerosis. Echocardiography (2-dimensional, Doppler, and speckle-tracking) was performed at rest and after passive leg raise to evaluate functional reserve after intravascular volume challenge.

RESULTS

Of 2,096 participants without HF (mean age 73 years, 48% men, 58% non-White), individuals with lower (worse) left atrial (LA) reservoir strain were older and had higher blood pressure. Lower resting LA reservoir strain (β coefficient per SD decrease: -5.0; 95% confidence interval [CI]: -8.8 to -1.3 m; p = 0.009), inability to augment LA reservoir strain after passive leg raise (β coefficient per SD decrease: -5.8; 95% CI: -9.1 to -2.5 m; p < 0.001), and lower right atrial reservoir strain (β coefficient per SD decrease: -4.4; 95% CI: -7.8 to -1.1 m; p = 0.01) were associated with shorter 6MWD. Worse left ventricular (LV) diastolic function was also associated with lower 6MWD. There were no independent associations of measures of LV systolic function (global longitudinal strain, circumferential strain, ejection fraction) with 6MWD.

CONCLUSIONS

Among individuals without HF, worse biatrial function, lack of LA functional reserve, and worse LV diastolic function were associated with reduced submaximal exercise capacity. Therapies aimed to improve these functional domains may increase exercise capacity and prevent HF.

Performance of the American Heart Association/American College of Cardiology Pooled Cohort Equations to Estimate Atherosclerotic Cardiovascular Disease Risk by Self-reported Physical Activity Levels

Importance

The American Heart Association/American College of Cardiology pooled cohort equations (PCEs) are used for predicting 10-year atherosclerotic cardiovascular disease (ASCVD) risk. Pooled cohort equation risk prediction capabilities across self-reported leisure-time physical activity (LTPA) levels and the change in model performance with addition of LTPA to the PCE are unclear.

Objective

To evaluate PCE risk prediction performance across self-reported LTPA levels and the change in model performance by adding LTPA to the existing PCE model.

Design, Setting, and Participants

Individual-level pooling of data from 3 longitudinal cohort studies-Atherosclerosis Risk in Communities, Multi-Ethnic Study of Atherosclerosis, and Cardiovascular Health Study-was performed. A total of 18 824 participants were stratified into 4 groups based on self-reported LTPA levels: inactive (0 metabolic equivalent of task [MET]-min/wk), less than guideline-recommended (<500 MET-min/wk), guideline-recommended (500-1000 MET-min/week), and greater than guideline-recommended (>1000 MET-min/wk). Pooled cohort equation risk discrimination was studied using the C statistic and reclassification capabilities were studied using the Greenwood Nam-D'Agostino χ2 goodness-of-fit test. Change in risk discrimination and reclassification on adding LTPA to PCEs was evaluated using change in C statistic, integrated discrimination index, and categorical net reclassification index.

Main Outcomes and Measures

Adjudicated ASCVD events during 10-year follow-up.

Results

Among 18 824 participants studied, 10 302 were women (54.7%); mean (SD) age was 57.6 (8.2) years. A total of 5868 participants (31.2%) were inactive, 3849 (20.4%) had less than guideline-recommended LTPA, 3372 (17.9%) had guideline-recommended LTPA, and 5735 (30.5%) had greater than guideline-recommended LTPA level. Higher LTPA levels were associated with a lower risk of ASCVD after adjustment for risk factors (hazard ratio [HR] per 1-SD higher LTPA, 0.91; 95% CI, 0.86-0.96). Across LTPA groups, PCE risk discrimination (C statistic, 0.76-0.78) and risk calibration (all χ2 P > .10) was similar. Addition of LTPA to the PCE model resulted in no significant change in the C statistic (0.0005; 95% CI, -0.0004 to 0.0015; P = .28) and categorical net reclassification index (-0.003; 95% CI, -0.010 to 0.010; P = .95), but a minimal improvement in the integrated discrimination index (0.0008; 95% CI, 0.0002-0.0013; P = .005) was observed. Similar results were noted when cohort-specific coefficients were used for creating the baseline model.

Conclusions and Relevance

Higher self-reported LTPA levels appear to be associated with lower ASCVD risk and increasing LTPA promotes cardiovascular wellness. These findings suggest the American Heart Association/American College of Cardiology PCEs are accurate at estimating the probability of 10-year ASCVD risk regardless of LTPA level. The addition of self-reported LTPA to PCEs does not appear to be associated with improvement in risk prediction model performance.

Prestroke Physical Activity and Adverse Health Outcomes After Stroke in the Atherosclerosis Risk in Communities Study

BACKGROUND AND PURPOSE

The association of physical activity (PA) before stroke (prestroke PA) with long-term prognosis after stroke is still unclear. We examined the association of prestroke PA with adverse health outcomes in the ARIC study (Atherosclerosis Risk in Communities).

METHODS

We included 881 participants with incident stroke occurring between 1993 and 1995 (visit 3) and December 31, 2016. Follow-up continued until December 31, 2017 to allow for at least 1-year after incident stroke. Prestroke PA was assessed using a modified version of the Baecke questionnaire in 1987 to 1989 (visit 1) and 1993 to 1995 (visit 3), evaluating PA domains (work, leisure, and sports) and total PA. We used Cox proportional hazards models to quantify the association between tertiles of accumulated prestroke PA levels over the 6-year period between visits 1 and 3 and mortality, risk of cardiovascular disease, and recurrent stroke after incident stroke.

RESULTS

During a median follow-up of 3.1 years after incident stroke, 676 (77%) participants had adverse outcomes. Highest prestroke total PA was associated with decreased risks of all-cause mortality (hazard ratio, 0.78 [95% CI, 0.63-0.97]) compared with lowest tertile. In the analysis by domain-specific PA, highest levels of work PA were associated with lower risk for all-cause (hazard ratio, 0.77 [95% CI, 0.62-0.96]) and cardiovascular mortality (hazard ratio, 0.45 [95% CI, 0.29-0.70]), and highest levels of leisure PA were associated with lower all-cause mortality (hazard ratio, 0.72 [95% CI, 0.58-0.89]) compared with lowest tertile of PA. No significant associations for sports PA were observed.

CONCLUSIONS

Higher levels of total prestroke PA as well as work and leisure PA were associated with lower risk of mortality after incident stroke. Public health strategies to increase lifetime PA should be encouraged to decrease long-term mortality after stroke.

The association of estimated cardiorespiratory fitness with COVID-19 incidence and mortality: A cohort study

Background

It has been suggested that cardiorespiratory fitness (CRF) may be used to identify those at greatest risk for severe COVID-19 illness. However, no study to date has examined the association between CRF and COVID-19. The objectives of this study were to determine whether CRF is independently associated with testing positive with or dying from COVID-19.

Methods

This is a prospective cohort study of 2,690 adults from the UK Biobank Study that were followed from March 16^th, 2020 to July 26^th, 2020. Participants who were tested for COVID-19 and had undergone CRF assessment were examined. CRF was estimated (eCRF) and categorized as low (<20^th percentile), moderate (20^th to 80^th percentile) and high (≥80^th percentile) within sex and ten-year age groups (e.g. 50–60 years). Participants were classified as having COVID-19 if they tested positive (primarily PCR tests) at an in-patient or out-patient setting as of July 26, 2020. Participants were classified as having died from COVID-19 if the primary or underlying cause of death was listed ICD-10 codes U071 or U072 by June 30^th, 2020. Adjusted risk ratios (aRR) and 95% confidence intervals (CI) were estimated and a forward model building approach used to identify covariates.

Findings

There was no significant association between eCRF and testing positive for COVID-19. Conversely, individuals with moderate (aRR = 0.43, 95% CI: 0.25, 0.75) and high fitness (aRR = 0.37, 95% CI: 0.16, 0.85) had a significantly lower risk of dying from COVID-19 than those with low fitness.

Conclusions

While eCRF was not significantly associated with testing positive for COVID-19, we observed a significant dose-response between having higher eCRF and a decreased risk of dying from COVID-19. This suggests that prior gains in CRF could be protective against dying from COVID-19 should someone develop the virus.

Effects of the total physical activity and its changes on incidence, progression, and remission of hypertension

OBJECTIVES

Moderate to vigorous physical activity is recommended to prevent hypertension according to the current guidelines. However, the degree to which the total physical activity (TPA) and its changes benefit normotensives and hypertensives is uncertain. We aimed to examine the effects of TPA and its changes on the incidence, progression, and remission of hypertension in the large-scale prospective cohorts.

METHODS

A total of 73,077 participants (55,101 normotensives and 17,976 hypertensives) were eligible for TPA analyses. During a mean follow-up of 7.16 years (394,038 person-years), 12,211 hypertension cases were identified. TPA was estimated as metabolic equivalents and categorized into quartiles. Cox proportional hazards regression and multivariable logistic regression were used to estimate associations of TPA and changes in TPA with incident hypertension and progression/remission of hypertension.

RESULTS

Compared with the lowest quartile of TPA, normotensives at the third and the highest quartile had a decreased risk of incident hypertension, with hazard ratios (HRs) of 0.86 [95% confidence interval (CI): 0.81-0.91] and 0.81 (95% CI: 0.77-0.86), respectively. Hypertensives at the highest quartile of TPA demonstrated a decreased risk of progression of hypertension [odds ratio (OR) = 0.87, 95% CI: 0.79-0.95], and an increased probability of hypertension remission (OR = 1.17, 95% CI: 1.05-1.29). Moreover, getting active from a sedentary lifestyle during the follow-up period could reduce 25% (HR = 0.75, 95% CI: 0.58-0.96) risk of incident hypertension, whereas those becoming sedentary did not achieve benefit from initially being active.

CONCLUSIONS

Our findings indicated that increasing and maintaining TPA levels could benefit normotensives, whereas higher TPA levels were needed to effectively control progression and improve remission of hypertension. Physical activity played undoubtedly an essential role in both primary and secondary prevention of hypertension.

Risk of specific cardiovascular diseases in obsessive-compulsive disorder

Individuals with obsessive-compulsive disorder (OCD) may have an increased risk of cardiovascular disease (CVD), but evidence for specific types of CVD is limited. This population-based, sibling-controlled cohort study investigated the risk of specific CVD in individuals with OCD. Linking data from various Swedish population-based registers, we explored the risk of a range of CVD in a cohort of individuals diagnosed with OCD between 1973 and 2013 (n = 33,561), compared to matched (1:10) unaffected individuals (n = 335,610). Hazard ratios (HR) with 95% confidence intervals (CI) were calculated using conditional Cox proportional hazards regression models, adjusting for history of somatic diseases. To control for familial confounders, we analyzed 23,263 clusters of full siblings discordant for OCD. Individuals with psychiatric comorbidities were systematically excluded to assess the impact of these comorbidities. Over an average follow-up time of 27 years, OCD was associated with an increased risk of a broad range of CVD (adjusted HR [aHR] for any CVD = 1.25 [95% confidence interval [CI], 1.22-1.29]). These associations were strongest for the subtypes venous thrombo-embolism (aHR = 1.48 [95% CI, 1.38-1.58]) and heart failure (aHR = 1.37 [95% CI, 1.28-1.46]). When comparing OCD-exposed individuals with their non-exposed full siblings, results were largely similar. Exclusion of several groups of psychiatric comorbidities resulted in comparable results, albeit attenuated. Individuals with OCD have a moderately increased risk of CVD-related morbidity, independent from history of somatic diseases, familial confounders, and psychiatric comorbidities. The time may be ripe for the development and evaluation of lifestyle interventions to help reduce the risk of cardiovascular morbidity in OCD.

Physical activity and the risk of heart failure: a systematic review and dose-response meta-analysis of prospective studies

Although physical activity is an established protective factor for cardiovascular diseases such as ischemic heart disease and stroke, less is known with regard to the association between specific domains of physical activity and heart failure, as well as the association between cardiorespiratory fitness and heart failure. We conducted a systematic review and meta-analysis of prospective observational studies to clarify the relations of total physical activity, domains of physical activity and cardiorespiratory fitness to risk of heart failure. PubMed and Embase databases were searched up to January 14th, 2020. Summary relative risks (RRs) were calculated using random effects models. Twenty-nine prospective studies (36 publications) were included in the review. The summary RRs for high versus low levels were 0.77 (95% CI 0.70–0.85, I² = 49%, n = 7) for total physical activity, 0.74 (95% CI 0.68–0.81, I² = 88.1%, n = 16) for leisure-time activity, 0.66 (95% CI 0.59–0.74, I² = 0%, n = 2) for vigorous activity, 0.81 (95% CI 0.69–0.94, I² = 86%, n = 3) for walking and bicycling combined, 0.90 (95% CI 0.86–0.95, I² = 0%, n = 3) for occupational activity, and 0.31 (95% CI 0.19–0.49, I² = 96%, n = 6) for cardiorespiratory fitness. In dose–response analyses, the summary RRs were 0.89 (95% CI 0.83–0.95, I² = 67%, n = 4) per 20 MET-hours per day of total activity and 0.71 (95% CI 0.65–0.78, I² = 85%, n = 11) per 20 MET-hours per week of leisure-time activity. Nonlinear associations were observed in both analyses with a flattening of the dose–response curve at 15–20 MET-hours/week for leisure-time activity. These findings suggest that high levels of total physical activity, leisure-time activity, vigorous activity, occupational activity, walking and bicycling combined and cardiorespiratory fitness are associated with reduced risk of developing heart failure.

Running away from cardiovascular disease at the right speed: The impact of aerobic physical activity and cardiorespiratory fitness on cardiovascular disease risk and associated subclinical phenotypes

Higher levels of physical activity (PA) and cardiorespiratory fitness (CRF) are associated with lower risk of incident cardiovascular disease (CVD). However, the relationship of aerobic PA and CRF with risk of atherosclerotic CVD outcomes and heart failure (HF) seem to be distinct. Furthermore, recent studies have raised concerns of potential toxicity associated with extreme levels of aerobic exercise, with higher levels of coronary artery calcium and incident atrial fibrillation noted among individuals with very high PA levels. In contrast, the relationship between PA levels and measures of left ventricular structure and function and risk of HF is more linear. Thus, personalizing exercise levels to optimal doses may be key to achieving beneficial outcomes and preventing adverse CVD events among high risk individuals. In this report, we provide a comprehensive review of the literature on the associations of aerobic PA and CRF levels with risk of adverse CVD outcomes and the preceding subclinical cardiac phenotypes to better characterize the optimal exercise dose needed to favorably modify CVD risk.

Age-related longitudinal change in cardiac structure and function in adults at increased cardiovascular risk

AIM

Heart failure (HF) incidence increases markedly with age. We examined age-associated longitudinal change in cardiac structure and function, and their prediction by age and cardiovascular disease (CVD) risk factors, in a community-based cohort aged ≥60 years at increased CVD risk but without HF.

METHODS AND RESULTS

CVD risk factors were recorded in 3065 participants who underwent a baseline echocardiographic examination, of whom 2358 attended a follow-up examination 3.8 [median, inter-quartile range (IQR) 3.5, 4.2] years later. Median age was 71 (IQR 67, 76) years and 55% of participants were male. Age was associated with longitudinal increase in left ventricular (LV) mass index (LVMI); decrease in LV volumes; increase in LV ejection fraction; decrease in mitral annular systolic velocity; decrease in diastolic function (decreased mitral early diastolic annular velocity (e'); and increase in left atrial volume index, mitral peak early diastolic flow velocity (E)/e' ratio, and tricuspid regurgitant velocity (TR_Vmax ) in men and women, except for TR_Vmax in men). In multivariable analysis, longitudinal increase in LVMI was explained by CVD risk factors alone, whereas age, together with CVD risk factors, independently predicted longitudinal change in all other echocardiographic parameters. CVD risk factors were differentially associated with longitudinal change in different echocardiographic parameters.

CONCLUSIONS

Whereas the increase in LVMI with age was explained by CVD risk factors alone, age, together with risk factors, independently predicted longitudinal change in all other echocardiographic parameters, providing evidence for age-specific mechanisms of change in cardiac structure and function as people age. Age-associated change in LVMI, LV volumes, and diastolic function resembled what might be expected for the evolution of HF with preserved ejection fraction. Given the differential association of different CVD risk factors with longitudinal change in different echocardiographic parameters, therapies aimed at attenuation of age-associated change in cardiac structure and function, and HF evolution, will likely need to address multiple CVD risk factors.

Timed synchronization of muscle contraction to heartbeat enhances muscle hyperemia

Blood flow (BF) to exercising muscles is susceptible to variations of intensity, and duration of skeletal muscle contractions, cardiac cycle, blood velocity, and vessel dilation. During cyclic muscle activity, these elements may change proportionally with or without direct optimal temporal alignment, likely influencing BF to active muscle. Ideally, the pulsed delivery of blood to active muscle timed with the inactive phase of muscle duty-cycle would enhance the peak and average BF. To investigate the phenomenon of muscle contraction and pulse synchronicity, electrically evoked muscle contractions (trains of 20 Hz, 200-ms duration) were synchronized with each systolic phase of the anterograde blood velocity spectrum (aBVS). Specifically, unilateral quadriceps contractions matched in-phase (IP) with the aBVS were compared with contractions matched out-of-phase (OP) with the aBVS in 10 healthy participants (26 ± 3 yr). During each trial, femoral BF of the contracting limb and central hemodynamics were recorded for 5 min with an ultrasound Doppler, a plethysmograph, and a cardioimpedance device. At steady state (5th min) IP BF (454 ± 30 mL/min) and vascular conductance (4.3 ± 0.2 mL·min^-1·mmHg^-1), and OP MAP (108 ± 2 mmHg) were significantly lower (P < 0.001) in comparison to OP BF (784 ± 25 mL/min) and vascular conductance (6.7 ± 0.2 mL·min^-1·mmHg^-1), and IP MAP (113 ± 3 mmHg). On the contrary, no significant difference (all, P > 0.05) was observed between IP and OP central hemodynamics (HR: 79 ± 10 vs. 76 ± 11 bpm, CO: 8.0 ± 1.6 vs. 7.3 ± 1.6 L/min), and ventilatory patterns (V̇e:14 ± 2 vs. 14 ± 1 L/min, V̇o₂:421 ± 70 vs. 397 ± 34 mL/min). The results suggest that muscle contractions occurring during OP that do not interfere with aBVS elicit a maximization of muscle functional hyperemia.NEW & NOTEWORTHY When muscle contraction is synchronized with the pulsed delivery of blood flow to active muscle, muscle functional hyperemia can be either maximized or minimized. This suggests a possibility to couple different strategies to enhance the acute and chronic effects of exercise on the cardiovascular system.

Association between resting painless ST-segment depression with sudden cardiac death in middle-aged population: A prospective cohort study

BACKGOUND

Silent electrocardiographic ST change predicts future coronary heart disease (CHD) incidence and mortality, but the prognostic significance of painless ST-segment depression (STD) with respect to sudden cardiac death (SCD) in subjects without apparent CHD remain unclear. This study sought to test the association between non-ischemic resting STD and risk of SCD in the general population.

METHODS

A total of 14,935 middle-aged subjects from the prospective, population-based Atherosclerosis Risk in Communities (ARIC) study were included in this analysis. Cox models were used to estimate the hazard ratios (HRs) adjusted for possible confounding factors. STD was defined as ST-segment depression of ≥0.05 mV in two or more contiguous leads.

RESULTS

A total of 626 sudden cardiac death occurred during the mean follow-up of 20.4 years. Compared with those without STD, subjects with resting painless STD of at least 0.05 mV had a significantly increased risk of developing SCD (adjusted HR, 1.45; 95% CI, 1.20 to 1.76), and those with STD ≥ 0.1 mV had even higher risk of SCD (adjusted HR, 1.90; 95% CI, 1.25 to 2.88). Significant interactions were present between gender and STD (P = .03), and between race and STD (P = .01). STD was significantly predictive of SCD in males (adjusted HR, 1.57; 95% CI, 1.22-2.01) and in whites (adjusted HR, 1.65; 95% CI, 1.27-2.14). STD in lateral leads and global leads were strong predictors of SCD.

CONCLUSIONS

Resting painless STD was an independent predictor of SCD in the middle-aged population without previously diagnosed CHD.

Beneficial effects of moderate to vigorous physical activity on cardiovascular disease among Chinese adults

BACKGROUND

In China, lack of evidence remains a significant challenge for the national initiative to promote physical activity (PA). We aimed to quantify the beneficial effects of meeting or maintaining the recommended PA level [150 minutes per week (min/wk) of moderate PA or 75 min/wk of vigorous PA or an equivalent combination] on incident cardiovascular disease (CVD) among Chinese population.

METHODS

We included 100,560 participants without history of CVD from three cohorts in the Prediction for Atherosclerotic Cardiovascular Disease Risk in China (China-PAR) project. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for CVD events and its subtypes, including stroke, coronary heart disease, heart failure, and CVD death.

RESULTS

During a median follow-up of 7.3 years (range: 6-15 years), 777,163 person-years and 4693 incident CVD events were observed. Compared with participants who were inactive at baseline, the multivariable adjusted HR (95% CI) of developing CVD was 0.74 (0.69-0.79) for those who met recommended moderate to vigorous physical activity (MVPA) level at baseline. Furthermore, the risk of CVD incidence was reduced with increment of MVPA (P trend < 0.001), and the HR (95% CI) of highly-active versus inactive category was 0.62 (0.56-0.68). Compared with individuals who were inactive both at the baseline and follow-up, those keeping active over the period of follow-up had a substantial lower risk of incident CVD with the HR (95% CI) of 0.57 (0.43-0.77).

CONCLUSIONS

The findings demonstrated that meeting and maintaining the recommended MVPA level could reduce the cardiovascular risk. Wider adoption of the PA recommendations would have considerable health impacts to the Chinese population.

Cyclic Guanosine Monophosphate and Risk of Incident Heart Failure and Other Cardiovascular Events: the ARIC Study

Background

Cyclic guanosine monophosphate (cGMP) is a second messenger regulated through natriuretic peptide and nitric oxide pathways. Stimulation of cGMP signaling is a potential therapeutic strategy for heart failure with preserved ejection fraction (HFpEF) and atherosclerotic cardiovascular disease (ASCVD). We hypothesized that plasma cGMP levels would be associated with lower risk for incident HFpEF, any HF, ASCVD, and coronary heart disease (CHD).

Methods and Results

We conducted a case–cohort analysis nested in the ARIC (Atherosclerosis Risk in Communities) study. Plasma cGMP was measured in 875 participants at visit 4 (1996–1998), with oversampling of incident HFpEF cases. We used Cox proportional hazard models to assess associations of cGMP with incident HFpEF, HF, ASCVD (CHD+stroke), and CHD. The mean (SD) age was 62.4 (5.6) years and median (interquartile interval) cGMP was 3.4 pmol/mL (2.4–4.6). During a median follow‐up of 9.9 years, there were 283 incident cases of HFpEF, 329 any HF, 151 ASCVD, and 125 CHD. In models adjusted for CVD risk factors, the hazard ratios (95% CI) associated with the highest cGMP tertile compared with lowest for HFpEF, HF, ASCVD, and CHD were 1.88 (1.17–3.02), 2.18 (1.18–4.06), 2.84 (1.44–5.60), and 2.43 (1.19–5.00), respectively. In models further adjusted for N‐terminal‐proB‐type natriuretic peptide, associations were attenuated for HFpEF and HF but remained statistically significant for ASCVD (2.56 [1.26–5.20]) and CHD (2.25 [1.07–4.71]).

Conclusions

Contrary to our hypothesis, higher cGMP levels were associated with incident CVD in a community‐based cohort. The associations of cGMP with HF or HFpEF may be explained by N‐terminal‐proB‐type natriuretic peptide, but not for ASCVD and CHD.

Sedentary Behavior, Exercise, and Cardiovascular Health

Sedentary behavior and physical inactivity are among the leading modifiable risk factors worldwide for cardiovascular disease and all-cause mortality. The promotion of physical activity and exercise training (ET) leading to improved levels of cardiorespiratory fitness is needed in all age groups, race, and ethnicities and both sexes to prevent many chronic diseases, especially cardiovascular disease. In this state-of-the-art review, we discuss the negative impact of sedentary behavior and physical inactivity, as well as the beneficial effects of physical activity /ET and cardiorespiratory fitness for the prevention of chronic noncommunicable diseases, including cardiovascular disease. We review the prognostic utility of cardiorespiratory fitness compared with obesity and the metabolic syndrome, as well as the increase of physical activity /ET for patients with heart failure as a therapeutic strategy, and ET dosing. Greater efforts at preventing sedentary behavior and physical inactivity while promoting physical activity, ET, and cardiorespiratory fitness are needed throughout the healthcare system worldwide and particularly in the United States in which the burden of cardiometabolic diseases remains extremely high.

Incorporation of Biomarkers Into Risk Assessment for Allocation of Antihypertensive Medication According to the 2017 ACC/AHA High Blood Pressure Guideline: A Pooled Cohort Analysis

BACKGROUND

Risk for atherosclerotic cardiovascular disease was a novel consideration for antihypertensive medication initiation in the 2017 American College of Cardiology/American Heart Association Blood Pressure (BP) guideline. Whether biomarkers of chronic myocardial injury (high-sensitivity cardiac troponin T ≥6 ng/L] and stress (N-terminal pro-B-type natriuretic peptide [NT-proBNP] ≥100 pg/mL) can inform cardiovascular (CV) risk stratification and treatment decisions among adults with elevated BP and hypertension is unclear.

METHODS

Participant-level data from 3 cohort studies (Atherosclerosis Risk in Communities Study, Dallas Heart Study, and Multiethnic Study of Atherosclerosis) were pooled, excluding individuals with prevalent CV disease and those taking antihypertensive medication at baseline. Participants were analyzed according to BP treatment group from the 2017 American College of Cardiology/American Heart Association BP guideline and those with high BP (120 to 159/<100 mm Hg) were further stratified by biomarker status. Cumulative incidence rates for CV event (atherosclerotic cardiovascular disease or heart failure), and the corresponding 10-year number needed to treat to prevent 1 event with intensive BP lowering (to target systolic BP <120 mm Hg), were estimated for BP and biomarker-based subgroups.

RESULTS

The study included 12 987 participants (mean age, 55 years; 55% women; 21.5% with elevated high-sensitivity cardiac troponin T; 17.7% with elevated NT-proBNP) with 825 incident CV events over 10-year follow-up. Participants with elevated BP or hypertension not recommended for antihypertensive medication with versus without either elevated high-sensitivity cardiac troponin T or NT-proBNP had a 10-year CV incidence rate of 11.0% and 4.6%, with a 10-year number needed to treat to prevent 1 event for intensive BP lowering of 36 and 85, respectively. Among participants with stage 1 or stage 2 hypertension recommended for antihypertensive medication with BP <160/100 mm Hg, those with versus without an elevated biomarker had a 10-year CV incidence rate of 15.1% and 7.9%, with a 10-year number needed to treat to prevent 1 event of 26 and 49, respectively.

CONCLUSIONS

Elevations in high-sensitivity cardiac troponin T or NT-proBNP identify individuals with elevated BP or hypertension not currently recommended for antihypertensive medication who are at high risk for CV events. The presence of nonelevated biomarkers, even in the setting of stage 1 or stage 2 hypertension, was associated with lower risk. Incorporation of biomarkers into risk assessment algorithms may lead to more appropriate matching of intensive BP control with patient risk.

Change in Physical Activity and Cardiac Structure over 10 Years: The Multi-Ethnic Study of Atherosclerosis

INTRODUCTION

Physical activity (PA) is inversely associated with risk of heart failure and cardiovascular disease (CVD), whereas increased left ventricular (LV) mass and mass to volume (m:v) ratio are unfavorable CVD risk factors. We assessed whether changes in leisure time PA were associated with longitudinal changes in cardiac structure in a community-based population.

METHODS

We included 2779 Multi-Ethnic Study of Atherosclerosis participants, free of baseline CVD, who had available data on PA and cardiac magnetic resonance imaging at examinations 1 (2000-2002) and 5 (2010-2012). Physical activity was measured by a Typical Week PA Survey and converted to MET-minutes per week of moderate+vigorous activity. We used linear mixed effect models to estimate the associations of baseline and change in PA with baseline and change in cardiac structure, adjusting for CVD risk factors and body size.

RESULTS

At baseline, the mean age was 59 yr, 53% were women, and 58% of nonwhite race/ethnicity. During average 10-yr follow-up, and after accounting for baseline PA levels, the highest quintiles of PA increase were significantly associated with increases in LV mass (2.3 g; 95% confidence interval [CI], 0.4-4.2), LV end-diastolic volume (4.7 mL; 95% CI, 2.4-7.0), and stroke volume (3.3 mL; 95% CI, 1.6-5.1), but lower M:V ratio (-2.9; 95% CI, -5.0 to -0.8) compared with the lowest quintiles. Increasing exercise PA was associated with increases in LV diameter and reductions in M:V ratio, whereas occupational PA was associated with increases in m:v ratio. Increasing PA over 10 yr was also associated with greater risk of eccentric dilated LV hypertrophy at examination 5.

CONCLUSIONS

After accounting for baseline PA, greater positive changes in leisure-time PA levels were associated with a more eccentric-type of LV remodeling pattern over 10 yr. The clinical implications of such findings remain to be determined.

Prevalence of American Heart Association Heart Failure Stages in Black and White Young and Middle-Aged Adults: The CARDIA Study

BACKGROUND

Staging criteria for heart failure (HF) range from stage 0 (without risk) to being at risk (stage A) to presence of cardiac structural/functional abnormalities (stage B) to symptomatic/end stage (stages C/D). There are limited data on the prevalence of these stages in early adulthood and predictors of HF stage and symptoms in middle age.

METHODS AND RESULTS

The CARDIA study (Coronary Artery Risk Development in Young Adults)-a cohort of generally healthy black and white men and women-collected phenotypic, echocardiographic, and outcomes data at the year 5 and year 30 examinations when participants were 22 to 37 and 47 to 62 years of age. Prevalence of HF stages was calculated and relationship of year 5 stage to year 30 classification and outcomes was assessed. At year 5, 2189 participants had complete data. Prevalence of HF stage A/B increased from 24% to 76% in black men, from 13% to 64% in white men, from 34% to 81% in black women, and from 13% to 56% in white women. Blacks were more likely to be in any stage or with morbidity at both time points because of higher risk factor prevalence. Of 33 participants with HF or HF deaths by year 30, 21 (64%) had been in stage A or B at year 5. Only 6 participants at year 5 in stage A (at risk) improved risk status at year 30.

CONCLUSIONS

Risk for HF increased in participants from 1990 (age 22-37 years) to 2015 (age 47-62 years). Symptomatic HF or death from HF is associated with HF stage at 22 to 37 years of age. Blacks are disproportionately affected.

Role of physical activity in ameliorating neuropsychiatric symptoms in Alzheimer disease: A narrative review

OBJECTIVE

Neuropsychiatric symptoms (NPs) affect almost all patients with Alzheimer disease (AD). Because of the complications associated with the pharmacological treatment, nonpharmacological treatment (such as physical activity) can be considered as an additional complementary treatment option for NPs. The aim of this review is to evaluate the impact of physical activity on NPs in patients with AD.

METHODS

We searched Pubmed and Google Scholar for potential eligible articles until March 1, 2018.

RESULTS

Although there are contradictory results showing the impact of physical exercise on NPs, most of them reported that it had a significant effect on depression and sleep disturbances in patients with AD. The beneficial effects could be explained through several mechanisms, including modulated production of neurotransmitters; increasing neurotrophins, such as brain-derived neurotrophic factor; reduction of oxidative stress and inflammation; elevation of cerebral blood flow; hypothalamic pituitary adrenal axis regulation; and support of neurogenesis and synaptogenesis. Physical activity can also improve cardiovascular risk factors, which may exaggerate NPs. There is limited evidence for other NPs such as agitation, disinhibition, apathy, hallucinations, and anxiety.

CONCLUSION

Physical activity may ameliorate depression and sleep disturbances in patients with AD. Therefore, physical activity can be a "potential" add-on treatment to drugs to reduce or prevent these symptoms onset and recurrence in patients with AD. However, further studies are needed to focus on relationship between physical activity and other NPs.

Heart failure drug treatment

Heart failure is the most common cardiovascular reason for hospital admission for people older than 60 years of age. Few areas in medicine have progressed as remarkably as heart failure treatment over the past three decades. However, progress has been consistent only for chronic heart failure with reduced ejection fraction. In acutely decompensated heart failure and heart failure with preserved ejection fraction, none of the treatments tested to date have been definitively proven to improve survival. Delaying or preventing heart failure has become increasingly important in patients who are prone to heart failure. The prevention of worsening chronic heart failure and hospitalisations for acute decompensation is also of great importance. The objective of this Series paper is to provide a concise and practical summary of the available drug treatments for heart failure. We support the implementation of the international guidelines. We offer views on the basis of our personal experience in research areas that have insufficient evidence. The best possible evidence-based drug treatment (including inhibitors of the renin-angiotensin-aldosterone system and β blockers) is useful only when optimally implemented. However, implementation might be challenging. We believe that disease management programmes can be helpful in providing a multidisciplinary, holistic approach to the delivery of optimal medical care.

Cardiovascular Effects and Benefits of Exercise

It is widely accepted that regular physical activity is beneficial for cardiovascular health. Frequent exercise is robustly associated with a decrease in cardiovascular mortality as well as the risk of developing cardiovascular disease. Physically active individuals have lower blood pressure, higher insulin sensitivity, and a more favorable plasma lipoprotein profile. Animal models of exercise show that repeated physical activity suppresses atherogenesis and increases the availability of vasodilatory mediators such as nitric oxide. Exercise has also been found to have beneficial effects on the heart. Acutely, exercise increases cardiac output and blood pressure, but individuals adapted to exercise show lower resting heart rate and cardiac hypertrophy. Both cardiac and vascular changes have been linked to a variety of changes in tissue metabolism and signaling, although our understanding of the contribution of the underlying mechanisms remains incomplete. Even though moderate levels of exercise have been found to be consistently associated with a reduction in cardiovascular disease risk, there is evidence to suggest that continuously high levels of exercise (e.g., marathon running) could have detrimental effects on cardiovascular health. Nevertheless, a specific dose response relationship between the extent and duration of exercise and the reduction in cardiovascular disease risk and mortality remains unclear. Further studies are needed to identify the mechanisms that impart cardiovascular benefits of exercise in order to develop more effective exercise regimens, test the interaction of exercise with diet, and develop pharmacological interventions for those unwilling or unable to exercise.

Physical Activity, Immune System, and the Microbiome in Cardiovascular Disease

Cardiovascular health is a primary research focus, as it is a leading contributor to mortality and morbidity worldwide, and is prohibitively costly for healthcare. Atherosclerosis, the main driver of cardiovascular disease, is now recognized as an inflammatory disorder. Physical activity (PA) may have a more important role in cardiovascular health than previously expected. This review overviews the contribution of PA to cardiovascular health, the inflammatory role of atherosclerosis, and the emerging evidence of the microbiome as a regulator of inflammation.