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

Machine learning-based risk assessment for cardiovascular diseases in patients with chronic lung diseases

The association between chronic lung diseases (CLDs) and the risk of cardiovascular diseases (CVDs) has been extensively recognized. Nevertheless, conventional approaches for CVD risk evaluation cannot fully capture the risk factors (RFs) related to CLDs. This research sought to construct a CLD-specific CVD risk prediction model based on machine learning models and evaluate the prediction performance. The cross-sectional study design was adopted with data retrieved from Waves 1 and 3 of the China Health and Retirement Longitudinal Study, including 1357 participants. Multiple RFs were integrated into the models, including conventional RFs for CVDs, pulmonary function indicators, physical features, and measures of quality of life and psychological state. Four machine learning algorithms, including extreme gradient boosting (XGBoost), logistic regression, random forest, and support vector machine, were evaluated for prediction performance. The XGBoost model displayed superior performance to machine learning algorithms for predictive accuracy (area under the receiver operating characteristic curve [AUC]: 0.788, accuracy: 0.716, sensitivity: 0.615, specificity: 0.803). This model pinpointed the top 5 RFs for CLD-specific CVD RFs: body mass index, age, C-reactive protein, uric acid, and grip strength. Moreover, the prediction performance of the random forest model (AUC: 0.709, accuracy: 0.633) was higher relative to the logistic regression (AUC: 0.619, accuracy: 0.584) and support vector machine (AUC: 0.584, accuracy: 0.548) models. Nonetheless, these models performed less favorably compared to the XGBoost model. The XGBoost model presented the most accurate predictions for CLD-specific CVD risk. This multidimensional risk assessment approach offers a promising avenue for the establishment of personalized prevention strategies targeting CVD in patients with CLDs.

Residential exposome and the risk of coronary obstruction and myocardial ischemia detected by coronary computed tomography

BACKGROUND AND AIMS

To assess independent impacts of air and noise pollution, and residential green exposure on non-invasively derived coronary obstruction and myocardial ischemia.

METHODS

Consecutive patients screened by coronary computed tomography angiography (CCTA) for stable chest pain between 01/01/2019 and 31/12/2020 were included in a registry. Exposure associations between residential PM2.5 (particulate matter <2.5 micrometres), NO2 (nitric dioxide), major road distance, airport distance and normalized difference vegetation index (NDVI), and obstructive coronary artery disease (OCAD, stenosis ≥50%) and abnormal fractional flow reserve (FFRCT<80%) measurement were assessed by propensity score-adjusted logistic regression. Subgroup analysis was performed according to Framingham low (<10%) and high (>20%) 10-year coronary heart disease risk categories.

RESULTS

2620 patients were enrolled, including 420(16%) FFRCT analyses. OCAD was reported in 518(20%) patients and abnormal FFRCT in 276(11%). People with OCAD lived closer to the airport (10.841 [7.869-19.022]km vs. 12.297 [8.691-22.843]km, p<0.001). People living closer to the airport had more cardiovascular and socio-economic risk factors. Distance to airport decreased OCAD risk (OR 0.983, 95%CI 0.974-0.992, per 1km) in univariable analysis. After propensity score (PS) adjustment, environmental stressors were not significantly associated with OCAD, regardless of risk categories. Only distance to major road decreased abnormal FFRCT risk (OR 0.634, 95%CI: 0.421-0.926, per 1km) in high-risk patients after PS adjustment.

CONCLUSIONS

We found no clear environmental associations with CT-derived coronary obstruction or ischemia. However, airport proximity was linked to OCAD risk via cardiovascular and socio-economic factors, while major road proximity was independently associated with myocardial ischemia in high-CV-risk patients, warranting further investigation.

Genetic insights into circulating osteocalcin for cardiovascular diseases and the role of vascular calcification

BACKGROUND AND AIMS

Studies have suggested that osteocalcin (OCN) is implicated in vascular calcification and linked to cardiovascular diseases (CVDs), but it is unclear whether the relationships are causal. The aim of this study is to evaluate the causal relationship of circulating OCN with CVDs and the role of vascular calcification.

METHODS AND RESULTS

Bi-directional, mediation, and multivariable Mendelian randomization (MVMR) were performed using summary-level data for circulating OCN levels, coronary artery calcification (CAC), and CVDs, including coronary artery disease (CAD), myocardial infarction (MI), heart failure, atrial fibrillation, stroke and its subtypes. Pooled estimates from two independent datasets of OCN were calculated using the inverse variance weighted method with sensitivity analyses. The conservative Hochberg correction method adjusted the P-value for multiple comparisons. Genetically predicted higher OCN levels were linked to an increased risk of CAD (odds ratio [OR] = 1.069, 95%CI = 1.037-1.102, P < 0.001) and MI (OR = 1.099, 95%CI = 1.069-1.130, P < 0.001). In addition, elevated OCN levels were associated with higher CAC (β = 0.180, 95%CI = 0.101-0.258, P = 0.006), which was related higher risk of CAD (OR = 1.225, 95%CI = 1.132-1.325, P < 0.001) and MI (OR = 1.286, 95%CI = 1.203-1.375, P < 0.001), mediating 54.5 % and 48.3 % of the effect of OCN on CAD and MI, respectively. Meanwhile, MVMR results also validated the mediating role of CAC. In contrast, CAD and MI were associated with decreased levels of plasma OCN.

CONCLUSION

Our findings reveal that higher OCN concentrations are associated with an elevated risk of CAD and MI, which was partially mediated by CAC. Lower OCN levels found in previous observational studies might be due to reverse causation.

Epidemiology and clinical implications of atrial fibrillation among stroke patients in Ethiopia: a comprehensive systematic review and meta-analysis

BACKGROUND

Atrial fibrillation (AF) is a significant risk factor for stroke, imposing a substantial burden on healthcare systems. While studies have shown varying AF prevalence among stroke patients, limited pooled data exists in low-resource settings like Ethiopia. This hinders our understanding of the problem's extent and limits effective prevention and management strategies. Therefore, this systematic review and meta-analysis aimed to determine the pooled prevalence of atrial fibrillation among stroke patients in Ethiopia.

METHODS

The searches were carried out in electronic databases such as PubMed/MEDLINE, EMBASE, Science Direct, Web of Science, and Google Scholar. Observational study designs were selected, and studies published until 30 November 2023 addressing the prevalence of atrial fibrillation among stroke patients were identified. Endnote citation manager software version X9 for Windows was used to collect and organize the search outcomes and remove duplicate articles. The relevant data were extracted from the included studies using a format prepared in Microsoft Excel and exported to STATA 18.0 software for the outcome measures analyses and subgrouping.

RESULTS

Twenty-three research articles were included in the final analysis. These studies evaluated a total of 4,544 stroke patients, of whom 529 were diagnosed with atrial fibrillation (AF). The overall pooled prevalence of AF among stroke patients was 13% [95% CI: (10%, 17%)]. Subgroup analysis by region revealed that the highest pooled prevalence of AF was 16% [95% CI: (8%, 25%)] in the Amhara region, followed by the Oromia region at 15% [95% CI: (7%, 23%)]. In Addis Ababa City, the pooled prevalence of AF among stroke patients was 11% [95% CI: (7%, 15%)]. The Tigray region reported a pooled prevalence of 9% [95% CI: (6%, 11%)]. However, one study from the Southern Nations, Nationalities, and Peoples' Region reported a lower prevalence of AF among stroke patients at 7% [95% CI: (3%, 11%)].

CONCLUSION

In summary, the study revealed that AF is prevalent among stroke patients in Ethiopia, with regional differences in prevalence. The high prevalence of AF emphasizes the necessity for effective management strategies to prevent recurrent strokes.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD: CRD42024581661.

Pain from Internal Organs and Headache: The Challenge of Comorbidity

Headache and visceral pain are common clinical painful conditions, which often co-exist in the same patients. Numbers relative to their co-occurrence suggest possible common pathophysiological mechanisms. The aim of the present narrative review is to describe the most frequent headache and visceral pain associations and to discuss the possible underlying mechanisms of the associations and their diagnostic and therapeutic implications based on the most recent evidence from the international literature. The conditions addressed are as follows: visceral pain from the cardiovascular, gastrointestinal, and urogenital areas and primary headache conditions such as migraine and tension-type headache. The most frequent comorbidities involve the following: cardiac ischemic pain and migraine (possible shared mechanism of endothelial dysfunction, oxidative stress, and genetic and hormonal factors), functional gastrointestinal disorders, particularly IBS and both migraine and tension-type headache, primary or secondary dysmenorrhea and migraine, and painful bladder syndrome and headache (possible shared mechanisms of peripheral and central sensitization processes). The data also show that the various visceral pain-headache associations are characterized by more than a simple sum of symptoms from each condition but often involve complex interactions with the frequent enhancement of symptoms from both, which is crucial for diagnostic and treatment purposes.

Teaching gender medicine can enhance the quality of healthcare

Teaching gender and sex differences is fundamental in medical classes because it has a strong impact in reducing disparity in treatment, in defining effective and personalized therapies that respect the different physiology and pathophysiology of women. Furthermore, it is the prerequisite for the pharmacoequity.

Comprehensive Evidence-Based Health Maintenance

The potential of primary prevention to prevent, delay, or ameliorate disease is immense. However, the total spending on preventive services in the United States remains astoundingly small and represents a meager 3.5% of total health care spending. Moreover, training focused on prevention in medical schools is often neglected, and time-constrained primary providers frequently omit effective preventive and early detection measures, or perform them perfunctorily. Indeed, preventable conditions of serious consequences including "premature" mortality, cardiovascular events, and major organ failure are ubiquitous with the global obesity and diabetes epidemics, and the ongoing high prevalence of noxious habits and drug abuse. Although each aspect has been the subject of extensive research, a succinct evidence-based summary is scarce. We have conducted a review of high-quality evidence (systematic reviews, meta-analyses, and practice guidelines) over the last 20 years to extract the best updated recommendations on comprehensive disease prevention and approved screening, briefly citing significant risk reductions by lifestyle interventions, pharmacological prevention, cancer screening, other endorsed screening, immunizations, and issues in the patient-provider interface.

Optimizing Cardiovascular Health: A Comprehensive Review of Risk Assessment Strategies for Primary Prevention

Cardiovascular disease (CVD) is a leading global health concern, and effective primary prevention strategies are essential to mitigate its impact. This comprehensive review examines current risk assessment strategies for primary prevention of CVD, emphasizing the importance of early identification and intervention to reduce disease incidence. Traditional risk factors such as hypertension, hyperlipidemia, smoking, and lifestyle choices are discussed alongside emerging factors, including genetic predispositions and biomarkers. The review evaluates various risk assessment tools and models, such as the Framingham risk score, atherosclerotic CVD risk calculator, QRISK, and Reynolds risk score, highlighting their methodologies, strengths, and limitations. Additionally, the review explores lifestyle modifications, including dietary changes, physical activity, weight management, smoking cessation, and pharmacological interventions like statins and antihypertensives. Special considerations for different populations, including the elderly, women, and those with a family history of CVD, are addressed. Future directions in cardiovascular risk assessment are also discussed, focusing on technological advancements and personalized medicine. This review aims to enhance the implementation of effective primary prevention measures and improve cardiovascular health outcomes by providing a thorough analysis of risk assessment strategies.

Causal relationship between depression and hypercholesterolemia: A bidirectional 2-sample Mendelian randomization study

Although observational studies have found both a positive and negative association between depression and hypercholesterolemia, the findings are mixed and contradictory. To our knowledge, this is the first study that employs the bidirectional Mendelian randomization (MR) and multivariable MR analysis with extensive genome-wide association studies (GWAS) data to examine the causal effect between depression and hypercholesterolemia. Using summary statistics obtained from GWAS of individuals with European ancestry, we utilize a bidirectional 2-sample MR approach to explore the potential causal association between hypercholesterolemia and depressive symptoms. Multivariable Mendelian randomization analysis was used to examine whether the direct causal effect of depression on the risk of hypercholesterolemia can be affected by traits associated with the increased risk of hypercholesterolemia. This MR analysis utilized inverse variance weighted (IVW), MR-Egger regression, weighted mode, and weighted median methods. Data on the summary level of depression were acquired from a GWAS that involved 500,199 participants. We used summary GWAS datasets for hypercholesterolemia including 206,067 participants. We also used another GWAS databases of hypercholesterolemiat (n = 463,010) to validate our results. By utilizing IVW, it was discovered that there is a possibility of a 31% rise in the risk of hypercholesterolemia due to depression (OR = 1.31, 95% CI = 1.10-1.57, P = .002). We found a consistent causal effect of depression on hypercholesterolemia from the IVW analyses using different hypercholesterolemia datasets. After adjustment of smoking, physical activity, and obesity, there remains significant causal relationship between depression and hypercholesterolemia (OR = 1.25, 95% CI = 1.01-1.54, P = .040). However, we did not find any evidence indicating that hypercholesterolemia leads to depression in the opposite direction. Directional pleiotropy was not observed in the MR-Egger regression analysis. Additionally, the MR-PRESSO analysis validated these discoveries. Neither the leave-one-out sensitivity test nor the funnel plots revealed any outliers. In both the unadjusted and adjusted estimates, depression has a consistent direct causal effect on hypercholesterolemia. Our study has led to an improved comprehension of the causal connections between hypercholesterolemia and depression, which could aid in the prevention and treatment of hypercholesterolemia.

Evolving Concepts of the SCORE System: Subtracting Cholesterol from Risk Estimation: A Way for a Healthy Longevity?

The role of cholesterol, mainly low-density lipoproteins (LDL-C), as a causal risk factor for atherosclerotic cardiovascular disease (ASCVD) is now established and accepted by the international scientific community. Based on this evidence, the European and American guidelines recommend early risk stratification and "rapid" achievement of the suggested target according to the risk estimation to reduce the number of major cardiovascular events. Prolonged exposure over the years to high levels of LDL-C is one of the determining factors in the development and progression of atherosclerotic plaque, on which the action of conventional risk factors (cigarette smoking, excess weight, sedentary lifestyle, arterial hypertension, diabetes mellitus) as well as non-conventional risk factors (gut microbiota, hyperuricemia, inflammation), alone or in combination, favors the destabilization of the atherosclerotic lesion with rupture/fissuration/ulceration and consequent formation of intravascular thrombosis, which leads to the acute clinical manifestations of acute coronary syndromes. In the current clinical practice, there is a growing number of cases that, although extremely common, are emblematic of the concept of long-term exposure to the risk factor (LDL hypercholesterolemia), which, not adequately controlled and in combination with other risk factors, has favored the onset of major cardiovascular events. The triple concept of "go lower, start earlier and keep longer!" should be applied in current clinical practice at any level of prevention. In the present manuscript, we will review the current evidence and documents supporting the causal role of LDL-C in determining ASCVD and whether it is time to remove it from any score.