The cardiovascular consequences of electronic cigarette smoking: a narrative review

INTRODUCTION

E-cigarettes have emerged as a popular alternative to traditional tobacco smoking in recent years. Despite their growing popularity, concerns have arisen regarding the cardiovascular implications of e-cigarette use.

AREAS COVERED

This narrative review aims to highlight the latest evidence on the impact of e-cigarettes on cardiovascular health.

EXPERT OPINION

Numerous studies have demonstrated that e-cigarette use can lead to acute adverse cardiovascular effects. Inhalation of e-cigarette aerosols exposes users to a wide range of potentially harmful substances that have been implicated in critical pathophysiologic pathways of cardiovascular disease, namely endothelial dysfunction, oxidative stress, inflammation, sympathetic overdrive, and arterial stiffness. While long-term epidemiological studies specifically focusing on the cardiovascular effects of e-cigarettes are still relatively scarce, early evidence suggests a potential association between e-cigarette use and an increased risk of adverse cardiovascular events. However, it is essential to recognize that e-cigarettes are relatively new products, and the full extent of their long-term cardiovascular impact has not been fully elucidated. In the meantime, promoting tobacco cessation strategies that are evidence-based and regulated, along with rigorous monitoring of e-cigarette use patterns and associated health outcomes, are essential steps in safeguarding cardiovascular health in the face of this emerging public health challenge.

The impact of diabetes mellitus on carotid atherosclerosis and arterial stiffness; results from the Corinthia study

Background

Evaluation of arterial stiffness and carotid atherosclerotic burden can provide important prognostic information regarding the risk for future cardiovascular events. In that context, we tried to determine those vascular properties of diabetic individuals compared to non-diabetics.

Methods

In this analysis of the observational “Corinthia” study, we included 1757 participants with determined diabetic status. Propensity scores were employed to match diabetics to non-diabetics with regards to known cardiovascular risk factors. Carotid ultrasonography was performed to evaluate intima-media thickness (cIMT) across the common carotid arteries and the carotid bulbs as well as carotid plaque burden. Arterial stiffness was estimated via assessment of carotid-to-femoral pulse wave velocity (cfPWV).

Results

Diabetic individuals had increased mean cIMT (diabetics: 1.12±0.50mm vs. 0.94±0.38mm, p<0.001) and maximum cIMT (diabetics: 1.50±0.93mm vs. 1.20±0.71mm, p<0.001) when compared to non-diabetics (Figure 1, Panel A and B). Carotid plaque burden was also increased in diabetics (34.4% vs. 19.4% in non-diabetics, p<0.001) while bilateral plaques were observed in 14.2% of diabetics opposed to 8.2% of non-diabetics (p<0.001). Concerning arterial stiffness, individuals with DM had significantly higher values of cfPWV (10.6±3.4m/s vs. 8.8±2.5m/s in non-diabetics, p<0.001) (Figure 1, Panel C). In the propensity-matched cohort, mean cIMT (diabetics: 1.13±0.51mm vs. 0.98±0.38mm, p<0.001) and maximum cIMT (diabetics: 1.53±0.95mm vs. 1.24±0.73mm, p<0.001) were significantly higher in diabetics (Figure 2, Panel A and B), as well as carotid plaque burden (36.6% vs. 21.9% in non-diabetics, p<0.001). Analysis according to territory of cIMT measurement displayed substantial differences in left (diabetics: 1.30±0.76mm vs. non-diabetics: 1.06±0.58mm, p<0.001) and right carotid bulbs (diabetics: 1.30±0.82mm vs. non-diabetics: 1.07±0.57mm, p<0.001) with respect to DM (Figure 2, Panel C) but, unexpectedly, non-significant variations were observed in left (diabetics: 0.97±0.48mm vs. non-diabetics: 0.90±0.42mm, p=0.06) and right common carotid artery (diabetics: 0.95±0.50mm vs. non-diabetics: 0.90±0.40mm, p=0.21) (Figure 2, Panel D).

Conclusion

We observed increased carotid artery intima-media thickness and cfPWV in individuals with diabetes mellitus. As opposed to non-diabetics, carotid lesions in diabetics were more pronounced in the carotid bulb and not in the common carotid artery. Our findings may raise awareness regarding the focus of atherosclerotic echocardiographic examination in subjects with diabetes mellitus while the impact of glucose-lowering therapies on these specific vascular lesions merits further assessment.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

The impact of physical activity on arterial stiffness and inflammation; results from the “Corinthia” study

Background

Diminished physical activity (PA) is associated with cardiovascular morbidity and mortality. Arterial stiffness and inflammation are associated with atherosclerosis and are established risk factors for cardiovascular disease.

Purpose

We investigated the association of PA status on arterial stiffness and inflammation.

Methods

Classification of PA was performed in 2053 participants of the cross-sectional “Corinthia” study using the International Physical Activity Questionnaire (IPAQ). In accordance with the standard IPAQ scoring procedures, participants were classified into one of the following groups: upper tertile: “vigorous” PA-IPAQ 2, middle tertile: “moderate” PA-IPAQ 1 or lower tertile: “low” PA-IPAQ 0. Arterial stiffness was estimated via carotid-femoral pulse wave velocity (cfPWV) estimation and inflammatory burden was assessed via high sensitivity C reactive protein (hsCRP) measurement.

Results

Participants with low PA had impaired cfPWV values (IPAQ 0: 9.5±3.2 m/s vs. IPAQ 1: 8.7±2.4 m/s vs. IPAQ 2: 8.7±2.2 m/s, p<0.001) (Figure 1, Panel A) while abnormal cfPWV –adjusted for age and blood pressure- were more frequently encountered in low PA individuals (IPAQ 0: 14% vs. IPAQ 1: 7.8% vs. IPAQ 2: 7.3%, p=0.001) (Figure 1, Panel B). Participants characterized as having vigorous physical activity had the lowest inflammatory burden, as estimated by hsCRP (IPAQ 0: 4.8±6.4 g/l vs. IPAQ 1: 4.6±5.2 g/l vs. IPAQ 2: 3.6±4.2 g/l, p=0.001) (Figure 1, Panel C). Importantly, results remained unaffected even after adjustment for confounders (Figure 1, Panel D). A correlation analysis between the total weekly physical activity (expressed as MET minutes/week) and arterial stiffness was performed demonstrating a statistically significant negative correlation was noted (r=−0.120, p<0.001) (Figure 1, Panel E).

Conclusion

A significant association between physical activity, arterial stiffness and inflammation was observed, even after adjusting for known cardiovascular risk factors. Our findings should raise public awareness about the beneficial effects of exercise on cardiovascular health.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Emotional and cardiovascular health: the impact of depression on cardiac autonomic activity

Background

The coexistence of depression and cardiovascular diseases is frequently accompanied by an increased risk of adverse outcomes. QTc, an indicator of ventricular depolarization and cardiac autonomic activity, has been proposed as a biomarker of this interplay.

Purpose

We aimed to investigate the possible association of depression with QTc interval.

Methods

Assessment of depressive symptoms was performed in 1637 participants of the cross-sectional Corinthia study with the Zung self-rating depression scale in those younger than 65 years of age (Group 1) and with the geriatric depression scale in elderly individuals (>65 years, Group 2). Moreover, electrocardiogram was performed and measurement of the QT interval was derived after correction for heart rate (QTc) using the Bazett's formula. Abnormal QTc was present when QTc duration exceeded 440 ms.

Results

Group 1 individuals classified as having depression had longer QTc duration (No depression: 389.3±27.0 ms vs. Depression: 401.1±32.9 ms, p<0.001) and percentage of abnormal QTc (No depression: 2.0% vs. Depression: 10.8%, p=0.001) (Figure 1, Panels A and B). Elderly individuals had similar values of QTc (No depression: 409.9±29.6 ms vs. Depression: 405.2±46.4 ms, p=0.37) and percentage of abnormal QTc (No depression: 13.2% vs. Depression: 12.3%, p=0.78) irrespective of depression status (Figure 1, Panels C and D). The presence of depression in Group 1 subjects was associated with an increased QTc- by 10.8 ms and with an approximately 7-fold higher prevalence of abnormal QTc duration, even after adjustment for confounders (). Such finding was not detected in elderly individuals (Figure 1, Panel F).

Conclusion

Depression might adversely affect ventricular repolarization especially in middle-aged subjects. These findings highlight the interrelationship between emotional and cardiovascular health and the role of depression as a cardiovascular risk factor.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Association of habitual alcohol consumption with carotid atherosclerotic lesions: results from the Corinthia study

Introduction

Alcohol is implicated in the pathophysiology of cardiovascular diseases. However, it is also believed to play a cardioprotective role if consumed in appropriate amounts.

Purpose

To assess the association between alcohol consumption and carotid atherosclerosis.

Methods

In the setting of the cross-sectional Corinthia study, volunteers filled in questionnaires regarding drinking habits and were characterized as social drinkers (SD) or habitual alcohol consumers (HAC). Furthermore, they underwent carotid ultrasonography examination to evaluate the carotid intima-media thickness (cIMT). Thickness of cIMT>1.5 mm or protrusion >50% compared to adjacent segments was considered as atherosclerotic plaque.

Results

HAC consumers were usually male (HAC: 61.1%, SD: 24.9%, p<0.001), smokers (HAC: 33.3%, SD: 23.5%, p<0.001) and frequently had a history of hypertension (HAC: 72.8%, SD: 67.5%, p=0.02) when compared to SD (Table 1). However, no significant differences were noted regarding other risk factors of atherosclerosis (Table). Notably, HAC had a greater extent of carotid atherosclerosis as demonstrated by an increased cIMT (HAC: 1.03±0.45mm, SD: 0.96±0.39mm, p<0.001) and carotid plaque burden (HAC: 27.7%, SD: 21.3%, p=0.004). Importantly, when taking into account the number of alcoholic drinks (in wine glasses), alcohol consumption of more than 1 wine glass resulted in significantly higher values of cIMT (1 wine glass: 1.00±0.42mm, >1 wine glass: 1.06±0.45mm, p=0.04) (Figure 1A) and extensive amount of carotid plaques (1 wine glass: 22.7%, >1 wine glass: 30.4%, p=0.02) when compared to consumption of 1 wine glass (Figure 1B).

Conclusion

Habitual alcohol consumption of more than one wine glass is associated with a higher carotid atherosclerotic burden.

Figure 1

Funding Acknowledgement

Type of funding source: None

Increased exposure to air pollutants leads to greater atherosclerotic burden mediated by systemic inflammation

Introduction

Air pollution has been a well-described environmental factor contributing significantly to the global disease burden.

Purpose

To examine the association of gaseous air pollutants with atherosclerosis, especially in subjects with coronary artery disease (CAD).

Methods

2053 individuals enrolled in the Corinthia study underwent clinical and biochemical assessment followed by carotid ultrasonography to evaluate carotid intima-media thickness (cIMT) and plaque burden. Inflammation was estimated via measurement of C-Reactive protein (CRP). Air pollutants concentration analysis was performed in prespecified regions with respect to their proximity to heavy industries, highways and shipyards.

Results

A higher concentration of gaseous air pollutants was observed in Region 4 when compared to other regions (Table). Mean cIMT, maximum cIMT and carotid plaque burden were significantly increased in individuals of Region 4 (Table, Figure A and B), a result which remained unaffected after adjustment for cardiovascular confounders (Figure C). In parallel, inhabitants of Region 4 had higher levels of CRP (Region 1: 4.60±5.01mg/l; Region 2: 3.08±3.26mg/l; Region 3: 4.37±4.70mg/l, Region 4: 6.78±9.77mg/l, p<0.001). To examine the effect of air pollution on atherosclerosis in CAD, propensity scores were applied to match healthy controls with CAD subjects in terms of atherosclerosis risk factors resulting in two matched groups; one in regions 1, 2 and 3 -low air pollution areas (LAPA)- and another in region 4 -high air pollution area (HAPA). Interestingly, we noted substantially higher inter-area differences in mean cIMT of CAD individuals (Figure D).

Conclusion

Air pollution may significantly contribute to atherosclerosis progression, potentially via the induction of inflammation. A more pronounced effect was noted in CAD individuals exposed to high air pollution.

Funding Acknowledgement

Type of funding source: None

Depression in young adults is associated with increased carotid atherosclerotic burden: insights from the Corinthia study

Introduction

Depression appears to have a detrimental effect not only on mental health but also in the progression of various diseases.

Purpose

The examination of a potential association between depression and atherosclerosis progression in a rural population.

Methods

In the context of the cross-sectional Corinthia study, volunteers fulfilled a questionnaire concerning emotional health. The Geriatric Depression Scale was used for individuals aged 60 or more while the Zung self-rating depression score was preferred in younger adults. Carotid ultrasonography examination was performed to evaluate the mean carotid intima-media thickness (cIMT). Thickness of cIMT>1.5 mm or protrusion >50% compared to adjacent segments was considered as atherosclerotic plaque.

Results

Young adults with significant depression were usually female and did not differ significantly on other risk factors of atherosclerosis compared to those with mild or no depressive disorder. Importantly, those with moderate-severe depression appeared to have increased mean cIMT (Mild-No depression: 0.85±0.30mm, Moderate-severe depression: 0.91±0.42mm, p=0.04) and a higher carotid plaque burden (Mild-No depression: 12.8%, Moderate-severe depression: 20.3%, p=0.04). With regards to the elderly, those with moderate-severe depression were usually smokers (Mild-No depression: 13.9%, Moderate-severe depression: 24.2%, p=0.01). However, mean cIMT (Mild-No depression: 1.11±0.47mm, Moderate-severe depression: 1.09±0.39mm, p=0.69) and carotid plaques (Mild-No depression: 31.1%, Moderate-severe depression: 36.1%, p=0.36) did not differ according to depression status in this subgroup.

Conclusion

Significant depressive disorder is associated with accelerated carotid atherosclerosis in young individuals.

Funding Acknowledgement

Type of funding source: None

Differential effect of anthracycline and trastuzumab cancer therapeutic related vascular toxicity in patients with breast cancer

Introduction

Both anthracyclines and trastuzumab are key regiments for the treatment of breast cancer, but their concurrent use is contraindicated because of their cardiotoxicity. Their effects on vascular function have been less well studied.

Purpose

We explored the effects of the anthracycline-based chemotherapy followed by trastuzumab-based treatment on endothelial function and arterial stiffness in patients with breast cancer.

Methods

46 female patients (54.56±11.5 years old) with breast cancer scheduled for anthracycline-based chemotherapy followed by the combination of trastuzumab and taxane were enrolled. Trastuzumab was continued until the completion of one-year treatment. All participants underwent assessment of the brachial flow mediated dilatation (FMD), endothelial independent dilatation (EID), carotid-femoral pulse wave velocity (PWV) and augmentation index (AIx) at baseline (BL), at the end of anthracycline treatment (FU1), 3 months following initiation of trastuzumab with taxane (FU2) and at the completion of treatment with trastuzumab (FU3).

Results

Over the follow-up period (15 months) there was significant deterioration in FMD (p=0.04) (Table 1, Figure 1). Importantly, while there was no significant difference in FMD between BL vs FU1 (p=0.6), FMD has been significantly deteriorated over the treatment with trastuzumab with taxane FU1 vs FU2 (p=0.01) and FU2 vs FU3 (p=0.01) (Table 1, Figure 1). EID did not change over the follow-up period (Figure 1). Similarly, PWV has been significantly increased over the follow up period (p=0.03). There was no significant difference in PWV BL vs FU1 (p=0.1), however PWV has been significantly increased over the treatment with trastuzumab with taxane FU1 vs FU 2 (p=0.02) and FU2 vs FU3 (p=0.01) (Table 1, Figure 1). A similar pattern of impairment was observed with AIx (Table 1, Figure 1).

Conclusion

We report a significant adverse effect of the anthracycline- and trastuzumab-based therapy on the arterial stiffness and endothelial function. This effect is more considerable after the exposure to trastuzumab.

Figure 1. Changes of FMD, PWV, Alx, EID during FU

Funding Acknowledgement

Type of funding source: None

Relationship of depressive symptoms with arterial stiffness and carotid atherosclerotic burden in the Corinthia study

BACKGROUND

It has been long hypothesized that emotional factors and depression may play role in the development of cardiovascular diseases.

AIM

The aim of this study was to examine the association between depression, arterial stiffness and atheromatic burden in carotid arteries.

DESIGN AND METHODS

Corinthia study is a cross-sectional epidemiological study conducted in subjects aged 40-99 years, inhabitants of the homonym region of Greece. Intima media thickness (IMT) was measured in the left and right common carotid artery, carotid bulb and internal carotid artery. The average of the measurements (mean IMT) and the maximum IMT were determined as the representative value of carotid atherosclerosis burden. Pulse wave velocity was used to evaluate arterial stiffness. The Zung Self-Rating Depression Scale was used to evaluate depressive symptoms in subjects <65 years and the Geriatric Depression Scale in those >65 years.

RESULTS

In this analysis, we included data from 1510 participants. In older subjects (i.e. >65 years), maximum IMT was significantly increased in subjects with depression compared to those without (1.57 ± 0.97 mm vs. 1.74 ± 1.05 mm, P = 0.04). Similarly, the prevalence of atheromatic plaques was higher in subjects with depression (46% vs. 34%, P = 0.005). In the younger subgroup (<65years), there was no difference in mean and maximum IMT. Pulse wave velocity was found higher in the presence of depression (8.35 ± 2.36m/s vs. 7.88 ± 1.77m/s, P = 0.007). No differences emerged for the rest of the variables assessed in the individual subgroups.

CONCLUSIONS

There is an age-dependent association between depression, arterial stiffness and carotid atheromatic burden highlighting the interplay between cardiovascular diseases and emotional status.

Hospital attendance and admission trends for cardiac diseases during the COVID-19 outbreak and lockdown in Greece

Objectives

The coronavirus disease 2019 (COVID-19) outbreak, along with implementation of lockdown and strict public movement restrictions, in Greece has affected hospital visits and admissions. We aimed to investigate trends of cardiac disease admissions during the outbreak of the pandemic and possible associations with the applied restrictive measures.

Study design

This is a retrospective observational study.

Methods

Data for 4970 patients admitted via the cardiology emergency department (ED) across 3 large-volume urban hospitals in Athens and 2 regional/rural hospitals from February 3, 2020, up to April 12 were recorded. Data from the equivalent (for the COVID-19 outbreak) time period of 2019 and from the postlockdown time period were also collected.

Results

A falling trend of cardiology ED visits and hospital admissions was observed starting from the week when the restrictive measures due to COVID-19 were implemented. Compared with the pre–COVID-19 outbreak time period, acute coronary syndrome (ACS) [145 (29/week) vs. 60 (12/week), −59%, P < 0.001], ST elevation myocardial infarction [46 (9.2/week) vs. 21 (4.2/week), −54%, P = 0.002], and non-ST elevation ACS [99 cases (19.8/week) vs. 39 (7.8/week), −60% P < 0.001] were reduced at the COVID-19 outbreak time period. Reductions were also noted for heart failure worsening and arrhythmias. The ED visits in the postlockdown period were significantly higher than in the COVID-19 outbreak time period (1511 vs 660; P < 0.05).

Conclusion

Our data show significant drops in cardiology visits and admissions during the COVID-19 outbreak time period. Whether this results from restrictive measures or depicts a true reduction of cardiac disease cases warrants further investigation.

•

The coronavirus disease 2019 (COVID-19) outbreak has led to an unprecedented health system overload.

•

The restrictive measures in Greece resulted in a low number of COVID-19 cases.

•

Hospital visits and cardiovascular events have diminished after implementation of restrictive measures.

•

Acute coronary syndromes reduced by approximately 55%, despite limited incidence of COVID-19.

•

The multifactorial etiology of this finding should be thoroughly investigated.

Incidence and cost of bleeding events requiring hospitalization in patients with atrial fibrillation treated with acenocoumarol in Greece

BACKGROUND

To estimate the incidence of hemorrhagic events in patients with atrial fibrillation (AF) treated with acenocoumarol, and the management cost of those requiring hospitalization in Greece.

METHODS

A nationwide telephone survey was conducted between December 2017 and January 2018, to identify cardiologists who treat AF patients with acenocoumarol. A total of 300 cardiologists were selected and reported the number of AF acenocoumarol-treated patients during the past 12 months and the number of those who experienced a hemorrhagic event. The hospital charges to sickness fund and the cost of resource utilization of AF patients hospitalized between January 2013 and June 2017 at a tertiary hospital in Athens due to acenocoumarol-related bleedings were retrieved.

RESULTS

Out of 48,255 AF patients, 12,633 (26.2%) were treated with acenocoumarol. In all, 5.1% of patients experienced a hemorrhagic event with the incidence of bleeding requiring hospitalization being 1.7%. The most common bleeding site was the gastrointestinal system (51.5%). The mean (95% CI) management cost per bleeding event requiring hospitalization was €1,202 (€1,058-€1,420). The higher cost was that of intracranial bleeding €3,887 (€2,700-€5,046). The expected annual economic burden for the management of bleedings related to acenocoumarol and requiring hospitalization was estimated at €1,463,955.

CONCLUSIONS

The incidence of bleeding events in AF acenocoumarol-treated patients in Greece as well as the estimated annual economic burden for the management of bleeding events requiring hospitalization, emphasize the need to comply with the current guidelines and to optimize therapeutic strategies for the management of AF side effects with oral anticoagulants, particularly in patients with high bleeding risk.

High-Intensity Endurance and Strength Training in Water Polo Olympic Team Players: Impact on Arterial Wall Properties

INTRODUCTION

Regular physical activity is recommended to minimize health risk. However, the upper intensity threshold associated with the best health outcomes is difficult to be determined. Water polo (WP) Olympic athletes present unique characteristics such as high-intensity exercise, long training sessions, and a combination of endurance and strength training. Therefore, we examined in which way the long-term, intense, mixed endurance and strength training affects the peripheral and central hemodynamics.

METHODS

The study population consisted of 20 WP Olympic team players, 20 matched recreationally active (RA) subjects, and 20 sedentary control subjects (Cl). Reflected waves were assessed with the augmentation index (AIx), central aortic stiffness with pulse wave velocity (PWV), and endothelial function with flow-mediated dilation (FMD).

RESULTS

Amongst Cl subjects, RA subjects, and WP players, there was no difference in age (p = 0.33) as well as in brachial systolic pressure (p = 0.52), while there was a stepwise decrease in aortic systolic pressure (116 ± 16 mm Hg vs. 107 ± 14 mm Hg vs. 106 ± 6 mm Hg, p = 0.03). There was also a stepwise improvement in AIx (-4.22 ± 9.97% vs. -6.97 ± 11.28% vs. -12.14 ± 6.62%, p = 0.03) and FMD (6.61 ± 1.78% vs. 7.78 ± 1.98% vs. 8.3 ± 2.05%, p = 0.04) according to the intensity of exercise, with WP players having lower AIx and higher FMD compared to RA subjects and Cl subjects. No difference was found in PWV (Cl: 5.88 ± 0.72 m/s vs. RA: 6.04 ± 0.75 m/s vs. WP: 5.97 ± 1.09 m/s, p = 0.82) among the three studied groups.

CONCLUSIONS

Young WP Olympic team players depict improved arterial wall properties and endothelial function compared to RA and Cl subjects.

Coronary Microcirculation and the No-reflow Phenomenon

The no-reflow phenomenon refers to the post-percutaneous coronary intervention condition in which, despite re-establishing epicardial coronary vessel patency, the flow to the previously ischemic myocardium is markedly reduced. When it does occur, it attenuates the beneficial effect of reperfusion therapy and substantial regions of the myocardium fail to receive adequate perfusion. The pathophysiology of this phenomenon is not completely understood. The possible mechanisms could be related to alterations in the microvascular circulation. Various mechanisms such as activation of inflammatory pathways, vascular damage and hemorrhage, leukocyte infiltration, and cellular edema may be responsible. As the no-reflow phenomenon is associated with adverse clinical consequences, it is of great importance to identify exact responsible mechanisms and apply effective preventive and therapeutic strategies. In this review, we describe an updated overview of the pathophysiological mechanisms and the current preventive tools for no-reflow as well as therapeutic interventions in order to improve coronary blood flow and consequently the prognosis for these patients.

P3450Aortic stiffness is significantly associated with left ventricular mass in females but not in males: insights from the CORINTHIA study

Introduction

Arterial stiffening may contribute to the increase of left ventricular mass (LVM) and the development of left ventricular hypertrophy (LVH). Although male gender has been also found to be an independent determinant of LVH, it is unknown if the adverse effect of increased aortic stiffening on LVM differs between males and females.

Aim

To evaluate the association of aortic stiffness as assessed by carotid-to-femoral pulse wave velocity (cf-PWV) with LVM and LVH in a general population and compare these associations between males and females.

Methods

Demographic, laboratory and clinical data of 1686 subjects (693 males and 993 females) from the cross-sectional, observational study “Corinthia” were analyzed. All subjects underwent applanation tonometry and pulse wave analysis for the measurement of cf-PWV and echocardiography examination for the computation of LVM which was adjusted by body surface area providing the LVM index (LVMI). Multivariate linear regression analysis was performed for the determination of independent factors related with LVMI. Receiver operator curve analysis (ROC) was used to compare the ability of cf-PWV to predict LVH, in males and females separately.

Results

In the female population, significant and independent determinants of LVMI were: age (beta=0.243, p<0.001), urea (beta=0.119, p=0.001), hypertension (beta=0.089, p=0.028) and cf-PWV (beta=0.096, p=0.021). In contrast, in the male population, LVMI was independently related with age (beta=0.242, p<0.001), systolic blood pressure (beta=0.095, p=0.027), LDL (beta=-0.087, p=0.047) and creatinine (beta=0.092, p=0.031). ROC analysis showed that cf-PWV is a stronger predictor of LVH in females than in males (figure).

Conclusion

Increased aortic stiffness measured by cf-PWV is significantly related with increased LVMI regardless from age and other risk factors only in females. Moreover cf-PWV was a stronger predictor of left-ventricular hypertrophy in females than males. These findings should be further explored in prospective studies.

405Acute and short-term effects of diesel exhaust fumes exposure on arterial wall properties, inflammatory process and fibrosis-fibrinolysis status

Introduction

Exhaust fumes from diesel engines are a complex mixture of toxic compounds with a wide variety of harmful effects. The acute effects of diesel exhaust fumes on the cardiovascular system are well-known. However, their short-term impact has not been thoroughly studied.

Purpose

To study the acute and short-term (24 h) effects of diesel exhaust particles (DEPs) on endothelial function, arterial wall properties, inflammatory process and fibrosis-fibrinolysis status.

Methods

In this blind cross over study, 40 healthy volunteers (median age 40 years old) have been exposed to diesel exhaust particles (DEPs) and then to filtered air (FA) over a 2-hour session with a wash out period of 4 weeks. Exposure to DEPs was calibrated based on the mass of microparticles less than 2,5 microns in diameter (PM 2,5). Flow-mediated-dilation (FMD) was used to estimate endothelial function. Pulse wave velocity (PWV) and augmentation index (AIx) assessed central aortic stiffness and arterial reflected waves respectively. C reactive protein (CRP) was measured to determine the inflammatory status, as well as fibrinogen and protein C levels to evaluate the impact on the coagulation cascade. All measurements were performed before each session (T0), at the end of the 2 hours exposure session (T2) and 24 hours after completion of each session (T24). Variables with normal distribution are presented as mean±SD otherwise as median±SEM.

Results

At T0 of DEP and FA exposure there was no significant difference in FMD, PWV, AIX, CRP, protein C and fibrinogen levels. Exposure to DEP decreased significantly FMD (T0: 11.97±4.61% vs T2: 7.71±3.36% vs. T24: 6.17±3.19%, p<0.001) and increased PWV (T0: 6.09±1.03m/sec vs T2: 7.22±1.31m/sec vs. T24: 6.90±1.03m/sec, p<0.001), AIx (T0: 8.17±3.19% vs T2: 12.71±3.36% vs. T24: 13.17±4.61%, p<0.001), CRP (T0: 1.41±0.18 mg/L vs T2: 1.99±0.21mg/L vs. T24: 2.08±0.24mg/L, p=0.04) and fibrinogen levels (T0: 269±44 mg/dL vs T2: 331±75 mg/dL vs. T24: 307±51 mg/dL, p=0.002). Protein C was significantly reduced (T0: 121±26% vs T2: 104±21% vs. T24: 105±20%, p=0.003). Exposure to FA had no significant impact on the study parameters.

Graph of results

Conclusion

Exposure to diesel exhaust fumes may have significant adverse effects on the cardiovascular system with impairment of endothelial function, arterial wall properties, inflammatory status and fibrosis-fibrinolysis parameters not only during the exposure period but as far as 24 hours after exposure.

Acknowledgement/Funding

None

P5312Sleep duration and carotid atheromatic burden. Insights from the Corinthia study

Background

Sleep is an essential physiological process and disturbance of sleeping pattern may be associated with cardiovascular risk profile and atheromatosis. Short but also long sleep duration (LSD) may be adversely affect cardiovascular parameters.

Purpose

To study how sleep duration is associated with cardiovascular risk profile and carotid atherosclerotic burden.

Methods

Corinthia study is a cross sectional epidemiological study based on 2043 inhabitants (age 40–99 years) of Corinthia region in Greece. Ultrasonography was used to measure intima media thickness (IMT) in the left and right common carotid artery, carotid bulb and internal carotid artery. The mean IMT (meanIMT) were determined as representative values of carotid atherosclerosis burden. Thickness of IMT>1.5 mm or protrusion >50% compared to adjacent segments was considered as atherosclerotic plaque. Based on questionnaires of Corinthia study, total sleeping time per day was recorded. A sleep duration of 7 to 8 h was consider normal (NSD), sleep duration <6 h was consider very short (VSSD), 6–7 h sleep duration was considered short (SSD) and participants with >8 h sleep duration was categorized as LSD.

Results

Concerning gender more men than women were categorized in the NSD (26% vs. 21%, p<0.001). Subjects in the NSD were also younger compared to subjects categorized in other sleeping patterns (VSSD: 66±12 y vs. SSD: 63±12 y vs. NSD: 62±12 y vs. LSD: 66±12 y, p<0.001), have less prevalence of diabetes mellitus (p<0.05). There was no difference according to sleeping pattern in body mass index, prevalence of hypertension, cardiovascular disease, hyperlipidemia and on current smoking habits according to sleeping patterns. Interestingly, meanIMT (VSSD: 1.08±0.51 mm vs. SSD: 0.97±0.42 mm vs. NSD: 0.97±0.41 mm vs. LSD: 1.14±1.64 mm, p=0.04) and carotid atherosclerotic plaque (VSSD: 35% vs. SSD: 25% vs. NSD: 20% vs. LSD: 30%, p=0.006) was decreased in NSD subjects. Importantly, even after adjustment for the confounders logistic regression analysis revealed that subjects in the NSD group have 50% less odds of carotid atheromatic plaque than subjects in the VSSD (Odds ratio: 0.5, 95% CI 0.28–0.90, p=0.02) (Figure).

Conclusion

A balanced sleeping pattern with 8h of sleep daily can act as an additive cardioprotective factor in the modern western type societies. Short especially less than 6 hours and long (>8 hours) sleeping duration may act as a cardiovascular risk factor.

4099High intensity endurance and strength training in water polo Olympic team players: impact on arterial wall properties

Background

Regular physical activity is recommended for health improvement. However the upper intensity threshold associated with best health outcome is difficult to determine. Water polo (WP) Olympic athletes present unique characteristics with very high intensity work, long training sessions and a combination of endurance and strength training.

Purpose

To examine how long term, intense mixed endurance and strength training affect peripheral and central hemodynamics and biomarkers of cardiovascular health.

Methods

The study population consisted of 20 WP Olympic team player's, 20 matched recreational active subjects (RA) and 20 sedentary control subjects (Cl). Reflected waves were assessed with the Augmentation index (AIx), central aortic stiffness with pulse wave velocity (PWV) and endothelial function with flow mediated dilation (FMD).

Results

From Cl subjects to RA active subjects and to WP players there was a stepwise decrease in aortic systolic pressure (116±16 mmHg vs. 107±14 mmHg vs. 106±6 mmHg, p=0.03) while there was no difference in branchial systolic pressure (p=0.52). There was also a stepwise improvement in AIx (−4.22±9.97% vs. −6.97±11.28% vs. −12.14±6.62%, p=0.03) and FMD (6.61±1.78% vs. 7.78±1.98% vs. 8.3±2.05%, p=0.04) according to the intensity of exercise and WP players had lower AIx and higher FMD compared to RA subjects and to Cl subjects.

Conclusions

In young WP Olympic team players intense mixed endurance and strength training has no adverse impact on arterial wall properties and endothelial function with a parallel improvement in central hemodynamics. These findings highlight that there are no definitive data to support on any adverse vascular related impact of ultra-endurance training while mixed endurance and strength training may be associated with a favorable vascular profile.

P1573Chemotherapy-induced vasotoxicity in patients undergoing therapy for breast cancer

Background

Cardiotoxicity is a well-known adverse effect of anthracycline and HER-2 monoclonal antibodies, however the vascular effects of these agents remain less-well studied.

Purpose

To explore the effects of breast chemotherapy on vascular function.

Methods

A total of 57 female patients undergoing breast diagnosed with breast cancer and scheduled for anthracycline-based and HER-2 chemotherapy were included in this study. At baseline, at 3, 6 and 12 months, patients underwent assessment of cardiac function by transthoracic echocardiography, endothelial function assessment by brachial flow mediated dilation (FMD) and assessment of arterial stiffness by carotid-radial pulse wave velocity (PWV) and augmentation index (Aix).

Results

There was a significant decrease in left ventricular ejection fraction (LVEF) overtime compared to baseline (A). This was paralleled by a significant decrease in brachial FMD at 6 months (B) and a significant increase in PWV compared to baseline (C). There was no significant change in Aix compared to baseline levels (D). Chemotherapy-induced cardiotoxicity (expressed by the change in LVEF) was not associated with either the change in FMD or PWV at 6 months.

Conclusions

Breast chemotherapy-induced cardiotoxicity is paralleled by vasotoxicity, which is manifested as endothelial dysfunction and increased arterial stiffness. Systemic vasotoxicity is not directly related to cardiotoxicity, suggesting that monitoring of both cardiac and vascular function could be useful in identifying early signs of cardiovascular toxicity.

P6255Impact of whole grain consumption on arterial stiffness. Results of the Corinthian cross-sectional survey

Introduction

The benefits of certain dietary patterns on cardiovascular diseases has been questioned over the last years. Whole grain consumption has been one of the controversial issues regarding the effect on cardiovascular disease. In Greek rural population consumptions of bread is part of the daily meal and a possible source of whole grain.

Purpose

To investigated the effect of whole grain bread consumption on arterial stiffness in Mediterranean population.

Methods

In a cross-sectional survey (Corinthia study) volunteers subjects completed a food frequency questioner (FFQ), including a question of consumption of bread on regular basis, whole grain (group I) or not (group II). Medical history, lifestyle habits, anthropometric and vital signs, as well as, laboratory blood test were performed. All patients underwent carotid-femoral pulse wave velocity (C-F PWV) measurements which were obtained noninvasively by SphygmoCor devise.

Results

Among the 2043 volunteers 1389 patients had adequate quality of pulse wave velocity recordings and were regular consumers of bread. Whole grain bread was consumed by 473 subjects (male 37%, female 63%,) but 916 (male 43.1%, female 56.9%) did not consume. Subjects consuming whole grain bread were younger compare to those who were not (group I: 62±11 years vs. group II: 64±12 years, p=0.02), have lower C-F PWV (group I: 9.04±2.93 m/sec vs. group II: 9.57±2.76 m/sec, p=0.01) but no other statistical difference were observe among other parameters (i.e. hypertension, diabetes mellitus, BMI, smoking etc). Hierarchical multiple regression showed that whole grain consumption predicted pulse wave velocity statistically significantly (b=−0.33, 95% CI: −0.62, −0.17, p=0.03) in addition to age (b=0.09, 95% CI 0.08–0.10, p<0.001), systolic blood pressure (b=0.02, 95% CI 0.01, 0.03, p<0.001) beta=0.157) and diabetes mellitus (b=0.75, 95% CI 0.40, 1.09, p<0.001).

Conclusion

Whole grain bread consumption has a beneficial effect on arterial stiffness as detected by better carotid femoral pulse wave velocity. This may have a positively effect on cardiovascular diseases.

Redox State in Atrial Fibrillation Pathogenesis and Relevant Therapeutic Approaches

BACKGROUND

Myocardial redox state is a critical determinant of atrial biology, regulating cardiomyocyte apoptosis, ion channel function, and cardiac hypertrophy/fibrosis and function. Nevertheless, it remains unclear whether the targeting of atrial redox state is a rational therapeutic strategy for atrial fibrillation prevention.

OBJECTIVE

To review the role of atrial redox state and anti-oxidant therapies in atrial fibrillation.

METHOD

Published literature in Medline was searched for experimental and clinical evidence linking myocardial redox state with atrial fibrillation pathogenesis as well as studies looking into the role of redoxtargeting therapies in the prevention of atrial fibrillation.

RESULTS

Data from animal models have shown that altered myocardial nitroso-redox balance and NADPH oxidases activity are causally involved in the pathogenesis of atrial fibrillation. Similarly experimental animal data supports that increased reactive oxygen / nitrogen species formation in the atrial tissue is associated with altered electrophysiological properties of atrial myocytes and electrical remodeling, favoring atrial fibrillation development. In humans, randomized clinical studies using redox-related therapeutic approaches (e.g. statins or antioxidant agents) have not documented any benefits in the prevention of atrial fibrillation development (mainly post-operative atrial fibrillation risk).

CONCLUSION

Despite strong experimental and translational data supporting the role of atrial redox state in atrial fibrillation pathogenesis, such mechanistic evidence has not been translated to clinical benefits in atrial fibrillation risk in randomized clinical studies using redox-related therapies.

Arterial stiffness and subclinical aortic damage of reclassified subjects as stage 1 hypertension according to the new 2017 ACC/AHA blood pressure guidelines

Background: The 2017 ACC/AHA blood pressure (BP) guidelines generated controversies due to the new proposed BP cut-off values defining hypertension. We aimed to assess aortic stiffness of subjects who are reclassified as stage 1 hypertensive according to the new guidelines and compare them with the subjects of "elevated BP" category. Patients and methods. Data from the "Corinthia" study, an observational, cross-sectional survey of 2,043 participants were analyzed. Subjects were classified into 4 groups: group A: systolic pressure (SBP) 120-129 and diastolic pressure (DBP) < 80 mmHg, group B: SBP 130-139 or DBP 80-89 mmHg, group B1: SBP 130-139 and DBP < 80 mmHg and group B2: SBP 130-139 and DBP 80-89 mmHg. Aortic stiffness was assessed by carotid-to-femoral pulse wave velocity (PWV). A value of PWV > 10m/s was consider indicative of asymptomatic organ damage while values of PWV exceeded the 90 % percentile for each age group were consider as abnormal. Results: Groups B, B1 and B2 have significantly increased PWV compared to group A, independently from age and other risk factors (PWV: 9.2 ± 2.8 vs 9.4 ± 2.7 vs 8.6 ± 2.5 vs 8.1 ± 2.3 m/s, p < 0.01, respectively). The prevalence of PWV > 10 m/s and abnormal PWV values in group A was significantly lower than the corresponding prevalence in randomly selected, age-matched subjects from group B (13.5 % vs 24.4 %, p = 0.027 and 5.6 % vs 14.2 %, p = 0.022, respectively). Conclusions: The reclassified subjects as stage 1 hypertensive by the new guidelines have a significantly increased aortic stiffness and greater prevalence in asymptomatic aortic damage compared to subjects with elevated BP. This finding may indirectly explain the increased cardiovascular risk of this group.

The association among biomarkers of renal and heart function in patients with heart failure: the role of NGAL

AIM

The NGAL is a biomarker of renal injury associated with the progression of heart failure (HF). We examine the association of NGAL with galectin-3 in patients with chronic HF.

METHODS

We consecutively enrolled 115 subjects with stable ischemic HF of reduced ejection fraction. Serum levels of galectin-3, b-type natriuretic peptide and NGAL were measured.

RESULTS

NGAL levels were positively correlated with galectin-3 (rho = 0.26; p = 0.04) and b-type natriuretic peptide levels (rho = 0.30; p = 0.005) and inversely correlated with ejection fraction (rho = -0.31; p = 0.02) and creatinine clearance levels. The NGAL was independently associated with galectin-3 levels.

CONCLUSION

A positive correlation between NGAL and galectin-3 in HF patients was found, revealing a potential association between renal injury and myocardial fibrosis and remodeling in HF.

Non-natriuretic peptide biomarkers in heart failure with preserved and reduced ejection fraction

Heart failure (HF) with reduced and preserved ejection fraction constitutes two entities with distinct pathogenetic backgrounds sharing common features. Beyond natriuretic peptides, several novel biomarkers have been proven useful in the diagnosis, prognosis and treatment of HF. Biomarkers of myocardial fibrosis have a low diagnostic yield in subjects with acute HF but may add prognostic information, especially in patients with HF and preserved ejection fraction. Biomarkers of renal impairment identify subjects with worse prognosis independently of left ventricle ejection fraction while inflammatory markers have not been proven useful in patients with systolic or diastolic impairment. In this review article, we summarize the main differences and application of non-natriuretic peptide biomarkers in HF patients with preserved and reduced ejection fraction.

Statins and inflammation in cardiovascular disease

BACKGROUND

Chronic inflammation and immune system activation underlie a variety of seemingly unrelated cardiac conditions including not only atherosclerosis and the subsequent coronary artery disease but also peripheral artery disease, hypertension with target organ damage and heart failure. The beneficial effects of HMG-CoA reductase inhibitors or statins are mainly attributed to their ability to inhibit hepatic cholesterol biosynthesis. Beyond their lipid lowering activity, ample evidence exists in support of their potent anti-inflammatory properties which initiate from the inhibition of GTPase isoprenylation, activating a cataract of secondary pathways and extend to the inhibition and blocking of immune cell activation and interaction.

OBJECTIVE

To summarize the anti-inflammatory mechanisms of statins in clinical and experimental settings in cardiovascular disease.

METHODS

A systematic search of PubMed and the Cochrane Database was conducted in order to identify the majority of trials, studies, current guidelines and novel articles related to the subject.

RESULTS

In vitro, statins have immuno-modulatory and anti-inflammatory effects, and they can exert anti-atherosclerotic effects independently of their hypolipidemic actions. In addition, positive results have emerged from mechanistic and experimental studies on the active role of HMG-CoA reductase inhibitors in HF. By extrapolating those data in clinical setting, we further understand how HMG-CoA reductase inhibitors can beneficially affect not only systolic but also diastolic HF.

CONCLUSION

In this review article, we present the basic pathophysiologic data supporting the anti-inflammatory actions of statins in clinical and experimental settings and we link these mechanisms with confirmatory clinical data on the potent non lipid lowering effects of HMG-CoA reductase inhibitors.

Statins and left ventricular function

BACKGROUND

Statins are a well-established class of drugs in both preventing coronary events and treating cardiovascular atherosclerotic disease, however their use in heart failure is still in debate.

OBJECTIVES

To establish whether statins' pleiotropic actions in endothelium, inflammation, remodeling of the heart and anti-arrhythmic potential may be in favorable of heart failure patients.

METHODS

We proceed to literature search of English bibliography under the terms heart failure, statins, 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors.

RESULTS

Various experimental and clinical trials on the use of statins in the different subtypes of heart failure according to the ejection fraction of the left ventricle have been conducted to conclude whether statins should be part of their patients' treatment. The evidence shows that the subgroup of patients with ischemic heart disease and those with preserved ejection fraction seems to have better results from the use of statins although randomized control trial in the total heart failure population did not show any benefit in mortality, Conclusion: Statins may be beneficial act to left ventricle systolic and diastolic performance of heart failure patients however their result in mortality cannot be established based on current evidence.

Genotyping, Platelet Activation, and Cardiovascular Outcome in Patients after Percutaneous Coronary Intervention: Two Pieces of the Puzzle of Clopidogrel Resistance

OBJECTIVES

Individual platelet responses to antiplatelet therapy depend on genetic, cellular, and clinical factors. CYP2C19 and P2Y12 receptor polymorphisms are implicated in platelet responses to antiplatelet treatment. We aimed to evaluate the impact of CYP2C19 and C34T P2Y12 genotyping on platelet reactivity and cardiovascular outcome in patients after percutaneous coronary intervention (PCI) on clopidogrel treatment.

METHODS

We enrolled 408 patients with stable coronary artery disease (CAD) receiving aspirin and clopidogrel (75 mg/day) 1 month after PCI. High on-treatment platelet reactivity was evaluated using the VerifyNow Assay in a subset of patients. CYP2C19*2 and C34T P2Y12 genotyping was performed by real-time polymerase chain reaction. The primary end point was the composite of death or hospitalization for cardiovascular causes, and patients were followed for a median time of 13 months.

RESULTS

In the total study population, 37% were carriers of at least 1 CYP2C19*2 loss-of-function allele, and 53% were carriers of at least 1 C34T loss-of-function allele. Interestingly, homozygotes of the CYP2C19*2 loss-of-function allele had significantly increased P2Y12 reaction units (PRU) (p = 0.007). However, PRU did not differ between carriers and noncarriers of the C34T loss-of-function allele (p = 0.41). Moreover, carriers of CYP2C19*2 had an increased hazard ratio (HR) for the occurrence of the primary end point (for carriers HR = 1.96, 95% CI 1.05-3.66, p = 0.03), whereas the C34T polymorphism had no impact on the cardiovascular outcome (p = 0.17). Finally, PRU was associated with cardiovascular outcome even after adjustment for the presence of any reduced function allele polymorphism.

CONCLUSIONS

We documented a different effect of CYP2C19 and P2Y12 receptor polymorphisms on platelet reactivity and cardiovascular outcome in CAD patients after PCI on clopidogrel treatment. Importantly, increased platelet reactivity adversely affects the cardiovascular outcome independently of the studied polymorphisms.

Usefulness of C-Reactive Protein as a Predictor of Contrast-Induced Nephropathy After Percutaneous Coronary Interventions in Patients With Acute Myocardial Infarction and Presentation of a New Risk Score (Athens CIN Score)

Contrast-induced nephropathy (CIN) after percutaneous coronary interventions (PCI) in patients with acute myocardial infarction (AMI) is associated with high morbidity and mortality, whereas there are no reliable predictive tools easy to use. We evaluated the association of pre-procedural high-sensitivity C-reactive protein (hsCRP) with the development of CIN and integrated this variable in a new risk CIN prediction model. Consecutive patients (348 AMI subjects) who underwent PCI were recruited. Creatinine levels were detected on admission, at 24, 48, and 72 hours after PCI. CIN was defined using the Kidney Disease: Improving Global Outcomes criteria. In our study population (348 subjects), CIN developed in 54 patients (15.5%). Patients with CIN were older and had higher hsCRP at admission, whereas their ejection fraction (EF) and glomerular filtration rate (GFR) were lower. In multivariate analysis after incorporating potential confounders, hsCRP at admission was an independent predictor of CIN (OR for logCRP 2.00, p = 0.01). In receiver-operating characteristic curve analysis, a model incorporating hsCRP, age, GFR, and EF showed good accuracy in predicting the development of CIN (c statistic 0.84, 95% confidence interval 0.793 to 0.879). A total risk score derived from the proposed model yielded significant positive and negative predictive values and classified 85.8% of our patients correctly for CIN. In conclusion, measuring hsCRP levels at admission in patients who underwent PCI for AMI may offer additional assistance in predicting the development of CIN. A model incorporating age and admission hsCRP, EF, and GFR emerged as an accurate tool for predicting CIN in this context.

Effects of CYP2C19 Polymorphism on Endothelial Function, Arterial Stiffness and Inflammation in Coronary Artery Disease Patients Under Clopidogrel Treatment

BACKGROUND

Clopidogrel's ability to inhibit platelet function determined its clinical usefulness. The role of CYP2C19*2 genotype on antiplatelet treatment is recently under question. Arterial wall properties and inflammation are key players in atherosclerosis development. Hence, we evaluated the impact of CYP2C19*2 genetic polymorphism on endothelial function, arterial stiffness and inflammation in coronary artery disease (CAD) patients receiving clopidogrel treatment.

METHODS AND RESULTS

In this study we enrolled 408 consecutive patients with stable CAD under dual antiplatelet therapy (clopidogrel 75mg/day, aspirin 100mg/day), 30 days after percutaneous coronary intervention. Measurement of flow-mediated dilation (FMD) of the brachial artery was used to evaluate endothelial function. Carotid-femoral pulse wave velocity (PWV) and augmentation index (AIx) was measured to estimate arterial stiffness. Real time polymerase chain reaction was used for the genotyping of CYP2C19*2. Levels of tumor necrosis factor alpha (TNF-a) and interleukin 6 (IL-6) were measured with ELISA. We found no difference in basic clinical and demographic characteristics nor in FMD, PWV, AIx and inflammatory status (p=NS for all) between CYP2C19 homozygotes for the wild type; carriers of reduced function allele and homozygotes for the reduced function allele.

CONCLUSION

CYP2C19*2 loss of action polymorphism causes no impact on vascular function and inflammatory status in stable CAD patients receiving clopidogrel treatment.