Use of aspirin in cardiovascular disease prevention-the role of online information search

OBJECTIVES

This study intends to examine influences of online information search on the use of aspirin in cardiovascular diseases (CVDs) prevention among the applicable adult population in the United States.

METHODS

We used data of 2018 National Health Interview Survey (NHIS). Our study sample is limited to adults age 40 or older to be consistent with the American Heart Association/American College of Cardiology Foundation (AHA/ACCF) guidelines for aspirin use. Linear probability models were used to test the association between patient's aspirin use behaviors and the variables of interest in four separate models.

RESULTS

Our results show that the use of aspirin for CVD prevention was associated with online health information seeking in different ways. When patients received doctors' advice to use aspirin, online information seeking has a negative influence, depending on whether the individual has CVD risk factors. However, for patients without recommendations from providers, the effects of online information seeking on self-initiated aspirin use depend on the different types of preventions (primary vs. secondary) and CVD risk factors.

CONCLUSION

Overall, online health information might lead to both overuse and underuse of aspirin in CVD preventions. Findings in this study may lead to decision-making that is not consistent with advice from healthcare professionals and/or established clinical guidelines.

Gender Bias in Diagnosis, Prevention, and Treatment of Cardiovascular Diseases: A Systematic Review

Cardiovascular disease (CVDs) has been perceived as a 'man's disease', and this impacted women's referral to CVD diagnosis and treatment. This study systematically reviewed the evidence regarding gender bias in the diagnosis, prevention, and treatment of CVDs. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. We searched CINAHL, PubMed, Medline, Web of Science, British Nursing Index, Scopus, and Google Scholar. The included studies were assessed for quality using risk bias tools. Data extracted from the included studies were exported into Statistical Product and Service Solutions (SPSS, v26; IBM SPSS Statistics for Windows, Armonk, NY), where descriptive statistics were applied. A total of 19 studies were analysed. CVDs were less reported among women who either showed milder symptoms than men or had their symptoms misdiagnosed as gastrointestinal or anxiety-related symptoms. Hence, women had their risk factors under-considered by physicians (especially by male physicians). Subsequently, women were offered fewer diagnostic tests, such as coronary angiography, ergometry, electrocardiogram (ECG), and cardiac enzymes, and were referred to less to cardiologists and/or hospitalisation. Furthermore, if hospitalised, women were less likely to receive a coronary intervention. Similarly, women were prescribed cardiovascular medicines than men, with the exception of antihypertensive and anti-anginal medicines. When it comes to the perception of CVD, women considered themselves at lower risk of CVDs than men. This systematic review showed that women were offered fewer diagnostic tests for CVDs and medicines than men and that in turn influenced their disease outcomes. This could be attributed to the inadequate knowledge regarding the differences in manifestations among both genders.

A community health promotion project: Amazing Race for Heart Health

Introduction

American Indians have higher rates of cardiovascular disease (CVD), likely due to disproportionate burden of diabetes and limited access to widespread CVD prevention programs such as Honoring the Gift of Heart Health (HGHH), a 10-week CVD risk factor awareness curriculum. Due to its length, HGHH may be difficult to complete; therefore, we aimed to evaluate a shortened CVD risk factor awareness program based on the HGHH educational materials for American Indians residing in southwest Oklahoma, entitled "The Amazing Race for Heart Health."

Methods

We conducted an interventional study where each participant served as their own control (n = 61), with pre- and post-intervention measurements. We included American Indians from seven tribal nations in southwest Oklahoma. At two interventional meetings we used educational materials and activities from HGHH focusing on nutrition, cholesterol, diabetes, hypertension, physical activity, and heart attack warning signs. McNemar's test was used to determine the effectiveness of the intervention on raising CVD risk factor awareness.

Results

When comparing the pre- and post-survey responses, the percentage of correct responses either stayed the same or increased. Knowledge improved in 11/25 (44%, p < 0.05) domains including the difference between good and bad cholesterol and types of physical activity that can prevent CVD. When considering diabetes, knowledge increased regarding the interaction between diabetes and cholesterol in the association with CVD.

Discussion

These results demonstrate that the "Amazing Race for Heart Health," a shortened CVD risk factor educational program based on the HGHH educational materials, was effective at increasing awareness regarding CVD risk factors.

Motivational communication skills to improve motivation and adherence in cardiovascular disease prevention: A narrative review

Lifestyle optimization is one of the most essential components of cardiovascular disease prevention. Motivational counseling provided by health care professionals could promote lifestyle modification. The purpose of the review is to identify possible evidence-based psychological principles that may be applicable to motivational counseling in the prevention of cardiovascular disease. These motivational communication skills promote behavioral change, improved motivation and adherence to cardiovascular disease prevention. A personal collection of the relevant publications. The review identified and summarized the previous evidence of implementation intentions, mental contrasting, placebo effect and nocebo effects and identity-based regulations in behavior change interventions and proposed their potential application in cardiovascular disease prevention. However, it is challenging to provide real support in sustainable CVD-risk reduction and encourage patients to implement lifestyle changes, while avoiding being unnecessarily judgmental, disrespectful of autonomy, or engaging patients in burdensome efforts that have little or no effect on the long run. Motivational communication skills have a great potential for effectuating sustainable lifestyle changes that reduce CVD-related risks, but it is also surrounded by ethical issues that should be appropriately addressed in practice. It is key to realize that motivational communication is nothing like an algorithm that is likely to bring about sustainable lifestyle change, but a battery of interventions that requires specific expertise and long term joint efforts of patients and their team of caregivers.

Obesity-Induced Hyperglycemia and Heart Failure Preserved Ejection Fraction: Uncharted Territories to Remission

Until the end of World War II, food security was a global challenge. Consequently, in 1948, type 2 diabetes was relatively uncommon, with the majority of cases being type 1 diabetes requiring insulin therapy. Since then, food has become increasingly palatable and readily available, leading to a rise in obesity across all age groups. Understanding the impact of obesity on our health has become crucial for optimizing healthcare. In this context, we draw attention to two significant, yet relatively uncharted pathogenic effects associated with obesity: Hyperglycemia and Heart Failure with Preserved Ejection Fraction (HFpEF). Thorough pathophysiologic, hemodynamic, and echocardiographic characterization have revealed the existence of a distinct phenotype known as "obese HFpEF" within the broader HFpEF population, and "obesity-induced hyperglycemia" within the diabetes population. In these phenotypes, patients often present with higher Body Mass Index and experience clinical symptoms decades earlier. Recent insights have enhanced our understanding of the mechanisms underlying obesity-mediated heart failure preserved ejection fraction and hyperglycemia. Early detection offers the potential for reversibility of many pathologies associated with obesity through adequate weight reduction. The objective of this review is to provide a deeper insight into these uncharted territories and explore the potential for improved outcomes by reframing these two narratives toward achieving remission. Such a shift has the potential to positively impact individual engagement with healthier lifestyles.

Bempedoic Acid: Lipid Lowering for Cardiovascular Disease Prevention

The management of low-density lipoprotein cholesterol (LDL-C) levels is a central strategy for the prevention of atherosclerotic cardiovascular disease. Current United States (2018 American Heart Association/American College of Cardiology/Multisociety) and European (2019 European Society of Cardiology/European Atherosclerosis Society) guidelines endorse statin therapy as the first-line therapy for pharmacologic LDL-C lowering. However, in clinical practice up to 30% of patients report partial or complete intolerance to statin therapy. While the nocebo effect with statins is well described, perceived statin intolerance prevents many patients from achieving LDL-C thresholds associated with clinical benefit. Bempedoic acid is a novel, oral, non-statin lipid-l owering therapy that works by inhibiting adenosine triphosphate-citrate lyase, an enzymatic reaction upstream of 3-hydroxy-3-methylglutaryl coenzyme A reductase in the hepatic cholesterol synthesis pathway. Bempedoic acid confers reduction in LDL-C of ~18% on background statin therapy,~21% in patients with statin intolerance, and ~38% when given in fixed-dose combination with ezetimibe. The CLEAR Outcomes trial, which enrolled high-risk primary and secondary prevention patients with reported statin intolerance and LDL-C levels ≥100 mg/dL, showed that bempedoic acid compared with placebo reduced 4-component major adverse cardiovascular events (MACE) by 13% (hazard ratio 0.87, 95% confidence interval 0.79-0.96). Bempedoic acid also reduced 3-component MACE by 15%, myocardial infarction by 23% and coronary revascularization by 19%. The benefit was even greater in the primary prevention cohort (hazard ratio 0.70, 95% confidence interval 0.55-0.89) for 4-component MACE. Bempedoic acid was associated with increases in uric acid levels and cholelithiasis, but numerically fewer events of myalgia and new-onset diabetes. These findings confirm that bempedoic acid is an effective approach to reduce cardiovascular outcomes in high-risk patients with statin intolerance who require further reduction in LDL-C.

Effect of Isoenergetic Substitution of Cheese with Other Dairy Products on Blood Lipid Markers in the Fasted and Postprandial State: An Updated and Extended Systematic Review and Meta-Analysis of Randomized Controlled Trials in Adults

Consumption of fat as part of a cheese matrix may differentially affect blood lipid responses when compared with other dairy foods. This systematic review was conducted to compare the impact of consuming equal amounts of fat from cheese and other dairy products on blood lipid markers in the fasted and postprandial state. Searches of PubMed (Medline), Cochrane Central and Embase databases were conducted up to mid-June 2022. Eligible human randomized controlled trials (RCTs) investigated the effect of isoenergetic substitution of hard or semi-hard cheese with other dairy products on blood lipid markers. Risk of bias (RoB) was assessed using the Cochrane RoB 2.0 tool. Random-effects meta-analyses assessed the effect of ≥2 similar dietary replacements on the same blood lipid marker. Of 1491 identified citations, 10 articles were included (RoB: all some concerns). Pooled analyses of 7 RCTs showed a reduction in fasting total cholesterol, LDL-C and HDL-C concentrations after ≥14 d mean daily intake of 135 g cheese (weighted mean difference [WMD]: -0.24 mmol/L; 95% confidence interval (CI): -0.34, -0.15; I2 = 59.8%, WMD: -0.19 mmol/L; 95% CI: -0.27, -0.12; I2 = 42.8%, and WMD: -0.04 mmol/L; 95% CI: -0.08, -0.00; I2 = 58.6%, respectively) relative to ∼52 g/d butter. We found no evidence of a benefit from replacing cheese for ≥14 d with milk on fasting blood lipid markers (n = 2). Limited postprandial RCTs, described in narrative syntheses, suggested that cheese-rich meals may induce differential fed-state lipid responses compared with some other dairy matrix structures, but not butter (n ≤ 2). In conclusion, these findings indicate that dairy fat consumed in the form of cheese has a differential effect on blood lipid responses relative to some other dairy food structures. However, owing to considerable heterogeneity and limited studies, further confirmation from RCTs is warranted. TRIAL REGISTRATION NUMBER: This systematic review protocol was registered at https://www.crd.york.ac.uk/PROSPERO/ as CRD42022299748.

Impact of Persistent Medication Adherence and Compliance with Lifestyle Recommendations on Major Cardiovascular Events and One-Year Mortality in Patients with Type 2 Diabetes and Advanced Stages of Atherosclerosis: Results From a Prospective Cohort Study

Background

The aim of this study was to evaluate the impact of single and combined effects of persistent medication adherence and compliance with lifestyle recommendations on the incidence of major adverse cardiovascular events (MACE) and one-year all-cause mortality in patients with type 2 diabetes (T2D) and peripheral artery disease (PAD) after partial foot amputation (PFA), representing a unique cohort of patients with advanced stages of atherosclerosis.

Methods

This is a prospective cohort study of 785 consecutive patients (mean age 60.9 ± 9.1 years; 64.1% males). Medication adherence was evaluated by using the proportion of days covered (PDC) measure calculation and was defined as a PDC ≥80%. It derived as an average of PDCs of the following four classes of drugs: a) antidiabetics (oral hypoglycemic medications and/or insulin); b) ACEI or ARBs; c) Statins; d) antiplatelet drugs. Lifestyle compliance was defined as a PDC ≥80% comprising of PDCs of a) physical activity of ≥30 minutes per day; b) healthy nutrition and weight management; c) non-smoking. Cox proportional hazard models adjusted for confounders were used.

Results

Total all-cause mortality was 16.9% (n = 133) at one-year follow-up. After adjusting for confounders, compared to adherent/compliant patients (n = 432), non-adherent and/or non-compliant patients had an increased risk of one-year mortality: HR = 8.67 (95% CI [5.29, 14.86] in non-adherent/non-compliant patients (n = 184), p < 0.001; HR = 3.81 (95% CI [2.03, 7.12], p < 0.001) in adherent/non-compliant patients (n = 101) and HR = 3.14 (95% CI [1.52, 6.45] p = 0.002) in non-adherent/compliant patients (n = 184). The incidence of MACE followed similar pattern (HR = 9.66 (95% CI [6.55, 14.25] for non-adherence/non-compliance; HR = 3.48 (95% CI [2.09, 5.77] and HR = 3.35 (95% CI [1.89, 5.91], p < 0.001 for single adherence or compliance.

Conclusions

Medication adherence and compliance to lifestyle recommendations have shown to be equally effective to reduce the incidence of MACE and one-year mortality in patients with diabetes and PAD after PFA representing a population with highly advanced stages of atherosclerotic disease. Our findings underline the necessity to give lifestyle intervention programs a high priority and that costs for secondary prevention medications should be covered for patients under these circumstances.

Lay Summary

This study analyzed the single and combined effects of medication adherence and compliance with lifestyle recommendations on cardiovascular events and mortality in patients with type 2 diabetes and advances stages of atherosclerosis over a period of one year.Evaluation of medication adherence included antidiabetics, statins, dual antiplatelets and ACEI/ARBs, whereas lifestyle recommendations included healthy nutrition, physical activity and smoking cessation.Persistent medication adherence and lifestyle changes have shown to be equally effective to reduce the incidence of MACE and one-year mortality in patients representing a population with highly advanced stages of atherosclerotic disease, and positive effects added up to a double effect if patients were persistently adherent and compliant with both interventions.

A Retrospective Five-Year Study of Cardiovascular Risk Assessment and Risk-Based Interventions Among Hypertensive Patients in Nairobi Hospital, Kenya

Introduction Cardiovascular disease (CVD) is a leading cause of global morbidity and mortality. It is projected that the prevalence of CVD will continue to rise in developing countries, largely driven by an increase in the prevalence of potentially modifiable risk factors. Atherosclerotic cardiovascular risk assessment among individuals with risk factors for CVD but without CVD is an inexpensive and viable strategy in CVD risk stratification and prevention. Despite the known benefits of CVD risk assessment, it is not well established whether physicians/ cardiologists in Kenya comply with the guideline-recommended practice of CVD risk stratification as a prerequisite for initiation of primary CVD preventive interventions. Aims and objectives This study was designed to audit the utilization of cardiovascular risk assessment tools in risk stratification of hypertensive individuals and physician provision of risk-based primary CVD prevention interventions. Results A five-year (2017-2022) retrospective study of patients' medical records was conducted in December 2022 at the PrimeCare cardiology clinic in Nairobi Hospital, Kenya. Data were collected from 373 patients' medical records retrospectively. The data were analyzed using IBM SPSS Statistics for Windows, Version 25 (Released 2017; IBM Corp., Armonk, New York, United States). The mean age of the patients was 60 years with the majority being female (54%). The mean BMI was 30.3 kg/m2 while the mean systolic and diastolic pressure was 140mmHg and 80mmHg, respectively. Only 2.1% of participants were current smokers. The national or alternative guideline-recommended CVD risk assessment tool was used in 0.3% and 2.4%, respectively. The 10-year CVD risk score was documented in only 1.3%. The majority of the participants (93%) had low CVD risk. Half of the patients were taking statins for primary prevention while > 60% of them had been offered therapeutic lifestyle advice. Conclusion The study revealed poor compliance with guideline-recommended CVD risk assessment tools and documentation of the CVD risk level. However, there was above-average adherence to documentation of therapeutic lifestyle measures for primary CVD prevention.

Life's Essential 8: Optimizing Health in Older Adults

The population worldwide is getting older as a result of advances in public health, medicine, and technology. Older individuals are living longer with a higher prevalence of subclinical and clinical cardiovascular disease (CVD). In 2010, the American Heart Association introduced a list of key prevention targets, known as "Life's Simple 7" to increase CVD-free survival, longevity, and quality of life. In 2022, sleep health was added to expand the recommendations to "Life's Essential 8" (eat better, be more active, stop smoking, get adequate sleep, manage weight, manage cholesterol, manage blood pressure, and manage diabetes). These prevention targets are intended to apply regardless of chronologic age. During this same time, the understanding of aging biology and goals of care for older adults further enhanced the relevance of prevention across the range of functions. From a biological perspective, aging is a complex cellular process characterized by genomic instability, telomere attrition, loss of proteostasis, inflammation, deregulated nutrient-sensing, mitochondrial dysfunction, cellular senescence, stem cell exhaustion, and altered intercellular communication. These aging hallmarks are triggered by and enhanced by traditional CVD risk factors leading to geriatric syndromes (eg, frailty, sarcopenia, functional limitation, and cognitive impairment) which complicate efforts toward prevention. Therefore, we review Life's Essential 8 through the lens of aging biology, geroscience, and geriatric precepts to guide clinicians taking care of older adults.

Use of a Statistical Adaptive Treatment Strategy Approach for Emulating Randomized Controlled Trials Using Observational Data: The Example of Blood-Pressure Control Strategies for the Prevention of Cardiovascular Events Among Individuals With Hypertension at High Cardiovascular Risk

Statistical approaches to adaptive treatment strategies (ATS) can be used to mimic the sequential decision-making inherently found in clinical practice. To illustrate the use of a statistical ATS approach, we emulated a target trial of different blood pressure (BP) control plans for the prevention of cardiovascular events among individuals with hypertension at high cardiovascular risk, inspired by the Systolic Blood Pressure Intervention Trial (SPRINT). We included 103,708 patients with hypertension and a "QRISK3" estimated 10-year risk of cardiovascular disease of ≥20% who initiated an antihypertensive drug between 1998 and 2018. Dynamic marginal structural models estimated the comparative effects of treating patients with intensive (target BP: 130/80 mm Hg), standard (140/90 mm Hg), and conservative (150/90 mm Hg) BP control strategies. The adjusted hazard ratios (HRs) for the intensive versus standard strategy were 0.96 (95% confidence interval (CI): 0.92, 1.00) for major adverse cardiovascular events and 0.93 (95% CI: 0.88, 0.97) for death from cardiovascular causes. For the conservative versus standard strategy, they were 1.06 (95% CI: 1.02, 1.10) and 1.08 (95% CI: 1.03, 1.13), respectively. These results are largely compatible with SPRINT. ATS can be used to emulate randomized controlled trials of complex treatment strategies in an observational setting and represents an alternative approach for situations where randomized controlled trials are not feasible.

Female-specific risk factors of parity and menopause age and risk of carotid plaque: the multi-ethnic study of atherosclerosis

BACKGROUND

Female-specific factors of grand multiparity (≥5 births) and early menopause age are associated with an increased risk of cardiovascular disease (CVD). However, mechanisms are incompletely understood. Carotid plaque is a marker of subclinical atherosclerosis and associated with increased CVD risk. We evaluated the association of female-specific factors with plaque burden.

METHODS

We included 2,313 postmenopausal women in the Multi-Ethnic Study of Atherosclerosis, free of clinical CVD, whose parity and menopause age were ascertained by questionnaires and carotid plaque measured by ultrasound at baseline and 10 years later. Parity was categorized as nulliparity (reference), 1-2, 3-4 and ≥5 live births. Menopause age was categorized as <45, 45-49, 50-54 (reference) and ≥55 years. Multivariable regression was performed to evaluate the association of parity and menopause age with carotid plaque presence (yes/no) and extent [carotid plaque score (CPS)].

RESULTS

The mean age was 64±9 years; 52.3% had prevalent carotid plaque at baseline. Compared to nulliparity, grand multiparity was significantly associated with prevalent carotid plaque after adjustment for CVD risk factors (prevalence ratio 1.17 (95% CI 1.03-1.35)) and progression of CPS over 10 years [percent difference 13% (95% CI 3-23)]. There was not any significant association of menopause age with carotid plaque presence or progression in fully-adjusted models.

CONCLUSION

In a multiethnic cohort, grand multiparity was independently associated with carotid plaque presence and progression. Early menopause, a known risk factor for CVD, was not captured by carotid plaque in this study. These findings may have implications for refining CVD risk assessment in women.

Silent Myocardial Infarction: A Case Report

Silent myocardial infarction (SMI) is a type of myocardial infarction (MI) that is asymptomatic or demonstrates mild symptoms; therefore, patients often do not seek medical treatment. SMI cases are often incidentally detected later by electrocardiogram (ECG). We present a case of a 59-year-old overweight woman with prediabetes, primary hypertension, and hypercholesterolemia who presented for herpes zoster (HZ) follow-up; she reported having skipped heartbeats and heart rate fluctuations during the review of systems. On further workup, ECG revealed low voltage QRS complexes, flat QRS complexes, flat T waves, and pathological Q waves, suggesting the diagnosis of SMI. Based on the identified risk factors, including high BMI, prediabetes, primary hypertension, hypercholesterolemia, HZ, and newly diagnosed SMI, the patient was advised to continue with lisinopril 20 mg daily, prescribed atorvastatin 80 mg daily, and was educated about maintaining a healthy diet, exercise, and receiving the shingles vaccination. To prevent the possible risks of poor outcomes such as those following MI, stroke, heart failure, arrhythmias, angina, and shortness of breath (SOB), the patient was referred to the cardiologist for a stress test and further treatment plan.

Vitamin D Deficiency and Its Association With Cardiovascular Diseases Among Patients Attending a Private Tertiary Sector Cardiovascular Heart Clinic in Nairobi

BACKGROUND

Vitamin D deficiency is a common condition that affects approximately 30-50% of the worldwide population. Vitamin D deficiency is associated with an increased risk of cardiometabolic diseases and is considered a cardiovascular risk factor globally.  Methods: This is a retrospective cross-sectional study that aimed to identify the prevalence of vitamin D deficiency and its associations with the cardiovascular disease (CVD) risk profile of patients presenting for cardiac evaluation at Primecare Heart Clinic, a private heart clinic in Nairobi, Kenya, between January 1, 2020 and January 31, 2022.

RESULTS

Females with vitamin D deficiency composed 58.87% of the study participants. The average 10-year Framingham CVD risk level of the vitamin D-deficient participants was 7.09%. Participants with vitamin D deficiency that were older and had low serum high-density lipoprotein C (HDL-C) levels and high systolic blood pressure (BP) had a higher risk of CVDs. Male participants were at five times higher risk of CVDs. Vitamin D-deficient patients who were older and had a low HDL cholesterol level and high systolic BP are at a high risk of CVDs. The two-way analysis of variance (ANOVA) test value was 345.6992, and the p-value was 0.002884.

CONCLUSION

Our study demonstrated that a low level of vitamin D was associated with a higher Framingham cardiovascular risk score and cardiovascular risk in patients. Nonetheless, this is a retrospective study, which is a major limitation of this study.

GWAS of folate metabolism with gene-environment interaction analysis revealed the possible role of lifestyles in the control of blood folate metabolites in Japanese - the J-MICC Study

BACKGROUND

The present genome-wide association study (GWAS) aimed to reveal the genetic loci associated with folate metabolites as well as to detect related gene-environment interactions in Japanese.

METHODS

We conducted the GWAS of plasma homocysteine (Hcy), folic acid (FA), and vitamin B12 (VB12) levels in the Japan Multi-Institutional Collaborative Cohort (J-MICC) Study participants who joined from 2005 to 2012, and also estimated gene-environment interactions. In the replication phase, we used data from the Yakumo Study conducted in 2009. In the discovery phase, data of 2,263 participants from four independent study sites of the J-MICC Study were analyzed. In the replication phase, data of 573 participants from the Yakumo Study were analyzed.

RESULTS

For Hcy, MTHFR locus on chr 1, NOX4 on chr 11, CHMP1A on chr 16, and DPEP1 on chr 16 reached genome-wide significance (P < 5×10-8). MTHFR also associated with FA, and FUT2 on chr 19 associated with VB12. We investigated gene-environment interactions in both studies and found significant interactions between MTHFR C677T and ever drinking, current drinking, and physical activity > 33% on Hcy (β = 0.039, 0.038 and -0.054, P = 0.018, 0.021 and < 0.001, respectively) and the interaction of MTHFR C677T with ever drinking on FA (β = 0.033, P = 0.048).

CONCLUSIONS

The present GWAS revealed the folate metabolism-associated genetic loci and gene-environment interactions with drinking and physical activity in Japanese, suggesting the possibility of future personalized CVD prevention.

Inclisiran: A New Strategy for LDL-C Lowering and Prevention of Atherosclerotic Cardiovascular Disease

Multiple lines of evidence confirm that the cumulative burden of low-density lipoprotein cholesterol (LDL-C) is causally related to the development of atherosclerotic cardiovascular disease (ASCVD). As such, lowering LDL-C is a central tenet in all ASCVD prevention guidelines, which recommend matching the intensity of LDL-C lowering with the absolute risk of the patient. Unfortunately, issues such as difficulty with long-term adherence to statin therapy and inability to achieve desired LDL-C thresholds with statins alone results in residual elevated ASCVD risk. Non-statin therapies generally provide similar risk reduction per mmol/L of LDL-C reduction and are included by major society guidelines as part of the treatment algorithm for managing LDL-C. Per the 2022 American College of Cardiology Expert Consensus Decision Pathway, patients with ASCVD are recommended to achieve both an LDL-C reduction ≥50% and an LDL-C threshold of <55 mg/dL in patients at very high-risk and <70 mg/dL in those not at very high risk. Patients with familial hypercholesterolemia (FH) but without ASCVD should lower LDL-C to <100 mg/dL. For patients who remain above LDL-C thresholds with maximally tolerated statin therapy plus lifestyle changes, non-statin therapy warrants strong consideration. While several non-statin therapies have been granted FDA approval for managing hypercholesterolemia (eg, ezetimibe, Proprotein Convertase Subtilisin/Kexin 9 [PCSK9] monoclonal antibodies, and bempedoic acid), the focus of the current review is on inclisiran, a novel small interfering RNA therapy that inhibits the production of the PCSK9 protein. Inclisiran is currently FDA approved as an adjunct to statin therapy in patients with clinical ASCVD or heterozygous FH who require additional LDL-lowering. The drug is administered by subcutaneous injection twice a year, after an initial baseline and 3 month dose. In this review, we sought to provide an overview of the use of inclisiran, review current trial data, and outline an approach to potential patient selection.

Team-Based Qualitative Rapid Analysis: Approach and Considerations for Conducting Developmental Formative Evaluation for Intervention Design

Qualitative rapid analysis is one of many rapid research approaches that offer a solution to the problem of time constrained health services evaluations and avoids sacrificing the richness of qualitative data that is needed for intervention design. We describe modifications to an established team-based, rapid analysis approach that we used to rapidly collect and analyze semi-structured interview data for a developmental formative evaluation of a cardiovascular disease prevention intervention. Over 18 weeks, we conducted and analyzed 35 semi-structured interviews that were conducted with patients and health care providers in the Veterans Health Administration to identify targets for adapting the intervention in preparation for a clinical trial. We identified 12 key themes describing actionable targets for intervention modification. We highlight important methodological decisions that allowed us to maintain rigor when using qualitative rapid analysis for intervention adaptation and we provide practical guidance on the resources needed to execute similar qualitative studies. We additionally reflect on the benefits and challenges of the described approach when working within a remote research team environment.ClinicalTrials.gov: NCT04545489.

Are Lipid-Lowering and Antihypertensive Medications Used as Complements to Heart-Healthy Diets? A Scoping Review

In cardiovascular disease (CVD) prevention, whether antihypertensive and lipid-lowering medications are used as complements to heart-healthy diets has not been thoroughly assessed. This scoping review aimed to 1) analyze observational studies that assessed the relationship between diet and antihypertensive/lipid-lowering medication use and 2) evaluate whether medication was used as a complement to heart-healthy dietary intakes. We searched MEDLINE, Embase, Web of Science, and CINAHL through 14 January, 2023, for studies that assessed either 1) intraindividual changes in diet associated with lipid-lowering/antihypertensive medication initiation or use or 2) interindividual differences in diet between users and nonusers of these medications. A total of 17 studies were included. Of those, 3 prospectively assessed the intraindividual changes in diet associated with medication initiation or use, but none documented potential changes in diet prior to medication initiation. The 14 other studies compared dietary intakes of medication users and nonusers, most of which also relied on an incomplete assessment of the temporal dynamics between diet and medication use as they employed cross-sectional (n = 12) or repeated cross-sectional (n = 2) designs. Data from 8 studies, including 4 of the 5 studies from Europe, suggested that medication was used as a complement to heart-healthy diets, whereas data from the 9 other studies, including the 4 conducted in the United States, provided no such evidence, indicating potential between-country differences in this relationship. Finally, no studies investigated how the dynamics between diet and medication use influenced the long-term CVD risk. This scoping review suggests that the current literature on the relationship between lipid-lowering/antihypertensive medication use and diet provides an incomplete perspective on how medication may influence diet in CVD prevention. Prospective studies assessing intraindividual changes in diet associated with medication initiation and use and how these dynamics influence the CVD risk are thus needed.

The Burden of Uncontrolled Cardiovascular Risk Factors in Men With Prostate Cancer: A RADICAL-PC Analysis

Background

Cardiovascular disease (CVD) incidence is higher in men with prostate cancer (PC) than without.

Objectives

We describe the rate and correlates of poor cardiovascular risk factor control among men with PC.

Methods

We prospectively characterized 2,811 consecutive men (mean age 68 ± 8 years) with PC from 24 sites in Canada, Israel, Brazil, and Australia. We defined poor overall risk factor control as ≥3 of the following: suboptimal low-density lipoprotein cholesterol (>2 mmol/L if Framingham Risk Score [FRS] ≥15 and ≥3.5 mmol/L if FRS <15), current smoker, physical inactivity (<600 MET min/wk), suboptimal blood pressure (BP) (≥140/90 mm Hg if no other risk factors, systolic BP ≥120 mm Hg if known CVD or FRS ≥15, and ≥130/80 mm Hg if diabetic), and waist:hip ratio >0.9.

Results

Among participants (9% with metastatic PC and 23% with pre-existing CVD), 99% had ≥1 uncontrolled cardiovascular risk factor, and 51% had poor overall risk factor control. Not taking a statin (odds ratio [OR]: 2.55; 95% CI: 2.00-3.26), physical frailty (OR: 2.37; 95% CI: 1.51-3.71), need for BP drugs (OR: 2.36; 95% CI: 1.84-3.03), and age (OR per 10-year increase: 1.34; 95% CI: 1.14-1.59) were associated with poor overall risk factor control after adjustment for education, PC characteristics, androgen deprivation therapy, depression, and Eastern Cooperative Oncology Group functional status.

Conclusions

Poor control of modifiable cardiovascular risk factors is common in men with PC, highlighting the large gap in care and the need for improved interventions to optimize cardiovascular risk management in this population.

Validation of a Brief Dietary Questionnaire for Use in Clinical Practice: Mini-EAT (Eating Assessment Tool)

Background There is a scarcity of validated rapid dietary screening tools for patient use in the clinical setting to improve health and reduce cardiovascular risk. The Healthy Eating Index (HEI) 2015 measures compliance with the 2015 to 2020 Dietary Guidelines for Americans but requires completion of an extensive diet assessment to compute, which is time consuming and impractical. The authors hypothesize that a 19-item dietary survey assessing consumption of common food groups known to affect health will be correlated with the HEI-2015 assessed by a validated food frequency questionnaire and can be further reduced without affecting validity. Methods and Results A 19-item Eating Assessment Tool (EAT) of common food groups was created through literature review and expert consensus. A cross-sectional survey was then conducted in adult participants from a preventive cardiology clinic or cardiac rehabilitation and in healthy volunteers (n=661, mean age, 36 years; 76% women). Participants completed an online 156-item food frequency questionnaire, which was used to calculate the HEI score using standard methods. The association between each EAT question and HEI group was analyzed by Kruskal-Wallis test. Linear regression models were subsequently used to identify univariable and multivariable predictors for HEI score for further reduction in the number of items. The final 9-item model of Mini-EAT was validated by 5-fold cross validation. The 19-item EAT had a strong correlation with the HEI score (r=0.73) and was subsequently reduced to the 9 items independently predictive of the HEI score: fruits, vegetables, whole grains, refined grains, fish or seafood, legumes/nuts/seeds, low-fat dairy, high-fat dairy, and sweets consumption, without affecting the predictive ability of the tool (r=0.71). Conclusions Mini-EAT is a 9-item validated brief dietary screener that correlates well with a comprehensive food frequency questionnaire. Future studies to test the Mini-EAT's validity in diverse populations and for development of clinical decision support systems to capture changes over time are needed.

Trends, Predictors, and Outcomes of Cardiovascular Complications at Delivery Associated With Gestational Diabetes: A National Inpatient Sample Analysis (2004-2019)

Background Gestational diabetes (GD) is associated with increased risk of long-term cardiovascular complications. However, data on acute peripartum cardiovascular complications are not well established. Hence, we aimed to investigate the association of GD with acute cardiovascular outcomes at the time of delivery admission. Methods and Results We used data from the National Inpatient Sample (2004-2019). International Classification of Diseases, Ninth Revision (ICD-9) or Tenth Revision (ICD-10) codes were used to identify delivery hospitalizations and GD diagnosis. A total of 63 115 002 weighted hospitalizations for deliveries were identified, of which 3.9% were among individuals with GD (n=2 435 301). The prevalence of both GD and obesity increased during the study period (P trends<0.01). Individuals with GD versus those without GD had a higher prevalence of obesity, hypertension, and dyslipidemia. After adjustment for age, race or ethnicity, comorbidities, insurance, and income, GD remained independently associated with cardiovascular complications including preeclampsia (adjusted odds ratio [aOR], 1.97 [95% CI, 1.96-1.98]), peripartum cardiomyopathy (aOR, 1.15 [1.08-1.22]), acute kidney injury (aOR, 1.16 [1.11-1.21]), stroke (aOR, 1.15 [1.09-1.23]), and arrhythmias (aOR, 1.48 [1.46-1.50]), compared with no GD. Moreover, delivery hospitalizations among individuals with GD were associated with increased length (3 versus 2 days, P<0.01) and cost of hospitalization ($4909 versus $3682, P<0.01). Even in the absence of preeclampsia, GD was associated with elevated cardiovascular risk. Conclusions Individuals with GD had a higher risk of preeclampsia, peripartum cardiomyopathy, acute kidney injury, stroke, and arrhythmias during delivery hospitalizations. As rates of GD are increasing globally, efforts to improve preconception cardiometabolic health and prevent GD may represent important strategies to improve peripartum maternal outcomes and mitigate long-term cardiovascular risk.

Physiological Bases for the Superiority of Apolipoprotein B Over Low-Density Lipoprotein Cholesterol and Non-High-Density Lipoprotein Cholesterol as a Marker of Cardiovascular Risk

In 2019, the European Society of Cardiology/European Atherosclerosis Society stated that apolipoprotein B (apoB) was a more accurate marker of cardiovascular risk than low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol. Since then, the evidence has continued to mount in favor of apoB. This review explicates the physiological mechanisms responsible for the superiority of apoB as a marker of the cardiovascular risk attributable to the atherogenic apoB lipoprotein particles chylomicron remnants, very low-density lipoprotein, and low-density lipoprotein particles. First, the nature and relative numbers of these different apoB particles will be outlined. This will make clear why low-density lipoprotein particles are almost always the major determinants of cardiovascular risk and why the concentrations of triglycerides and LDL-C may obscure this relation. Next, the mechanisms that govern the number of very low-density lipoprotein and low-density lipoprotein particles will be outlined because, except for dysbetalipoproteinemia, the total number of apoB particles determines cardiovascular risk, Then, the mechanisms that govern the cholesterol mass within very low-density lipoprotein and low-density lipoprotein particles will be reviewed because these are responsible for the discordance between the mass of cholesterol within apoB particles, measured either as LDL-C or non-high-density lipoprotein cholesterol, and the number of apoB particles measured as apoB, which creates the superior predictive power of apoB over LDL-C and non-high-density lipoprotein cholesterol. Finally, the major apoB dyslipoproteinemias will be briefly outlined. Our objective is to provide a physiological framework for health care givers to understand why apoB is a more accurate marker of cardiovascular risk than LDL-C or non-high-density lipoprotein cholesterol.

Dietary Effects of Introducing Salt-Reduced Bread with and without Dietary Counselling-A Cluster Randomized Controlled Trial

Successful strategies for policy makers and the food industry are required to reduce population salt intake. A 4-month cluster randomized controlled trial was conducted to evaluate whether the provision of salt-reduced bread with or without dietary counselling affected the dietary intake of selected food groups, energy, macronutrients, sodium, and potassium. Eighty-nine families (n = 309) consisting of minimum one parent and one child were assigned to receive bread gradually reduced in salt content alone (Intervention A), combined with dietary counselling (Intervention B), or bread with regular salt content (control). Food intake was recorded for seven consecutive days at baseline and follow-up. Salt intake was reduced in both Intervention A (−1.0 g salt/10 MJ, p = 0.027) and Intervention B (−1.0 g salt/10 MJ, p = 0.026) compared to the control. Consumption of bread and both total and salt-rich bread fillings remained similar between groups, while ‘cheese and cheese products’ were reduced in Intervention A (−38%, p = 0.011). Energy intake and macronutrient distribution were not affected in Intervention A, but Intervention B resulted in a higher energy intake (512 kJ, p = 0.019) and a lower energy % (E%) from saturated fat (−1.0 E%, p = 0.031) compared to the control. In conclusion, provision of salt-reduced bread both with and without dietary counselling successfully reduced dietary salt intake without adversely affecting the dietary nutritional quality.

Addressing gaps in cardiovascular care for people with HIV: bridging scientific evidence and practice

PURPOSE OF REVIEW

People with HIV continue to have an excess burden of cardiovascular disease compared to the general population. The reasons for these disparities in cardiovascular disease include HIV-specific risk enhancers, traditional atherosclerotic cardiovascular disease risk factors, and sociodemographic disparities, all of which are ripe targets for intervention.

RECENT FINDINGS

Accurate risk prediction of atherosclerotic cardiovascular disease remains difficult, and cardiovascular risk for people with HIV may be underestimated in the absence of HIV-specific risk enhancers. Despite this increased cardiovascular risk, people with HIV are undertreated and often placed on inadequate lipid lowering therapy. Structural racism and HIV-related stigma play a role, and provider-level and structural-level interventions to encourage early identification and treatment of persons at high risk are necessary.

SUMMARY

Persons with HIV should be screened with existing cardiovascular risk prediction tools, and those at high risk cardiovascular disease should be promptly referred for lifestyle and pharmacologic interventions as appropriate. System-level implementation research is ongoing in attempts to narrow the gap in cardiovascular care, particularly for vulnerable communities in low resource settings.

Comprehensive Care after Myocardial Infarction (CCMI): Long-Term Investment in the Health of Polish Citizens

The comprehensive care model after myocardial infarction (CCMI, in Polish: KOS-Zawał) has been in effect continuously since October 2017. Within the bundle of services financed by the Polish National Health Fund (NHF), patients receive a diagnosis, conservative and invasive treatment, early cardiac rehabilitation and follow-up visits for 12 months. The existing model of managing patients after myocardial infarction (MI) implements all crucial aspects of care recommended by the European Society of Cardiology (ESC), emphasised many times. The purpose of this paper was to report and describe the course of the implementation of the unique concept—CCMI model, including the scope of the introduced changes and the implementation and structural evaluation of its effects over the period 2017–2021. Our preliminary study reported that the CCMI programme reduces the risk of patient death in the first year after MI by 29%. Furthermore, the authors point out the strict cause and effect relationship between the cardiovascular disease prevention programme since 2004 as the key instrument for the primary systemic prevention implemented outside the CCMI model.

Contextualizing National Policies Regulating Access to Low-Dose Aspirin in America and Europe Using the Full Report of a Transatlantic Patient Survey of Aspirin in Preventive Cardiology

Background Aspirin is widely administered to prevent cardiovascular disease (CVD). However, appropriate use of aspirin depends on patient understanding of its risks, benefits, and indications, especially where aspirin is available over the counter (OTC). Methods and Results We did a survey of patient-reported 10-year cardiovascular risk; aspirin therapy status; form of aspirin access (OTC versus prescription); and knowledge of the risks, benefits, and role of aspirin in CVD prevention. Consecutive adults aged ≥50 years with ≥1 cardiovascular risk factor attending outpatient clinics in America and Europe were recruited. We also systematically reviewed national policies regulating access to low-dose aspirin for CVD prevention. At each site, 150 responses were obtained (300 total). Mean±SD age was 65±10 years, 40% were women, and 41% were secondary prevention patients. More than half of the participants at both sites did not know (1) their own level of 10-year CVD risk, (2) the expected magnitude of reduction in CVD risk with aspirin, or (3) aspirin's bleeding risks. Only 62% of all participants reported that aspirin was routinely indicated for secondary prevention, whereas 47% believed it was routinely indicated for primary prevention (P=0.048). In America, 83.5% participants obtained aspirin OTC compared with 2.5% in Europe (P<0.001). Finally, our review of European national policies found only 2 countries where low-dose aspirin was available OTC. Conclusions Many patients have poor insight into their objectively calculated 10-year cardiovascular risk and do not know the risks, benefits, and role of aspirin in CVD prevention. Aspirin is mainly obtained OTC in America in contrast to Europe, where most countries restrict access to low-dose aspirin.

Prescription Patterns for the Use of Antihypertensive Drugs for Primary Prevention Among Patients With Hypertension in the United Kingdom

BACKGROUND

Several antihypertensive drugs are available for the primary prevention of cardiovascular disease (CVD). However, existing evidence on prescription patterns was primarily generated among patients at high CVD risk with short-term follow-up, and failed to capture impacts of time and patient characteristics. Our objective was therefore to describe longitudinal prescription patterns for antihypertensive drugs for the primary prevention of CVD among patients with arterial hypertension in the United Kingdom.

METHODS

This population-based cohort study used data from the Clinical Practice Research Datalink, included 660,545 patients with hypertension who initiated an antihypertensive drug between 1998 and 2018. Antihypertensive treatments were measured by drug class and described overall and in subgroups, focusing on first-line therapy (first antihypertensive drug(s) recorded after a diagnosis of hypertension) and second-line therapy (antihypertensive drug(s) prescribed as part of a treatment change following first-line therapy).

RESULTS

Angiotensin-converting enzyme (ACE) inhibitors (29.0%), thiazide diuretics (22.1%), and calcium-channel blockers (CCBs) (21.0%) were the most prescribed first-line therapies. ACE inhibitors have been increasingly prescribed as first-line therapy since 2001. Men were more likely to be prescribed ACE inhibitors than women (43.5% vs. 32.1%; difference: 11.4%; 95% confidence interval [CI], 11.0%-11.8%), and Black patients were more likely to be prescribed CCBs than White patients (63.6% vs. 37.0%; difference: 26.6%; 95% CI, 24.8%-28.4%).

CONCLUSIONS

Antihypertensive prescription patterns for the primary prevention of CVD among patients with hypertension are consistent with treatment guidelines that were in place during the study period, providing reassurance regarding the use of evidence-based prescribing.

Variability in Daily Eating Patterns and Eating Jetlag Are Associated With Worsened Cardiometabolic Risk Profiles in the American Heart Association Go Red for Women Strategically Focused Research Network

Background

Sleep variability and social jetlag are associated with adverse cardiometabolic outcomes via circadian disruption. Variable eating patterns also lead to circadian disruption, but associations with cardiometabolic health are unknown.

Methods and Results

Women (n=115, mean age: 33±12 years) completed a 1‐week food record using the Automated Self‐Administered 24‐Hour Dietary Assessment Tool at baseline and 1 year. Timing of first and last eating occasions, nightly fasting duration, and %kcal consumed after 5 pm (%kcal 5 pm) and 8 pm (%kcal 8 pm) were estimated. Day‐to‐day eating variability was assessed from the SD of these variables. Eating jetlag was defined as weekday‐weekend differences in these metrics. Multivariable‐adjusted linear models examined cross‐sectional and longitudinal associations of day‐to‐day variability and eating jetlag metrics with cardiometabolic risk. Greater jetlag in eating start time, nightly fasting duration, and %kcal 8 pm related to higher body mass index and waist circumference at baseline (P<0.05). In longitudinal analyses, a 10% increase in %kcal 8 pm SD predicted increased body mass index (β, 0.52; 95% CI, 0.23–0.81) and waist circumference (β, 1.73; 95% CI, 0.58–2.87); greater %kcal 8 pm weekday‐weekend differences predicted higher body mass index (β, 0.25; 95% CI, 0.07–0.43). Every 30‐minute increase in nightly fasting duration SD predicted increased diastolic blood pressure (β, 0.95; 95% CI, 0.40–1.50); an equivalent increase in nightly fasting duration weekday‐weekend differences predicted higher systolic blood pressure (β, 0.58; 95% CI, 0.11–1.05) and diastolic blood pressure (β, 0.45; 95% CI, 0.10–0.80). Per 10% increase in %kcal 5 pm SD, there were 2.98 mm Hg (95% CI, 0.04–5.92) and 2.37mm Hg (95% CI, 0.19–4.55) increases in systolic blood pressure and diastolic blood pressure; greater %kcal 5 pm weekday‐weekend differences predicted increased systolic blood pressure (β, 1.83; 95% CI, 0.30–3.36). For hemoglobin A1c, every 30‐minute increase in eating start and end time SD and 10% increase in %kcal 5 pm SD predicted 0.09% (95% CI, 0.03–0.15), 0.06% (95% CI, 0.001–0.12), and 0.23% (95% CI, 0.07–0.39) increases, respectively.

Conclusions

Variable eating patterns predicted increased blood pressure and adiposity and worse glycemic control. Findings warrant confirmation in population‐based cohorts and intervention studies.

Purely Behavioral: A Scoping Review of Nonpharmacological Behavioral and Lifestyle Interventions to Prevent Cardiovascular Disease in Persons Living With HIV

ABSTRACT

Cardiovascular disease (CVD) is the leading cause of death in the United States, accounting for 900,000 deaths annually. People living with HIV are at a higher risk of developing CVD. We conducted a scoping review guided by the Joanna Briggs Institute Manual for Evidence Synthesis. In July 2020, six databases were searched: PubMed, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Web of Science, Embase, and The Cochrane Central Register of Controlled Trials, as well as reference lists of relevant studies and key journals. Our review identified 18 studies that addressed nonpharmacological behavioral interventions into the following: physical activity (n = 6), weight loss (n = 2), dietary interventions (n = 1), and multicomponent interventions (n = 9). In the past 10 years, there has been an increased emphasis on nonpharmacological behavioral approaches, including the incorporation of multicomponent interventions, to reduce cardiovascular risk in people living with HIV. The extant literature is limited by underrepresentation of geographic regions and populations that disproportionately experience CVD.

The Effect of Vitamin D on Coronary Atherosclerosis: A Propensity Score Matched Case-Control Coronary CTA Study

Background: Vitamin D supplementation may be associated with lower cardiovascular (CV) events, but the data are controversial. It remains speculative whether vitamin D supplementation has a direct effect on coronary atherosclerosis. We therefore set out to assess the influence of vitamin D supplementation on the coronary atherosclerosis profile quantified by coronary computed tomography angiography (CTA) in a retrospective case–control cohort study. Methods: 176 patients (age: 62.4 ± 10.4) referred to coronary CTA for clinical indications were included. A total of 88 patients receiving vitamin D supplementation (mean duration 65.3 ± 81 months) were 1:1 propensity score matched with 88 controls for age, gender, smoking, arterial hypertension, positive family history, dyslipidemia, and diabetes. Coronary stenosis severity (CAD-RADS^TM), mixed plaque burden (weighted for non-calcified), high-risk-plaque (HRP) features, and plaque density (HU) were quantified by CTA. Serum 25-hydroxyvitamin D (OH)-levels were measured in 138 patients and categorized into four groups (0: <20 ng/mL; 1: 20–40 ng/mL; 2: 40–60 ng/mL; and 3: >60 ng/mL) and compared with CTA. Results: The prevalence of atherosclerosis by CTA was similar in both groups (75.6% versus 74.3%, p = 0.999), >50% coronary stenosis was slightly higher in controls (p = 0.046), but stenosis severity score (CAD-RADS) was not different (p = 0.106). Mixed plaque burden (weighted for non-calcified) was lower in patients receiving vitamin D supplementation (p = 0.002) and high-risk-plaque prevalence was markedly lower (3.8% versus 32%, p < 0.001). CT plaque density (HU) was higher (p < 0.001) in the vitamin D group. Patients with serum vitamin D (OH) levels >60 ng/mL had higher plaque density (p = 0.04), indicating more calcified and less vulnerable plaque. Conclusions: In this retrospective case–control cohort study, vitamin D supplementation was associated with less high-risk plaque, less non-calcified plaque burden, and a higher calcified plaque independent of CV risk factors.

Abnormal hearing patterns are not associated with endothelium-dependent vasodilation and carotid intima-media thickness: The Framingham Heart Study

INTRODUCTION

Prior data suggest associations between hearing loss, cardiovascular (CV) risk factors, and CV disease. Whether specific hearing loss patterns, including a strial pattern associated with inner ear vascular disease, are associated with systemic endothelial dysfunction and carotid intima-media thickness (IMT) remains unclear.

METHODS

We evaluated participants without prevalent CVD in the Framingham Offspring Study who underwent formal audiogram testing and brachial and carotid artery ultrasounds. Audiograms were categorized as normal or as belonging to one of four abnormal patterns: cochlear-conductive, low-sloping, sensorineural, or strial. Endothelial function as measured by brachial artery flow-mediated dilation (FMDmm and FMD%). Internal and common intima-media thicknesses (icIMT and ccIMT, respectively) were compared between audiogram patterns.

RESULTS

We studied 1672 participants (mean age 59 years, 57.6% women). The prevalence of each hearing pattern was as follows: 43.7% normal; 20.3% cochlear-conductive; 20.3% sensorineural; 7.7% low-sloping; and 8.0% strial. Strial pattern hearing loss was nearly twice as prevalent (p = 0.001) in those in the highest quartile of ccIMT and nearly 50% higher in those in the highest icIMT quartile (p = 0.04). There were no statistically significant differences between the prevalence of the strial pattern comparing the lowest quartiles of FMDmm and FMD% with the upper three quartiles. Age- and sex-adjusted linear regression models did not show significant associations between the vascular measures and hearing patterns.

CONCLUSION

Abnormal hearing patterns were not significantly associated with impaired brachial FMD and increased carotid IMT after adjusting for age and sex effects, which may reflect age and sex-related distributional differences based on hearing loss pattern.

[Use of simulation models in health economic evaluation studies of dietary salt-reduction policies for cardiovascular disease prevention]

Objectives　Social security costs related to the healthcare and long-term care of patients with cardiovascular diseases is a national burden that is expected to grow as Japan's population ages. Nutritional policies for improving the nation's diet could prevent cardiovascular diseases, but scientific evidence on their costs and outcomes is limited. This study gives an overview of health economic evaluation studies on population-wide dietary salt-reduction policies that have been instituted for the purposes of cardiovascular disease prevention. Thus, this study provides background information for the development of evaluation methods that can be utilized in Japan for analyzing the effects of nutritional policies on public health and social security cost containment.Methods　We extracted representative health economic simulation models that are used for predicting the effects of cardiovascular disease-related interventions: Cardiovascular Disease Policy Model, IMPACT Coronary Heart Disease Policy and Prevention Model, US IMPACT Food Policy Model, Assessing Cost-Effectiveness (ACE) approach to priority-setting, and Prevention Impacts Simulation Model (PRISM). Next, we collected original articles on studies that used these models for assessing the costs and effects of national population-wide dietary salt-reduction policies. We then outlined the background, structure, and applied studies associated with each model.Results　The five models utilized Markov cohort simulation, microsimulation, proportional multistate life tables, and system dynamics to predict the effect of dietary salt-reduction policies on blood pressure reduction and cardiovascular disease prevention. The models were applied to countries such as Australia, England, and the United States to simulate long-term (10 years to lifetime) costs and effects. These applied studies examined policies that included health promotion campaigns, sodium labels on the front of food packages, and mandatory or voluntary reformulation by the food industry to reduce the salt content of processed foods.Conclusion　Health economic simulation modeling is actively being used to evaluate scientific evidence on the costs and outcomes of national dietary salt-reduction policies. Similarly, leveraging simulation modeling techniques could facilitate the evaluation and planning of dietary salt-reduction policies and other nutritional policies in Japan.

Exercise, cancer and cardiovascular disease: what should clinicians advise?

Cardiovascular disease is one of the leading causes of morbidity and mortality in persons with cancer. The elevated risk is thought to derive from the combination of cardiovascular risk factors and direct cardiotoxicity from cancer therapies. Exercise may be a potential strategy to counteract these toxicities and maintain cardiovascular reserve. In this article, we review the evidence for the potential cardioprotective effects of exercise training in cancer patients before, during, and following treatment. We also propose a patient-tailored approach for the development of targeted prescriptions based on individual exercise capacity and cardiovascular reserve.

Variation in the Content of Postpartum Visits by Maternal Race/Ethnicity, Preconception, and Pregnancy-Related Cardiovascular Disease Risk, PRAMS, 2016-2017

OBJECTIVES

Limited evidence suggests racial/ethnic disparities in postpartum visit attendance; however, little is known about patterns in postpartum visit content. We sought to determine whether receipt of screening and counseling varies by race/ethnicity and whether cardiovascular disease (CVD) risk (preconception or pregnancy related) predicts postpartum visit content.

METHODS

We used data from the Pregnancy Risk Assessment Monitoring System 2016-2017 (39 sites) to calculate the prevalence of self-reported receipt of screening, services, and counseling at the postpartum visit by race/ethnicity and CVD risk (unweighted analytic sample n = 59 427). We created a score representing receipt of 5 key screenings or messages at the visit (counseling on healthy eating and exercise, cigarettes, pregnancy spacing, and birth control methods; screening for depression), which we used as a binary indicator of visit content in regression models. We fit a logistic regression model to determine the magnitude of association between CVD risk and receipt of the 5 key messages, prevention screening, or CVD-specific counseling (on healthy eating and exercise, smoking), adjusting for maternal age, race/ethnicity, and health insurance status.

RESULTS

Overall, 40% of women reported receiving all CVD-specific prevention messages. Both prepregnancy and pregnancy-related CVD risk were associated with increased odds of receipt of CVD prevention messages (adjusted odds ratios [aOR] = 1.2; 95% CI, 1.1-1.3; and 1.1; 95% CI, 1.1-1.2, respectively). Race/ethnicity was a stronger predictor than CVD risk: non-Hispanic Black women were twice as likely as non-Hispanic White women to receive CVD prevention messages, regardless of CVD risk (aOR = 1.9; 95% CI, 1.7-2.0).

CONCLUSIONS

Health systems should consider novel strategies to improve and standardize the content of postpartum visits.

Does Physical Activity Modify the Association between Air Pollution and Recurrence of Cardiovascular Disease?

We aimed to assess a possible interaction effect between physical activity and particulate air pollution exposure on recurrence of ischemic heart disease (IHD) and stroke. We followed 2221 adult participants comprising first time IHD (1403) and stroke (818) cases from the Västerbotten Intervention Program between 1 January 1990 to 31 December 2013. During mean follow-up times of 5.5 years, 428 and 156 participants developed IHD and stroke recurrence, respectively. PM2.5 concentrations above the median (5.48 µg/m³) were associated with increased risk of IHD and stroke recurrence by 13% (95% CI −17–45%) and 21% (95% CI −19–80%), respectively. These risk increases were however only observed among those that exercised at most once a week at 21% (95% CI −5–50%) and 25% (95% CI −19–90%) for IHD and stroke recurrence, respectively. Higher frequency of exercise at recruitment was positively associated with IHD and stroke recurrence but only the association with IHD recurrence among participants with low residential PM2.5 was statistically significant (96% increased risk (95%-CI 22–215%)). However, no interaction effect between physical activity and PM2.5 exposure was found. Our findings suggest that physical activity may reduce the air pollution exposure associated risk for recurrent cardiovascular disease, likely by reducing the inflammatory response.

Severe hypertension in China: results from the China PEACE million persons project

INTRODUCTION

People with severe hypertension have high risk of target organ damage, yet few studies focus specifically on this population. We sought to assess the characteristics, prevalence, awareness, and treatment patterns of severe hypertension among middle-aged adults in China.

METHODS

We enrolled 2 660 666 participants aged 35-75 years from 31 provinces between 2014 and 2018 in the cross-sectional China Patient-Centered Evaluative Assessment of Cardiac Events Million Persons Project. Severe hypertension was defined as SBP of at least 160 mmHg or DBP of at least 100 mmHg. Awareness and treatment were defined as self-reported diagnosis of hypertension and current use of antihypertensive medication, respectively. Analyses were completed in 2019.

RESULTS

Our sample included 2 618 757 adults with a mean age of 55.6 years (SD 9.8), 59.6% of whom were women. A total of 378 457 (14.5%) participants had severe hypertension, of whom 222 533 (58.8%) were untreated. The age--sex-standardized rate of severe hypertension was 11.6% based on the 2010 Chinese Census data. Advanced age, female sex, current drinking, obesity, lower income, diabetes, and prior cardiovascular events were associated with higher risk of severe hypertension (all P < 0.01). Of untreated participants with severe hypertension, only 60 484 (27.1%) were aware of their conditions. Among participants with severe hypertension despite treatment, 84.7% reported taking one class of antihypertensive medication; only 15% reported taking guideline-recommended combination therapy.

CONCLUSION

Many millions of people in China have severe hypertension and the vast majority are unaware of their condition and undertreated. There are immense opportunities to improve outcomes in this high-risk group.

Current state-of-the-art knowledge on the role of omega-3 fatty acids in the prevention of cardiovascular disease

INTRODUCTION

Polyunsaturated n-3 fatty acid preparations containing eicosapentaenoic acid (EPA) and docosahexanaenoic acid (DHA), or EPA only, have long been recommended in the management of hypertriglyceridaemia, especially when severe (triglyceride levels ≥500 mg/dL), at the dose of 2-4 g/d, mostly for the prevention of acute pancreatitis.

MATERIAL AND METHODS

The presented article reviews clinical trials and their metaanalyses which evaluated the effect of n-3 fatty acids on cardiovascular disease risk, and regulatory agencies' and cardiac societies' positions regarding their use.

RESULTS

The findings indicate that only EPA is effective. Particular clinical benefit (25% reduction of cardiovascular events) was observed in the recently published REDUCE-IT trial which evaluated EPA (icosapent ethyl) at the dose of 4 g/d for 4.9 years (median), compared to placebo, in hypertriglycerydaemic patients at high or very high cardiovascular risk. This positive effect has been reflected in the expert opinions which recommend eicosapent ethyl (4 g/d) in patients similar to those participating in the REDUCE-IT trial. Additional data in favour of the above position have been provided by the EVAPORATE trial results which showed reduced progression of coronary atherosclerosis with EPA at the dose of 4 g/d.

CONCLUSIONS

The clinical studies and metaanalyses strongly point out that only EPA (icosapent ethyl), especially at dose of 4 g/d, is effective in reducing cardiovascular events in very high and high risk patients with hypertriglyceridemia. The use of EPA + DHA preparations in doses up to 1 g/d does not prevent recurrent cardiovascular events.

Challenges and Opportunities for the Prevention and Treatment of Cardiovascular Disease Among Young Adults: Report From a National Heart, Lung, and Blood Institute Working Group

Improvements in cardiovascular disease (CVD) rates among young adults in the past 2 decades have been offset by increasing racial/ethnic and gender disparities, persistence of unhealthy lifestyle habits, overweight and obesity, and other CVD risk factors. To enhance the promotion of cardiovascular health among young adults 18 to 39 years old, the medical and broader public health community must understand the biological, interpersonal, and behavioral features of this life stage. Therefore, the National Heart, Lung, and Blood Institute, with support from the Office of Behavioral and Social Science Research, convened a 2-day workshop in Bethesda, Maryland, in September 2017 to identify research challenges and opportunities related to the cardiovascular health of young adults. The current generation of young adults live in an environment undergoing substantial economic, social, and technological transformations, differentiating them from prior research cohorts of young adults. Although the accumulation of clinical and behavioral risk factors for CVD begins early in life, and research suggests early risk is an important determinant of future events, few trials have studied prevention and treatment of CVD in participants <40 years old. Building an evidence base for CVD prevention in this population will require the engagement of young adults, who are often disconnected from the healthcare system and may not prioritize long-term health. These changes demand a repositioning of existing evidence-based treatments to accommodate new sociotechnical contexts. In this article, the authors review the recent literature and current research opportunities to advance the cardiovascular health of today's young adults.

Experiences of a National Web-Based Heart Age Calculator for Cardiovascular Disease Prevention: User Characteristics, Heart Age Results, and Behavior Change Survey

Background

Heart age calculators are used worldwide to engage the public in cardiovascular disease (CVD) prevention. Experimental studies with small samples have found mixed effects of these tools, and previous reports of population samples that used web-based heart age tools have not evaluated psychological and behavioral outcomes.

Objective

This study aims to report on national users of the Australian heart age calculator and the follow-up of a sample of users.

Methods

The heart age calculator was launched in 2019 by the National Heart Foundation of Australia. Heart age results were calculated for all users and recorded for those who signed up for a heart age report and an email follow-up over 10 weeks, after which a survey was conducted. CVD risk factors, heart age results, and psychological and behavioral questions were analyzed using descriptive statistics and chi-square tests. Open responses were thematically coded.

Results

There were 361,044 anonymous users over 5 months, of which 30,279 signed up to receive a heart age report and 1303 completed the survey. There were more women (19,840/30,279, 65.52%), with an average age of 55.67 (SD 11.43) years, and most users knew blood pressure levels (20,279/30,279, 66.97%) but not cholesterol levels (12,267/30,279, 40.51%). The average heart age result was 4.61 (SD 4.71) years older than the current age, including (23,840/30,279, 78.73%) with an older heart age. For the survey, most users recalled their heart age category (892/1303, 68.46%), and many reported lifestyle improvements (diet 821/1303, 63.01% and physical activity 809/1303, 62.09%). People with an older heart age result were more likely to report a doctor visit (538/1055, 51.00%). Participants indicated strong emotional responses to heart age, both positive and negative.

Conclusions

Most Australian users received an older heart age as per international and UK heart age tools. Heart age reports with follow-up over 10 weeks prompted strong emotional responses, high recall rates, and self-reported lifestyle changes and clinical checks for more than half of the survey respondents. These findings are based on a more engaged user sample than previous research, who were more likely to know blood pressure and cholesterol values. Further research is needed to determine which aspects are most effective in initiating and maintaining lifestyle changes. The results confirm high public interest in heart age tools, but additional support is needed to help users understand the results and take appropriate action.

Overruling uncertainty about preventative medications: the social organisation of healthcare professionals' knowledge and practices

In this article, we draw on an institutional ethnographic (IE) study of cardiovascular disease prevention in general practice, exploring the work of healthcare professionals who introduce a discussion of risk and preventative medications into consultations with patients. Our aim is to explicate, using IE's theoretical ontology and analytical tools, how troubling patient experiences in this clinical context are coordinated institutionally. We focus our attention on the social organisation of healthcare professionals' knowledge and front-line practices, highlighting the textual processes through which they overrule patients' concerns and uncertainties about taking preventative medication, such that some patients feel unable to openly discuss their health needs in preventative consultations. We show how healthcare professionals activate knowledge of 'evidence-based risk reduction' to frame patients' queries as 'barriers' to be overcome. Our analysis points not to deficiencies of healthcare professionals who lack the expertise or inclination to adequately 'share decisions' with patients, but to the ways in which their work is institutionally orientated towards performance measures which will demonstrate to local and national policymakers that they are tackling the 'burden of (cardiovascular) disease'.

Reducing Premature Mortality from Cardiovascular and Other Non-Communicable Diseases by One Third: Achieving Sustainable Development Goal Indicator 3.4.1

Non-communicable diseases (NCDs) are the world's leading causes of death and disability, with cardiovascular disease (CVD) accounting for half of NCD deaths. An ambitious global target established by the United Nations Sustainable Development Goals - indicator 3.4.1 - aims to reduce the risk of premature death among people aged 30-69 years from CVD, cancer, diabetes, and chronic lung disease by one third by 2030. This article reviews the science and practice informing what is required to achieve this target, identifying seven interventions that can accelerate progress: 1) tobacco control; 2) treatment to reduce cardiovascular risk; 3) reduction of dietary sodium; 4) reduction of household air pollution; 5) elimination of artificial trans fat; 6) reduction of alcohol use; and 7) prevention, detection, and treatment of cancers. Achieving the target is possible - there has already been progress in some areas, particularly related to CVD reduction - but only if there is faster, more concerted action.