High-Sensitivity Troponin T and I Among Pregnant Women in the US-The National Health and Nutrition Examination Survey, 1999-2004

This cross-sectional study investigates the expected physiologic concentrations of high-sensitivity cardiac troponin in normal pregnancy.

Prevalence and Correlates of Elevated NT-proBNP in Pregnant Women in the General U.S. Population

BACKGROUND

Physiologic changes in N-terminal pro-B-type natriuretic peptide (NT-proBNP) across trimesters of pregnancy have not been well studied.

OBJECTIVES

The authors aimed to measure NT-proBNP in adult women, by pregnancy status and trimester, in a nationally representative sample from the National Health and Nutrition Examination Survey 1999 to 2004.

METHODS

We conducted a cross-sectional analysis of 2,134 women (546 pregnant) aged 20 to 40 years without a history of cardiovascular disease.

RESULTS

Among pregnant women in the first trimester, the prevalence of elevated NT-proBNP (>125 pg/mL) was 20.0% (SE, 6.6%) compared to 2.4% (SE, 0.8%) among women in the third trimester and 8.0% among nonpregnant women. After adjustment for demographics and cardiovascular risk factors, NT-proBNP was 44% higher (absolute difference 26.4 [95% CI: 11.2-41.6] pg/mL) in the first trimester of pregnancy compared to nonpregnant women. Among pregnant women only, adjusted NT-proBNP was 46% lower (absolute difference -22.2 [95% CI: -36.9 to -7.5] pg/mL) in women in the third trimester compared to women in the first trimester. NT-proBNP was inversely associated with body mass index and with systolic blood pressure.

CONCLUSIONS

Women in the first trimester of pregnancy had significantly higher NT-proBNP than those in the third trimester and compared to similarly aged nonpregnant women. The dynamic nature of NT-proBNP should be taken into consideration when ordering NT-proBNP lab tests in pregnant women.

Impact of antihypertensive medication regimens on blood pressure control in individuals with established coronary heart disease

Background and purpose

Hypertension is a major risk factor for coronary heart disease (CHD) development and progression, with pharmacological control of blood pressure reducing the risk of CHD events and death [1].

Treatment and control of blood pressure in CHD is suboptimal, with many patients failing to achieve guideline-directed targets [1,2]. This study aims to assess the relationship between antihypertensive medication regimens and blood pressure control in patients with hypertension and established coronary heart disease.

Methods

The iASPIRE study recently evaluated secondary prevention in an Irish cohort with coronary heart disease [2]. Based on a method used in a similar study [3], we calculated the average percentage daily dose of each prescribed antihypertensive agent. We then assessed the relationship between dose and number of antihypertensive agents with blood pressure control.

Results

540 (75.5%) of iASPIRE participants had an underlying diagnosis of hypertension, and at the study examination, 56% of these had a blood pressure ≥140/90 mmHg, while 83% had a blood pressure ≥130/80 mmHg. The median number of antihypertensive agents prescribed was 2 (IQR 1–2), with 88% of those with hypertension on at least one blood pressure medication. In participants with hypertension on treatment, the median percentage daily medication dose was 29% (IQR 14–50). After adjustment for age and sex, the addition of further antihypertensive medications increased the odds of achieving a blood pressure target of <130/80 mmHg (OR 1.3, 95% CI 1.07–1.69, p=0.012). The average percentage daily dose of each antihypertensive agent was lower in both participants with a medication-controlled blood pressure of <130/80 mmHg and <140/90 mmHg compared to those without blood pressure control (30% versus 37% p=0.006 and 33% versus 38% p=0.028 respectively).

Conclusion

Many patients with hypertension and coronary heart disease currently fail to achieve blood pressure control. This analysis found that an increasing number of antihypertensive medications but not increasing dose was associated with better blood pressure control. Combination therapy is superior to sequential monotherapy in the treatment of hypertension [1], and an approach that emphasises the initiation of several antihypertensive agents would likely lead to better blood pressure control in individuals with coronary heart disease.

Funding Acknowledgement

Type of funding sources: None.

Glycemic excursions and subclinical cardiac damage in adults with type 2 diabetes: Results from the ADVANCE Trial

We found that 1,5-anhydroglucitol-a marker of glucose excursions-was not independently associated with subclinical cardiac damage, nor with vascular outcomes, in the ADVANCE Trial. High-sensitivity cardiac troponin T and N-terminal pro-b-type natriuretic peptide provided better prognostic information regarding vascular risk in diabetes than 1,5-anhydroglucitol.

Рекомендации - 2019 Американского колледжа кардиологии (АСС) / Американской ассоциации сердца (АНА) по первичной профилактике сердечно-сосудистых заболеваний

No abstract

Association Between Omega-3 Fatty Acid Levels and Risk for Incident Major Bleeding Events and Atrial Fibrillation: MESA

Background

Randomized trials of pharmacologic strength omega‐3 fatty acid (n3‐FA)–based therapies suggest a dose‐dependent cardiovascular benefit. Whether blood n3‐FA levels also mediate safety signals observed in these trials, such as increased bleeding and atrial fibrillation (AF), remains uncertain. We hypothesized that higher baseline n3‐FA levels would be associated with incident bleeding and AF events in MESA (Multi‐Ethnic Study of Atherosclerosis), which included a population free of clinical cardiovascular disease at baseline.

Methods and Results

We examined the association between baseline plasma n3‐FA levels (expressed as percent mass of total fatty acid) with incident bleeding and AF in MESA, an ongoing prospective cohort study. Bleeding events were identified from review of hospitalization International Classification of Diseases, Ninth Revision (ICD‐9), and International Classification of Diseases, Tenth Revision (ICD‐10), codes, and AF from participant report, discharge diagnoses, Medicare claims data, and study ECGs performed at MESA visit 5. Separate multivariable Cox proportional hazard modeling was used to estimate hazard ratios of the association of continuous n3‐FA (log eicosapentaenoic acid [EPA], log docosahexaenoic acid [DHA], log [EPA+DHA]) and incident hospitalized bleeding events and AF. Among 6546 participants, the mean age was 62.1 years and 53% were women. For incident bleeding, consistent statistically significant associations with lower rates were seen with increasing levels of EPA and EPA+DHA in unadjusted and adjusted models including medications that modulate bleeding risk (aspirin, NSAIDS, corticosteroids, and proton pump inhibitors). For incident AF, a significant association with lower rates was seen with increasing levels of DHA, but not for EPA or EPA+DHA.

Conclusions

In MESA, higher plasma levels of n3‐FA (EPA and EPA+DHA, but not DHA) were associated with significantly fewer hospitalized bleeding events, and higher DHA levels (but not EPA or EPA+DHA) with fewer incident AF events.

Higher Prevalence of Concurrent Thrombocytopenia in Patients Receiving Continuous Renal Replacement Therapy in the Cardiac Intensive Care Unit

INTRODUCTION

Thrombocytopenia (TCP) is a common finding in patients receiving continuous renal replacement therapy (CRRT).

OBJECTIVE

The purpose of this study was to assess the nature of TCP in patients receiving CRRT.

METHODS

This is a single-center case-control observational study of 795 patients involving over 166,950 h of delivered CRRT at Johns Hopkins Hospital. Concurrent TCP in patients receiving CRRT was defined as a decrease in platelet count of ≥50% any time within 72 h of initiation of CRRT with strict exclusion criteria.

RESULTS

There was a higher incidence of TCP in the cardiac intensive care unit (CICU) (22.5%) compared to medical ICU (MICU) (13.1%). Using logistic regression, the odds of developing concurrent TCP in patients receiving CRRT was 2.46 (95% CI 1.32-3.57, p < 0.05) times higher in the CICU compared with the MICU. There was no difference in the incidence of severe or profound TCP or timing of acute TCP between the CICU and MICU.

CONCLUSION

Safe delivery of dialysis care in the ICU is paramount and creating awareness of potential risks such as concurrent TCP in patients receiving CRRT should be part of this care.

Association of hypertension and antihypertensive treatment with COVID-19 mortality: a retrospective observational study

AIMS

It remains unknown whether the treatment of hypertension influences the mortality of patients diagnosed with coronavirus disease 2019 (COVID-19).

METHODS AND RESULTS

This is a retrospective observational study of all patients admitted with COVID-19 to Huo Shen Shan Hospital. The hospital was dedicated solely to the treatment of COVID-19 in Wuhan, China. Hypertension and the treatments were stratified according to the medical history or medications administrated prior to the infection. Among 2877 hospitalized patients, 29.5% (850/2877) had a history of hypertension. After adjustment for confounders, patients with hypertension had a two-fold increase in the relative risk of mortality as compared with patients without hypertension [4.0% vs. 1.1%, adjusted hazard ratio (HR) 2.12, 95% confidence interval (CI) 1.17-3.82, P = 0.013]. Patients with a history of hypertension but without antihypertensive treatment (n = 140) were associated with a significantly higher risk of mortality compared with those with antihypertensive treatments (n = 730) (7.9% vs. 3.2%, adjusted HR 2.17, 95% CI 1.03-4.57, P = 0.041). The mortality rates were similar between the renin-angiotensin-aldosterone system (RAAS) inhibitor (4/183) and non-RAAS inhibitor (19/527) cohorts (2.2% vs. 3.6%, adjusted HR 0.85, 95% CI 0.28-2.58, P = 0.774). However, in a study-level meta-analysis of four studies, the result showed that patients with RAAS inhibitor use tend to have a lower risk of mortality (relative risk 0.65, 95% CI 0.45-0.94, P = 0.20).

CONCLUSION

While hypertension and the discontinuation of antihypertensive treatment are suspected to be related to increased risk of mortality, in this retrospective observational analysis, we did not detect any harm of RAAS inhibitors in patients infected with COVID-19. However, the results should be considered as exploratory and interpreted cautiously.

Primary prevention aspirin among the elderly: challenges in translating trial evidence to the clinic

The ASPirin in Reducing Events in the Elderly trial (ASPREE) contributed important knowledge about primary cardiovascular disease (CVD) prevention among healthy older adults. The finding that daily low-dose aspirin (LDA) does not statistically prevent disability or CVD among adults aged over 70 years when compared with placebo, but does significantly increase risk of haemorrhage, immediately influenced clinical practice guidelines. In this article, we discuss nuances of the trial that may impact the extrapolation of the ASPREE trial results to the everyday individual clinical care of older adults.

2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Geriatrics Society, the American Society of Preventive Cardiology, and the Preventive Cardiovascular Nurses Association

2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

1. The most important way to prevent atherosclerotic vascular disease, heart failure, and atrial fibrillation is to promote a healthy lifestyle throughout life.

2. A team-based care approach is an effective strategy for the prevention of cardiovascular disease. Clinicians should evaluate the social determinants of health that affect individuals to inform treatment decisions.

3. Adults who are 40 to 75 years of age and are being evaluated for cardiovascular disease prevention should undergo 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimation and have a clinician–patient risk discussion before starting on pharmacological therapy, such as antihypertensive therapy, a statin, or aspirin. The presence or absence of additional risk-enhancing factors can help guide decisions about preventive interventions in select individuals, as can coronary artery calcium scanning.

4. All adults should consume a healthy diet that emphasizes the intake of vegetables, fruits, nuts, whole grains, lean vegetable or animal protein, and fish and minimizes the intake of trans fats, processed meats, refined carbohydrates, and sweetened beverages. For adults with overweight and obesity, counseling and caloric restriction are recommended for achieving and maintaining weight loss.

5. Adults should engage in at least 150 minutes per week of accumulated moderate-intensity physical activity or 75 minutes per week of vigorous-intensity physical activity.

6. For adults with type 2 diabetes mellitus, lifestyle changes, such as improving dietary habits and achieving exercise recommendations are crucial. If medication is indicated, metformin is first-line therapy, followed by consideration of a sodium-glucose cotransporter 2 inhibitor or a glucagon-like peptide-1 receptor agonist.

7. All adults should be assessed at every healthcare visit for tobacco use, and those who use tobacco should be assisted and strongly advised to quit.

8. Aspirin should be used infrequently in the routine primary prevention of ASCVD because of lack of net benefit.

9. Statin therapy is first-line treatment for primary prevention of ASCVD in patients with elevated low-density lipoprotein cholesterol levels (≥190 mg/dL), those with diabetes mellitus, who are 40 to 75 years of age, and those determined to be at sufficient ASCVD risk after a clinician–patient risk discussion.

10. Nonpharmacological interventions are recommended for all adults with elevated blood pressure or hypertension. For those requiring pharmacological therapy, the target blood pressure should generally be <130/80 mm Hg.