Partial substitutions of animal with plant protein foods in Canadian diets have synergies and trade-offs among nutrition, health and climate outcomes

Dietary guidelines emphasize the consumption of plant protein foods, but the implications of replacing animal with plant sources on a combination of diet sustainability dimensions are unknown. Using a combination of data from a national nutrition survey, greenhouse gas emissions from dataFIELD and relative risks from the Global Burden of Disease Study 2017, we assess the impact of partially substituting red and processed meat or dairy with plant protein foods in Canadian self-selected diets on nutrition, health and climate outcomes. The substitutions induced minor changes to the percentage of the population below requirements for nutrients of concern, but increased calcium inadequacy by up to 14% when dairy was replaced. Replacing red and processed meat or dairy increased life expectancy by up to 8.7 months or 7.6 months, respectively. Diet-related greenhouse gas emissions decreased by up to 25% for red and processed meat and by up to 5% for dairy replacements. Co-benefits of partially substituting red and processed meat with plant protein foods among nutrition, health and climate outcomes are relevant for reshaping consumer food choices in addressing human and planetary health.

Effects on child and adolescent health of climate change mitigation policies: A systematic review of modelling studies

There is a growing body of modelling evidence that demonstrates the potential for immediate and substantial benefits to adult health from greenhouse gas mitigation actions, but the effects on the health of younger age groups is largely unknown. We conducted a systematic review to identify the available published evidence of the modelled effects on child and adolescent health (≤18 years of age) of greenhouse gas mitigation. We searched six databases of peer-reviewed studies published between January 1, 1990 and July 27, 2022, screened 27,282 original papers and included 23 eligible papers. All included studies were set in high- and middle-income countries; and all studies modelled the effects of interventions that could mitigate greenhouse gas emissions and improve air quality. Most of the available evidence suggests positive benefits for child and adolescent respiratory health from greenhouse gas mitigation actions that simultaneously reduce air pollution (specifically PM2.5 and nitrogen dioxide). We found scant evidence on child and adolescent health from regions more vulnerable to climate change, or on mitigation interventions that could affect exposures other than air pollution.

School building energy efficiency and NO2 related risk of childhood asthma in England and Wales: Modelling study

BACKGROUND

Climate change legislation will require dramatic increases in the energy efficiency of school buildings across the UK by 2050, which has the potential to affect air quality in schools. We assessed how different strategies for improving the energy efficiency of school buildings in England and Wales may affect asthma incidence and associated healthcare utilization costs in the future.

METHODS

Indoor concentrations of traffic-related NO2 were modelled inside school buildings representing 13 climate regions in England and Wales using a building physics school stock model. We used a health impact assessment model to quantify the resulting burden of childhood asthma incidence by combining regional health and population data with exposure-response functions from a recent high-quality systematic review/meta-analysis. We compared the effects of four energy efficiency interventions consisting of combinations of retrofit and operational strategies aiming to improve indoor air quality and thermal comfort on asthma incidence and associated hospitalization costs.

RESULTS

The highest childhood asthma incidence was found in the Thames Valley region (including London), in particular in older school buildings, while the lowest concentrations and health burdens were in the newest schools in Wales. Interventions consisting of only operational improvements or combinations of retrofit and operational strategies resulted in reductions in childhood asthma incidence (547 and 676 per annum regional average, respectively) and hospital utilization costs (£52,050 and £64,310 per annum regional average, respectively. Interventions that improved energy efficiency without operational measures resulted in higher childhood asthma incidence and hospital costs.

CONCLUSION

The effect of school energy efficiency retrofit on NO2 exposure and asthma incidence in schoolchildren depends critically on the use of appropriate building operation strategies. The findings from this study make several contributions to fill the knowledge gap about the impact of retrofitting schools on exposure to air pollutants and their effects on children's health.

Urban-rural disparity in global estimation of PM2·5 household air pollution and its attributable health burden

BACKGROUND

Polluting fuels and inefficient stove technologies are still a leading cause of premature deaths worldwide, particularly in low-income and middle-income countries. Previous studies of global household air pollution (HAP) have neither considered the estimation of PM2·5 at national level nor the corresponding attributable mortality burden. Additionally, the effects of climate and ambient air pollution on the global estimation of HAP-PM2·5 exposure for different urban and rural settings remain largely unknown. In this study, we include climatic effects to estimate the HAP-PM2·5 exposure from different fuel types and stove technologies in rural and urban settings separately and the related attributable global mortality burden.

METHODS

Bayesian hierarchical models were developed to estimate an annual average HAP-PM2·5 personal exposure and HAP-PM2·5 indoor concentration (including both outdoor and indoor sources). Model variables were selected from sample data in 282 peer-reviewed studies drawn and updated from the WHO Global HAP dataset. The PM2·5 exposure coefficients from the developed model were applied to the external datasets to predict the HAP-PM2·5 exposure globally (personal exposure in 62 countries and indoor concentration in 69 countries). Attributable mortality rate was estimated using a comparative risk assessment approach. Using weighted averages, the national level 24 h average HAP-PM2·5 exposure due to polluting and clean fuels and related death rate per 100 000 population were estimated.

FINDINGS

In 2020, household use of polluting solid fuels for cooking and heating led to a national-level average personal exposure of 151 μg/m3 (95% CI 133-169), with rural households having an average of 171 μg/m3 (153-189) and urban households an average of 92 μg/m3 (77-106). Use of clean fuels gave rise to a national-level average personal exposure of 69 μg/m3 (62-76), with a rural average of 76 μg/m3 (69-83) and an urban average of 49 μg/m3 (46-53). Personal exposure-attributable premature mortality (per 100 000 population) from the use of polluting solid fuels at national level was on average 78 (95% CI 69-87), with a rural average of 82 (73-90) and an urban average of 66 (57-75). The average attributable premature mortality (per 100 000 population) from the use of clean fuels at the national level is 62 (54-70), with a rural average of 66 (58-74) and an urban average of 52 (47-57). The estimated HAP-PM2·5 indoor concentration shows that the use of polluting solid fuels resulted in a national-level average of 412 μg/m3 (95% CI 353-471), with a rural average of 514 μg/m3 (446-582) and an urban average of 149 μg/m3 (126-173). The use of clean fuels (gas and electricity) led to an average PM2·5 indoor concentration of 135 μg/m3 (117-153), with a rural average of 174 μg/m3 (154-195) and an urban average of 71 μg/m3 (63-80). Using time-weighted HAP-PM2·5 indoor concentrations, the attributable premature death rate (per 100 000 population) from the use of polluting solid fuels at the national level is on average 78 (95% CI 72-84), the rural average being 84 (78-91) and the urban average 60 (54-66). From the use of clean fuels, the average attributable premature death rate (per 100 000 population) at the national level is 59 (53-64), the rural average being 68 (62-74) and the urban average 45 (41-50).

INTERPRETATION

A shift from polluting to clean fuels can reduce the average PM2·5 personal exposure by 53% and thereby lower the death rate. For all fuel types, the estimated average HAP-PM2·5 personal exposure and indoor concentrations exceed the WHO's Interim Target-1 average annual threshold. Policy interventions are urgently needed to greatly increase the use of clean fuels and stove technologies by 2030 to achieve the goal of affordable clean energy access, as set by the UN in 2015, and address health inequities in urban-rural settings.

FUNDING

Wellcome Trust, The Lancet Countdown, the Engineering and Physical Sciences Research Council, and the Natural Environment Research Council.

Sports Utility Vehicles: A Public Health Model of Their Climate and Air Pollution Impacts in the United Kingdom

The emission benefits of shifting towards battery electric vehicles have so far been hampered by a trend towards sports utility vehicles (SUVs). This study assesses the current and future emissions from SUVs and their potential impact on public health and climate targets. We modelled five scenarios of varying SUV sales and electrification rates, and projected associated carbon dioxide (CO2) and nitrogen oxide (NOx) emissions. Multiple linear regression was used to determine the relationship between vehicle characteristics and emissions. Cumulative CO2 emissions were valued using the social cost of carbon approach. Life table analyses were used to project and value life years saved from NOx emission reductions. Larger SUVs were disproportionately high emitters of CO2 and NOx. Replacing these with small SUVs achieved significant benefits, saving 702 MtCO2e by 2050 and 1.8 million life years from NO2 reductions. The largest benefits were achieved when combined with electrification, saving 1181 MtCO2e and gaining 3.7 million life years, with a societal value in the range of GBP 10-100s billion(s). Downsizing SUVs could be associated with major public health benefits from reduced CO2 and NOx emissions, in addition to the benefits of electrification. This could be achieved by demand-side mass-based vehicle taxation and supply-side changes to regulations, by tying emission limits to a vehicle's footprint rather than its mass.

Air pollution and child health impacts of decarbonization in 16 global cities: Modelling study

Most research on the air pollution-related health effects of decarbonization has focused on adults. We assess the potential health benefits that could be achieved in children and young people in a global sample of 16 cities through global decarbonization actions. We modelled annual average concentrations of fine particulate matter (PM_2.5) and nitrogen dioxide (NO₂) at 1x1 km resolution in the cities using a general circulation/atmospheric chemistry model assuming removal of all global combustion-related emissions from land transport, industries, domestic energy use and power generation. We modelled the impact on childhood asthma incidence and adverse birth outcomes (low birthweight, pre-term births) using published exposure-response relationships. Removal of combustion emissions was estimated to decrease annual average PM_2.5 by between 2.9 μg/m³ (8.4%) in Freetown and 45.4 μg/m³ (63.7%) in Dhaka. For NO₂, the range was from 0.3 ppb (7.9%) in Freetown to 18.8 ppb (92.3%) in Mexico City. Estimated reductions in asthma incidence ranged from close to zero in Freetown, Tamale and Harare to 149 cases per 100,000 population in Los Angeles. For pre-term birth, modelled impacts ranged from a reduction of 135 per 100,000 births in Dar es Salaam to 2,818 per 100,000 births in Bhubaneswar and, for low birthweight, from 75 per 100,000 births in Dar es Salaam to 2,951 per 100,000 births in Dhaka. The large variations chiefly reflect differences in the magnitudes of air pollution reductions and estimated underlying disease rates. Across the 16 cities, the reduction in childhood asthma incidence represents more than one-fifth of the current burden, and an almost 10% reduction in pre-term and low birthweight births. Decarbonization actions that remove combustion-related emissions contributing to ambient PM_2.5 and NO₂ would likely lead to substantial but geographically-varied reductions in childhood asthma and adverse birth outcomes, though there are uncertainties in causality and the precision of estimates.

Impact on mortality of pathways to net zero greenhouse gas emissions in England and Wales: a multisectoral modelling study

BACKGROUND

The UK is legally committed to reduce its greenhouse gas emissions to net zero by 2050. We aimed to understand the potential impact on population health of two pathways for achieving this target through the integrated effects of six actions in four sectors.

METHODS

In this multisectoral modelling study we assessed the impact on population health in England and Wales of six policy actions relating to electricity generation, transport, home energy, active travel, and diets relative to a baseline scenario in which climate actions, exposures, and behaviours were held constant at 2020 levels under two scenarios: the UK Climate Change Committee's Balanced Pathway of technological and behavioural measures; and its Widespread Engagement Pathway, which assumes more substantial changes to consumer behaviours. We quantified the impacts of each policy action on mortality using a life table comprising all exposures, behaviours, and health outcomes in a single model.

FINDINGS

Both scenarios are predicted to result in substantial reductions in mortality by 2050. The Widespread Engagement Pathway achieves a slightly greater reduction in outdoor fine particulate matter air pollution of 3·2 μg/m³ (33%) and, under assumptions of appropriate ventilation, a greater improvement in indoor air pollution (a decrease in indoor-generated fine particulate matter from 9·4 μg/m³ to 4·6 μg/m³) and winter temperatures (increasing from 17·8°C to 18·1°C), as well as appreciably greater changes in levels of active travel (27% increase in metabolic equivalent hours per week of walking and cycling) by 2050. Additionally, the greater reduction in red meat consumption (50% compared with 35% under the Balanced Pathway) by 2050 results in greater consumption of fruits (17-18 g/day), vegetables (22-23 g/day), and legumes (5-7 g/day). Combined actions under the Balanced Pathway result in more than 2 million cumulative life-years gained over 2021-50; the estimated gain under the Widespread Engagement Pathway is greater, corresponding to nearly 2·5 million life-years gained by 2050 and 13·7 million life-years gained by 2100.

INTERPRETATION

Reaching net zero greenhouse gas emissions is likely to lead to substantial benefits for public health in England and Wales, with the cumulative net benefits being correspondingly greater with a pathway that entails faster and more ambitious changes, especially in physical activity and diets.

FUNDING

National Institute for Health Research and the Wellcome Trust.

Let's just ask them. Perspectives on urban dwelling and air quality: A cross-sectional survey of 3,222 children, young people and parents

This research aimed to capture and synthesise the views of children, young people, parents and expectant parents (CYPP) about the cities where they live, with a specific focus on air pollution (AP), in order to support the generation of evidence-informed policy that reflects CYPP's perspectives, ultimately contributing to the development of child-centered, healthier, sustainable cities. The Children, Cities and Climate (CCC) project used targeted social media adverts to recruit CYPP to complete an online survey with a combination of open and closed questions in order to collect perceptions about air quality in their home cities, the main sources of AP, and how they would improve their cities. The survey was completed by 3,222 CYPP in 59 of the most polluted cities in 14 countries. Nearly two in five (39%) CYPP cited AP as one of the worst things about their city, with motor transport perceived as the main contributor. CYPP reported differing views on whether their cities were becoming better (43%) or worse (34%) places to live (33% reported it was 'staying the same'). Numerous specific ideas to improve cities and urban air quality emerged, alongside an emphasis on also addressing structural barriers to change. A clear set of principles that should guide how city leaders act was also described, including the need to engage with young people meaningfully. CYPPs articulated good and bad experiences of urban living and perceived AP and traffic as pressing concerns. They provided a clear set of suggestions for improving their cities. Further efforts to engage young people on these issues are warranted.

Poster No. 012 Premature myocardial infarction: a decade-long analysis of patients admitted to a single-center coronary care unit

Background

Despite being primarily a disease of older patients, acute myocardial infarction (AMI) has been increasingly recognized in young individuals. This study sought to characterize and determine the prognosis of AMI in patients aged ≤ 45 years old.

Methods

We retrospectively analyzed patients consecutively admitted to the coronary care unit with AMI. Two groups were identified: patients aged ≤ 45 and > 45 years old.

Results and conclusions

A total of 5696 AMI patients were included in the analysis: median age of 70 (IQR 19) years and 68.6% (n = 3906) were male; 5.6% (n = 318) of patients were aged ≤ 45 years old.

In contrast to the older patients, those aged ≤ 45 years old were more likely to be male (P < 0.001), presented more often with a history of smoking (P < 0.001), and family history of premature coronary artery disease (P < 0.001), but less often hypertension, hyperlipidemia, and diabetes.

In coronary angiography, most younger patients presented a single-vessel disease (57.1%), more commonly affecting the left anterior descending artery (51.7%); left main involvement was rare (0.8%); and 14.2% presented MINOCA (vs. 11.4% of older patients).

Regarding prognosis, 6.4% (n = 366) of patients died in the hospital and 24.2% (n = 1380) died during the 5-year follow-up. Younger patients had a lower risk of in-hospital mortality (OR 0.22, 95% CI 0.09–541, P = 0.001) and 5-year mortality (OR 0.12, 95% CI 0.06–0.201, P < 0.001), compared to the older patients.

In conclusion, patients with premature AMI have a different proportion of risk factors, less extensive coronary artery disease, and more commonly present MINOCA, compared to the older patients.

Oral Presentation No. 10 Pharmacological therapy in patients with myocardial infarction with nonobstructive coronary arteries (MINOCA): long-term prognosis

Background

The optimal management of myocardial infarction with nonobstructive coronary arteries (MINOCA) is still uncertain. This study sought to determine the association between pharmacological therapies after hospital discharge and the long-term prognosis of MINOCA patients.

Material and methods

We analyzed patients consecutively admitted to the coronary care unit with myocardial infarction (MI). Multivariate analysis was performed to determine which drugs were implicated in the prognosis of MINOCA patients. The primary endpoint was all-cause mortality at 5 years.

Results and conclusions

From a total of 3721 MI patients, MINOCA was identified in 11.6% (n = 430), of whom 56 (13.0%) experienced the primary endpoint. Median age was 66 years (IQR 19), and 51.6% (n = 222) of patients were male.

At discharge, 81.2% of MINOCA patients were prescribed aspirin, 87.4% a statin, 78.6% beta-blockers, and 66.7% angiotensin-converting enzyme inhibitors (ACEI). MINOCA patients were less likely to be prescribed these medications compared to patients with obstructive coronary artery disease (all P < 0.001). 1.4% (n = 6) of MINOCA patients died in the hospital, and the 5-year mortality rate was 13.0% (n = 56). In multivariate Cox regression, treatment with ACEI at discharge was found to be independently associated with a 5-year mortality benefit (HR = 0.29, 95% CI 0.12–0.67, adjusted P = 0.004) in MINOCA patients.

In conclusion, compared with patients with obstructive CAD, patients with MINOCA are less likely to be treated with secondary prevention drugs and are at lower risk of all-cause mortality during long-term follow-up. Treatment with ACEI seems to provide an additional mortality benefit in MINOCA patients.

Poster No. 009 In-hospital bleeding in acute coronary syndrome: new antithrombotics, old problems

Background

Progress in decreasing ischemic complications in acute coronary syndrome (ACS) has come at the expense of increased risk of bleeding. This study sought to determine the incidence, predictors, and prognosis of in-hospital bleeding (IHB) in ACS patients.

Material and methods

We retrospectively analyzed patients consecutively admitted to the coronary care unit (CCU) with ACS. Patients who suffered clinically significant IHB were compared to the remaining ACS patients. The primary endpoint was all-cause in-hospital death.

Results and conclusions

From a total of 1032 ACS patients, clinically significant IHB was identified in 5.6% (n = 58) of patients, of whom 13 patients presented serious bleeding. Patients with IHB were older (P = 0.003), more often female (P = 0.012), were more likely to have prior heart failure (P = 0.007) and chronic kidney disease (P = 0.001). At admission, they presented more often with Killip-Kimball class > I (P = 0.001), lower hemoglobin (P = 0.013), lower eGFR (P = 0.005), and a higher CRUSADE score (P < 0.001). In multivariate logistic regression, female sex (OR = 2.26, 1.17–4–38, P = 0.023), acute kidney injury (OR = 2.23, 1.12–4.45, P = 0.028), and non-radial access in coronary angiography (OR = 2.04, 1.08–3.87, P = 0.028), were identified as independent predictors of IHB.

The primary endpoint occurred in 5.8% of ACS patients. Patients who suffered IHB were at higher risk of death during hospitalization (OR = 2.39, 95% CI 1.03–5.51, P = 0.042), but not during the 2-year follow-up (P = 0.429).

In conclusion, IHB is not an uncommon complication in ACS patients and is associated with an increased risk of in-hospital mortality.

Rediscovering CPET: the prognostic value of hemodynamic gain index in heart failure

Introduction

Cardiopulmonary exercise testing (CPET) is recommended in patients with heart failure (HF) to optimize exercise prescription and as part of the evaluation for heart transplantation. Hemodynamic gain index (HGI) derived from CPET has been proposed as a new marker of risk stratification in general population cohorts.

Purpose

We aimed to evaluate the prognostic value of HGI in patients with HF.

Methods

We conducted a single-centre study assessing consecutive patients with HF who underwent CPET from 2013 to 2017. HGI was calculated based on heart rate (HR) and systolic blood pressure (SBP): HGI = [(HRpeak × SBPpeak) − (HRrest × SBPrest)] / (HRrest × SBPrest). Classic and recently proposed variables were collected, including peak O2 uptake (pVO2), minute ventilation–CO2 production (VE/VCO2 slope), circulatory power (CP = pVO2 × peak SBP), and ventilatory power (VP = peak SBP/(VE/VCO2) slope). The primary outcome was a composite of HF hospitalization, heart transplant, and all-cause mortality.

Results

A total of 212 patients (mean age 55.4±10.9, 76.9% male) were included. Most patients had dilated cardiomyopathy (43.9%) followed by ischaemic aetiology (38.7%), with a mean left ventricle ejection fraction of 29±13%. The most used exercise protocol was the modified Naughton (76.6%), followed by the original Naughton (18.7%), and Bruce (4.8%). Mean pVO2 was 16.7±5.9mL O2 kg–1 min–1 and median VE/VCO2 slope was 37.5 [32.7–44.3]. Mean VP was 3.46±1.31mmHg while median CP was 1927 [1427–2697]mmHg min/mL/kg. Mean HGI was 0.90±0.5 bpm/mmHg. Despite weak, there were significant positive correlations between HGI and mean pVO2 (rs=0.55, p<0.01), VP (r=0.60, p<0.01), and CP (rs=0.68, p<0.01), but negative correlation between HGI and VE/VCO2 slope (rs=−0.45, p<0.01). HGI was grouped by terciles: T1 (<0.59), T2 (0.59–1.02), and T3 (>1.02). After a median follow-up of 71 [49–81] months, the primary outcome occurred in 66.0% of patients (rehospitalization, heart transplant, and all-cause death occurred in 56.1%, 25.9%, and 32.5%, respectively). In the T1 group, the multivariable-adjusted odds ratio (OR) for the primary outcome was 3.73 (95% CI 1.97–7.06, p<0.01) compared to the T3. In the T2 group, the multivariable-adjusted OR for the primary outcome was 0.47 (95% CI 0.27–0.81, p<0.01) compared to T1. There were no significant differences between T2 and T3 groups. Kaplan-Meier estimates of primary outcome during follow-up according to HGI tercile are shown in Figure 1.

Conclusion

HGI is inversely associated with the composite of HF hospitalization, heart transplant, and all-cause mortality in patients with heart failure, enhancing the role of CPET in risk stratification.

Funding Acknowledgement

Type of funding sources: None.

Barriers and facilitators to nationwide implementation of the malaria vaccine in Ghana

Interventions such as antimalarial drugs, bed nets and insecticides have helped curb the burden of malaria in the past decade, yet malaria remains a leading cause of morbidity and mortality in children below the age of 5 years. In 2019, Ghana, Malawi and Kenya in sub-Saharan Africa (countries with moderate to high transmission areas of malaria and deaths) started piloting the RTS,S/AS01E malaria vaccine in selected regions. Using qualitative methods, this study examined the main factors (forces) that will influence or hinder the nationwide implementation of the malaria vaccine, if approved, in Ghana. We conducted in-depth interviews with 12 key individuals (national, research/academia and programme implementing partners) in the public health sector in Ghana from October 2018 to February 2019. Results were analysed using Kurt Lewin's force field analysis to understand how organizations interact with their external environment in the delivery of health policies such as the implementation of the malaria vaccine. We found that the disease burden of malaria deaths in Ghana, the efficacy of the vaccine, stakeholder involvement and evidence for the feasibility of vaccine delivery generated by the consortium of researchers (body of researchers) that can track the implementation were the driving forces to scale up the vaccine into a routine health system. On the other hand, the needed logistics, funding, administration of the four-dose vaccine and follow-up were identified as potential barriers. The most influential force collectively highlighted by the respondents was the disease burden, and the most influential barrier was the logistics of delivering the vaccine. Our findings provide decision makers with key barriers and facilitators to guide policy and decision-making for malaria control in Ghana and other similar settings in low- and middle-income countries.

The relationship between greenspace and personal exposure to PM2.5 during walking trips in Delhi, India

The presence of urban greenspace may lead to reduced personal exposure to air pollution via several mechanisms, for example, increased dispersion of airborne particulates; however, there is a lack of real-time evidence across different urban contexts. Study participants were 79 adolescents with asthma who lived in Delhi, India and were recruited to the Delhi Air Pollution and Health Effects (DAPHNE) study. Participants were monitored continuously for exposure to PM_2.5 (particulate matter with an aerodynamic diameter of less than 2.5 μm) for 48 h. We isolated normal day-to-day walking journeys (n = 199) from the personal monitoring dataset and assessed the relationship between greenspace and personal PM_2.5 using different spatial scales of the mean Normalised Difference Vegetation Index (NDVI), mean tree cover (TC), and proportion of surrounding green land use (GLU) and parks or forests (PF). The journeys had a mean duration of 12.7 (range 5, 53) min and mean PM_2.5 personal exposure of 133.9 (standard deviation = 114.8) μg/m³. The within-trip analysis showed weak inverse associations between greenspace markers and PM_2.5 concentrations only in the spring/summer/monsoon season, with statistically significant associations for TC at the 25 and 50 m buffers in adjusted models. Between-trip analysis also indicated inverse associations for NDVI and TC, but suggested positive associations for GLU and PF in the spring/summer/monsoon season; no overall patterns of association were evident in the autumn/winter season. Associations between greenspace and personal PM_2.5 during walking trips in Delhi varied across metrics, spatial scales, and season, but were most consistent for TC. These mixed findings may partly relate to journeys being dominated by walking along roads and small effects on PM_2.5 of small pockets of greenspace. Larger areas of greenspace may, however, give rise to observable spatial effects on PM_2.5, which vary by season.

Exposure to urban greenspace and pathways to respiratory health: An exploratory systematic review

BACKGROUND/OBJECTIVE

Urban greenspace may have a beneficial or adverse effect on respiratory health. Our objective was to perform an exploratory systematic review to synthesise the evidence and identify the potential causal pathways relating urban greenspace and respiratory health.

METHODS

We followed PRISMA guidelines on systematic reviews and searched five databases for eligible studies during 2000-2021. We incorporated a broad range of urban greenspace and respiratory health search terms, including both observational and experimental studies. Screening, data extraction, and risk of bias, assessed using the Navigation Guide criteria, were performed independently by two authors. We performed a narrative synthesis and discuss suggested pathways to respiratory health.

RESULTS

We identified 108 eligible papers (n = 104 observational, n = 4 experimental). The most common greenspace indicators were the overall greenery or vegetation (also known as greenness), green land use/land cover of physical area classes (e.g., parks, forests), and tree canopy cover. A wide range of respiratory health indicators were studied, with asthma prevalence being the most common. Two thirds (n = 195) of the associations in these studies were positive (i.e., beneficial) with health, with 31% (n = 91) statistically significant; only 9% (n = 25) of reported associations were negative (i.e., adverse) with health and statistically significant. The most consistent positive evidence was apparent for respiratory mortality. There were n = 35 (32%) 'probably low' and n = 73 (68%) 'probably high' overall ratings of bias. Hypothesised causal pathways for health benefits included lower air pollution, more physically active populations, and exposure to microbial diversity; suggested mechanisms with poorer health included exposure to pollen and other aeroallergens.

CONCLUSION

Many studies showed positive association between urban greenspace and respiratory health, especially lower respiratory mortality; this is suggestive, but not conclusive, of causal effects. Results underscore the importance of contextual factors, greenspace metric employed, and the potential bias of subtle selection factors, which should be explored further.

Cardiac resynchronization therapy: long-term impact of echocardiographic non-progression

Funding Acknowledgements

Type of funding sources: None.

Background

As heart failure (HF) is a progressive disease, there has been a raising idea that considering the absence of echocardiographic improvement as non-response to cardiac resynchronization therapy (CRT) may not be appropriate. In fact, in some classical echocardiographic non-responders, CRT might have prevented HF deterioration.

Purpose

Our aim was to compare the composite outcome of death and re-admissions due to HF according to a new classification of CRT response: responders, non-progressors and progressors.

Methods

We included 144 consecutive patients with HF, left ventricle (LV) ejection fraction < 40% and QRS duration > 120mseg submitted to CRT implantation. Patients were divided into 3 groups according to the variation of LV end-systolic volume (LVESV) at 6-month: ≥15% reduction in LVESV - responders (R); 0–15% reduction in LVESV – non-progressors (NPr); increase in LVESV – progressors (Pr). A long-term follow-up (4.9 ± 2.9 years) was performed targeting mortality and re-admissions due to HF.

Results

In our population, 78 patients (54.2%) were classified as R, 21 (14.5%) as NPr and 45 (31.3%) as Pr. Baseline comparison between groups is presented in table 1. Compared with R, N-Pr had ischemic aetiology more frequently. The prescription of digoxin was more common in Pr. The Kaplan-Meier curves (figure 1) demonstrate that the composite outcome of death and re-admission due to HF had a lower incidence in R, but was similar between N-Pr and Pr. After adjustment of possible confounders (ischemic aetiology and digoxin use), the type of response to CRT remained as the only predictor of outcomes (OR 0.61; CI 0.41-0.90). 144

Conclusion

In our population, patients without progression of HF had a similarly negative prognosis to the ones that deteriorated. Hence, positive LV remodelling, and not only stabilization seems to be necessary to improve long-term prognosis.

The CUSSH programme: supporting cities' transformational change towards health and sustainability

This paper describes a global research programme on the complex systemic connections between urban development and health. Through transdisciplinary methods the Complex Urban Systems for Sustainability and Health (CUSSH) project will develop critical evidence on how to achieve the far-reaching transformation of cities needed to address vital environmental imperatives for planetary health in the 21st Century. CUSSH’s core components include: (i) a review of evidence on the effects of climate actions (both mitigation and adaptation) and factors influencing their implementation in urban settings; (ii) the development and application of methods for tracking the progress of cities towards sustainability and health goals; (iii) the development and application of models to assess the impact on population health, health inequalities, socio-economic development and environmental parameters of urban development strategies, in order to support policy decisions; (iv) iterative in-depth engagements with stakeholders in partner cities in low-, middle- and high-income settings, using systems-based participatory methods, to test and support the implementation of the transformative changes needed to meet local and global health and sustainability objectives; (v) a programme of public engagement and capacity building. Through these steps, the programme will provide transferable evidence on how to accelerate actions essential to achieving population-level health and global climate goals through, amongst others, changing cities’ energy provision, transport infrastructure, green infrastructure, air quality, waste management and housing.

A pacemaker pocket mass has many faces

The development of malignant neoplasms over the site of pacemaker implantation is a rare event, with a limited number of published case reports. We report the case of a 78-year-old male who presented with discomfort and pocket mass expansion, reportedly following trauma. Due to initial presumption of a simple hematoma, dissection and drainage were performed without tissue collection for histology. Later presentation with an exophytic ulcerated mass led to biopsy and identification of a lymphoplasmacytic lymphoma. To the best of our knowledge this is the first reported case of a cutaneous lymphoplasmacytic lymphoma presenting as a pacemaker pocket mass, and underlines the importance of systematic pacemaker inspection, of adequate histological characterization and of a high degree of clinical suspicion for the identification malignancy in this context. <Learning objective: We report the first case of a lymphoplasmacytic lymphoma presenting primarily as a pacemaker pocket mass. Lymphoplasmacytic lymphoma is a rare and indolent subtype of Non-Hodgkin lymphoma that may present with cutaneous manifestations. Due to the extreme rarity of malignant neoplasms presenting as pacemaker pocket masses, a high degree is clinical suspicion is required, and tissue histology plays a key role in the diagnosis.>.

Estimating pVO2 and prognosis through cardiac exercise stress test in a heart failure population

Background

Compared with the cardiac exercise stress test, more commonly used to assess the presence of ischemia, the cardiopulmonary exercise test has the advantage of providing expired gas analysis. According to current guidelines, cardiopulmonary exercise testing should be considered to stratify the risk of adverse events and to provide measures of survival improvement in heart failure populations. However, cardiac exercise stress test is more readily available and widespread than cardiopulmonary exercise testing. We aimed to compare prognostic information given by estimated pVO2 – which can be obtained from cardiac exercise stress test – and real measured pVO2 – which requires cardiopulmonary exercise test – in a heart failure population.

Methods

We conducted a retrospective analysis of 214 patients with HF underwent cardiac exercise stress test and accessed their 5 year survival. Non-urgent transplanted (UNOS Status 2) patients were censored alive on the date of the transplant. Duringthe cardiopulmonary exercise test, cardiac exercise stress test data simultaneously collected. Based on protocol stage achieved, estimated METs were used to calculate estimated pVO2 (pVO2 = estimated METs x 3.5). Estimated and real pVO2 were correlated using Pearson correlation and the age-adjusted prognostic power of each was determined using Cox proportional hazardsanalysis.

Results

164 patients were male (77%) and the mean age of the population was 56±10 years. 78 (36%) patients had an ischemic etiology. Within 5 years from testing, 46 patients died (21.5%) and 55 patients (26%) were transplanted. Naughton modified (n=165) was the most commonly used protocol, followed by Naughton (n=39) and Bruce (n=10). Estimated pVO2 and measured pVO2 correlated significantly (R=0.66, p&lt;0.01) (Figure 1). Both estimated (HR=0.91, 95% CI 0.86–0.95, p&lt;0.01) and measured pVO2 (HR=0.86, 95% CI 0.80–0.91, p&lt;0.01) strongly predicted prognosis in this population.

Conclusions

Estimated pVO2 correlated with measured pVO2 and strongly predicted prognosis in this heart failure population. Because it can be obtained from conventional cardiac exercise testing, it may become an alternative prognostic tool to cardiopulmonary testing.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Measured vs estimated pVO2

Cardiopulmonary exercise testing; do circulatory and ventilatory power predict cardiovascular outcomes in patients with heart failure

Background

Cardiopulmonary exercise testing (CPET) has an important role in mortality prediction in heart failure (HF) and patient selection for heart transplant. New indices as circulatory power (CP) and ventilatory power (VP) have been proposed as predictors of cardiac events. In addition, VP predicts mean pulmonary artery pressure (mPAP) in patients with pulmonary arterial hypertension.

Purpose

We aimed to analyse the prognostic value of classic and new CPET variables in patients with HF.

Methods

We retrospectively assessed consecutive patients with HF who underwent CPET in a single-centre between 2013 and 2017. New CPET variables were collected: CP was defined as the product of peak O2 uptake and peak systolic blood pressure (SBP), while VP was defined as peak SBP divided by the minute ventilation–CO2 production (VE/VCO2) slope. The primary endpoint was a composite of all-cause mortality, heart transplant, or HF hospitalization. Survival analysis was performed using Kaplan-Meier curves and multivariable Cox regression.

Results

Overall, 216 patients (mean age 55.4±10.9, 77.3% male) were included, 38.4% with ischemic HF, and mean left ventricle ejection fraction (LVEF) 30±14%. Most patients were evaluated through the modified Naughton (76.3%), the original Naughton (19.0%), and Bruce protocols (4.7%). Regarding classic CPET variables: mean pVO2 16.8±6.0 mL O2 kg–1 min–1, mean percent-predicted pVO2 62.6±23.9%, median VE/VCO2 slope 37.3 [32.6–44.5], exercise oscillatory ventilation (EOV) present in 13.9%, resting partial pressure of end-tidal carbon dioxide (PETCO2) ≥33 mmHg with an increase of 3–8 mmhg during exercise in 17.1%, and mean peak SBP 128.8±27.2 mmHg. Median circulatory power was 1927 [1404–2694] mmHg·min/mL/kg and mean ventilatory power 3.47±1.32 mmHg. After a median follow-up of 5 [4–6] years, the primary endpoint occurred in 66.2% of patients (rehospitalization, heart transplant, and all-cause death occurred in 57.0%, 25.9%, and 32.4%, respectively). In Cox regression multivariate analysis, the primary endpoint was predicted by pVO2 (HR 0.90, 95% CI: 0.87–0.93), percent-predicted pVO2 (HR 0.97, 95% CI: 0.96–0.98), VE/VCO2 slope (HR 1.04, 95% CI: 1.03–1.06), VP (HR 0.62, 95% CI: 0.52–0.73) but not CP (HR 0.99, 95% CI: 0.98–1.01). Kaplan-Meier curves according to the LVEF are depicted in Fig. 1A. ROC analysis (Fig. 1B) revealed that VP (AUC 0.768) has higher discriminative power for the primary endpoint, compared to pVO2 (AUC 0.741). One hundred and twenty-seven patients also underwent right heart catheterization: mean mPAP was 30.6±12.9 and it was not correlated with VP (r=−0.06, p=0.47).

Conclusion

CPET variables are good predictors of all-cause mortality, heart transplant, or HF hospitalization. Ventilatory power (but not circulatory power) is an additional useful variable in event prediction. On the other hand, VP is not correlated with mPAP in patients with HF.

Funding Acknowledgement

Type of funding sources: None.

Relationship-building around a policy decision-support tool for urban health

Contemporary challenges linked to public health and climate change demand more effective decision-making and urban planning practices, in particular by taking greater account of evidence. In order to do this, trust-building relationships between scientists and urban practitioners through collaborative research programmes is required. Based on a policy-relevant research project, Complex Urban Systems for Sustainability and Health (CUSSH), this project aims to support the transformation of cities to meet environmental imperatives and to improve health with a quantitative health impact assessment. A case study in Rennes, France, focuses on the role of a policy decision-support tool in the production and use of knowledge to support evidence-informed decision-making. Although the primary objective of informing decision-making through evidence-based science is not fulfilled, the use of a decision-making support tool can lay the foundations for relationship-building. It can serve as a support for boundary-spanning activities, which are recognised for their effectiveness in linking science to action. This case study illustrates that the path of knowledge transfer from science to policy can be challenging, and the usefulness of using models may not be where it was thought to have been.

Pathways to "5-a-day": modeling the health impacts and environmental footprints of meeting the target for fruit and vegetable intake in the United Kingdom

BACKGROUND

Fruit and vegetable consumption in the United Kingdom is currently well below recommended levels, with a significant associated public health burden. The United Kingdom has committed to reducing its carbon emissions to net zero by 2050, and this transition will require shifts towards plant-based diets.

OBJECTIVE

The aim was to quantify the health effects, environmental footprints, and cost associated with 4 different pathways to meeting the United Kingdom's "5-a-day" recommendation for fruit and vegetable consumption.

METHODS

Dietary data based on 18,006 food diaries from 4528 individuals participating in the UK National Diet and Nutrition Survey (2012/13-2016/17) constituted the baseline diet. Linear programming was used to model the hypothetical adoption of the 5-a-day (400 g) recommendation, which was assessed according to 4 pathways differing in their prioritization of fruits versus vegetables and UK-produced versus imported varieties. Increases in fruit and vegetable consumption were substituted for consumption of sweet snacks and meat, respectively. Changes in life expectancy were assessed using the IOMLIFET life table model. Greenhouse gas emissions (GHGEs), blue water footprint (WF), and total diet cost were quantified for each 5-a-day diet.

RESULTS

Achieving the 5-a-day target in the United Kingdom could increase average life expectancy at birth by 7-8 mo and reduce diet-related GHGEs by 6.1 to 12.2 Mt carbon dioxide equivalents/y; blue WFs would change by -0.14 to +0.07 km3/y. Greater reductions in GHGEs were achieved by prioritizing increased vegetable consumption over fruit, whereas the greatest reduction in WF was obtained by prioritizing vegetable varieties produced in the United Kingdom. All consumption pathways increased diet cost (£0.34-£0.46/d).

CONCLUSIONS

Benefits to both population and environmental health could be expected from consumption pathways that meet the United Kingdom's 5-a-day target for fruit and vegetables. Our analysis identifies cross-sectoral trade-offs and opportunities for national policy to promote fruit and vegetable consumption in the United Kingdom.

A system dynamics-based scenario analysis of residential solid waste management in Kisumu, Kenya

The problem of solid waste management presents an issue of increasing importance in many low-income settings, including the progressively urbanised context of Kenya. Kisumu County is one such setting with an estimated 500 t of waste generated per day and with less than half of it regularly collected. The open burning and natural decay of solid waste is an important source of greenhouse gas (GHG) emissions and atmospheric pollutants with adverse health consequences. In this paper, we use system dynamics modelling to investigate the expected impact on GHG and PM_2.5 emissions of (i) a waste-to-biogas initiative and (ii) a regulatory ban on the open burning of waste in landfill. We use life tables to estimate the impact on mortality of the reduction in PM_2.5 exposure. Our results indicate that combining these two interventions can generate over 1.1 million tonnes of cumulative savings in GHG emissions by 2035, of which the largest contribution (42%) results from the biogas produced replacing unclean fuels in household cooking. Combining the two interventions is expected to reduce PM_2.5 emissions from the waste and residential sectors by over 30% compared to our baseline scenario by 2035, resulting in at least around 1150 cumulative life years saved over 2021–2035. The contribution and novelty of this study lies in the quantification of a potential waste-to-biogas scenario and its environmental and health impact in Kisumu for the first time.

•

We present a system dynamics study of solid waste management in Kisumu, Kenya.

•

Scenarios involve a waste-to-biogas initiative and a ban on open burning in landfill.

•

Combined scenario generates 1.1m tonnes cumulative GHG savings by 2035.

•

Largest contribution (42%) is from biogas substituting traditional cooking fuels.

•

Combined scenario may save 1,150 cumulative life years by 2035, plus ~220 more p.a.

Potential health impact of increasing adoption of sustainable dietary practices in Sweden

BACKGROUND

An urgent transition to more sustainable diets is necessary for the improvement of human and planetary health. One way to achieve this is for sustainable practices to become mainstream. We estimated the potential health impact of wider adoption of dietary practices deemed by consumers, researchers and stakeholders in Sweden to be niche, sustainable and with the potential to be scaled up.

METHODS

A life table method was used to estimate the impact - changes in years of life lost (YLL) - over periods of 20 and 30 years in the Swedish population had the practices been adopted in 2010-11, when the last national adult dietary survey was conducted. The practices modelled were reducing red and processed meat (by 25, 50 and 100%), and assuming, for each stage, replacement by an equal weight of poultry/fish and vegetables +/- legumes; reducing milk intake (by 25, 50 and 100%); and reducing sugar-sweetened beverage intake (by 25, 50 and 100%). Using population data together with data on cause-specific mortality and relative risks for diet-disease outcomes, impacts were estimated for each scenario separately and in combination, for the outcomes ischaemic heart disease (IHD), ischaemic stroke, diabetes type 2 and colorectal cancer.

RESULTS

For a "moderate" combination of scenarios (changes at the 50% level), reductions of 513,200 YLL (lower-upper uncertainty estimate 59,400-797,900) could have been achieved over 20 years and 1,148,500 YLL (135,900-1,786,600) over 30 years. The majority (over 90%) of YLLs prevented were related to IHD, and the majority were in men. The singular practice that had the most impact was reducing the intake of red and processed meat and replacing it with a mixture of vegetables and legumes. Reducing milk intake resulted in an increase in YLL, but this was compensated for by other scenarios.

CONCLUSION

If these practices were more widely adopted, they would be expected to lead to improvements in public health in Sweden. Over the long term, this would translate to many premature deaths postponed or prevented from a number of chronic diseases, to the benefit of individuals, society, the climate and the economy.

Impact of SARS-CoV-2 pandemic on ST-elevation myocardial infarction admissions and outcomes in a Portuguese primary percutaneous coronary intervention center: Preliminary Data

INTRODUCTION

Coronavirus disease (COVID-19) has led to significant changes in healthcare systems and its impact on the treatment of cardiovascular conditions, such as ST-elevation myocardial infarction (STEMI), is unknown in countries where the healthcare systems were not saturated, as was the case in Portugal. As such, we aimed to assess the effect on STEMI admissions and outcomes in Portuguese centers.

METHODS

We conducted a single-center, observational, retrospective study including all patients admitted to our hospital due to STEMI between the date of the first SARS-CoV-2 case diagnosed in Portugal and the end of the state of emergency (March and April 2020). Patient characteristics and outcomes were assessed and compared with the same period of 2019.

RESULTS

A total of 104 STEMI patients were assessed, 55 in 2019 and 49 in 2020 (-11%). There were no significant differences between groups regarding age (62±12 vs. 65±14 years, p=0.308), gender (84.8% vs. 77.6% males, p=0.295) or comorbidities. In the 2020 group, there was a significant decrease in the proportion of patients transported to the hospital in pre-hospital emergency medical transportation (38.2% vs. 20.4%, p=0.038), an increase in system delay (49 [30-110.25] vs. 140 [90-180] minutes, p=0.019), a higher Killip-Kimball class, with a decrease in class I (74.5% vs. 51%) and an increase in class III (1.8% vs. 8.2%) and IV (5.5% vs. 18.4%) (p=0.038), a greater incidence of vasoactive support (3.7% vs. 26.5%, p=0.001), invasive mechanic ventilation usage (3.6% vs. 14.3%, p=0.056), and an increase in severe left ventricular dysfunction at hospital discharge (3.6% vs. 16.3%, p=0.03). In-hospital mortality was 14.3% in the 2020 group and 7.3% in the 2019 group p=0.200).

CONCLUSION

Despite a lack of significant variation in the absolute number of STEMI admissions, there was an increase in STEMI clinical severity and significantly worse outcomes during the SARS-CoV-2 pandemic. An increase in system delay, impaired pre-hospital care and patient fear of in-hospital infection can partially justify these results and should be the target of future actions in further waves of the pandemic.

Impact of SARS-CoV-2 pandemic on ST-elevation myocardial infarction admissions and outcomes in a Portuguese primary percutaneous coronary intervention center: Preliminary Data

INTRODUCTION

Coronavirus disease (COVID-19) has led to significant changes in healthcare systems and its impact on the treatment of cardiovascular conditions, such as ST-elevation myocardial infarction (STEMI), is unknown in countries where the healthcare systems were not saturated, as was the case in Portugal. As such, we aimed to assess the effect on STEMI admissions and outcomes in Portuguese centers.

METHODS

We conducted a single-center, observational, retrospective study including all patients admitted to our hospital due to STEMI between the date of the first SARS-CoV-2 case diagnosed in Portugal and the end of the state of emergency (March and April 2020). Patient characteristics and outcomes were assessed and compared with the same period of 2019.

RESULTS

A total of 104 STEMI patients were assessed, 55 in 2019 and 49 in 2020 (-11%). There were no significant differences between groups regarding age (62±12 vs. 65±14 years, p=0.308), gender (84.8% vs. 77.6% males, p=0.295) or comorbidities. In the 2020 group, there was a significant decrease in the proportion of patients transported to the hospital in pre-hospital emergency medical transportation (38.2% vs. 20.4%, p=0.038), an increase in system delay (49 [30-110.25] vs. 140 [90-180] minutes, p=0.019), a higher Killip-Kimball class, with a decrease in class I (74.5% vs. 51%) and an increase in class III (1.8% vs. 8.2%) and IV (5.5% vs. 18.4%) (p=0.038), a greater incidence of vasoactive support (3.7% vs. 26.5%, p=0.001), invasive mechanic ventilation usage (3.6% vs. 14.3%, p=0.056), and an increase in severe left ventricular dysfunction at hospital discharge (3.6% vs. 16.3%, p=0.03). In-hospital mortality was 14.3% in the 2020 group and 7.3% in the 2019 group p=0.200).

CONCLUSION

Despite a lack of significant variation in the absolute number of STEMI admissions, there was an increase in STEMI clinical severity and significantly worse outcomes during the SARS-CoV-2 pandemic. An increase in system delay, impaired pre-hospital care and patient fear of in-hospital infection can partially justify these results and should be the target of future actions in further waves of the pandemic.

Building a Methodological Foundation for Impactful Urban Planetary Health Science

Anthropogenic environmental change will heavily impact cities, yet associated health risks will depend significantly on decisions made by urban leaders across a wide range of non-health sectors, including transport, energy, housing, basic urban services, and others. A subset of planetary health researchers focus on understanding the urban health impacts of global environmental change, and how these vary globally and within cities. Such researchers increasingly adopt collaborative transdisciplinary approaches to engage policy-makers, private citizens, and other actors in identifying and evaluating potential policy solutions that will reduce environmental impacts in ways that simultaneously promote health, equity, and/or local economies-in other words, maximising 'co-benefits'. This report presents observations from a participatory workshop focused on challenges and opportunities for urban planetary health research. The workshop, held at the 16th International Conference on Urban Health (ICUH) in Xiamen, China, in November 2019, brought together 49 participants and covered topics related to collaboration, data, and research impact. It featured research projects funded by the Wellcome Trust's Our Planet Our Health (OPOH) programme. This report aims to concisely summarise and disseminate participants' collective contributions to current methodological practice in urban planetary health research.

A tool for assessing the climate change mitigation and health impacts of environmental policies: the Cities Rapid Assessment Framework for Transformation (CRAFT)

Background: A growing number of cities, including Greater London, have set ambitious targets, including detailed policies and implementation plans, to reach global goals on sustainability, health, and climate change. Here we present a tool for a rapid assessment of the magnitude of impact of specific policy initiatives to reach these targets. The decision-support tool simultaneously quantifies the environmental and health impacts of specified selected policies. Methods: The 'Cities Rapid Assessment Framework for Transformation (CRAFT)' tool was applied to Greater London. CRAFT quantifies the effects of ten environmental policies on changes in (1) greenhouse gas (GHG) emissions, (2) exposures to environmental hazards, (3) travel-related physical activity, and (4) mortality (the number of attributable deaths avoided in one typical year). Publicly available data and epidemiological evidence were used to make rapid quantitative estimates of these effects based on proportional reductions in GHG emissions and environmental exposures from current baseline levels and to compute the mortality impacts. Results: The CRAFT tool estimates that, of roughly 50,000 annual deaths in Greater London, the modelled hazards (PM 2.5 (from indoor and outdoor sources), outdoor NO 2, indoor radon, cold, overheating) and low travel-related physical activity are responsible for approximately 10,000 premature environment-related deaths. Implementing the selected polices could reduce the annual mortality number by about 20% (~1,900 deaths) by 2050. The majority of these deaths (1,700) may be avoided through increased uptake in active travel. Thus, out of ten environmental policies, the 'active travel' policy provides the greatest health benefit. Also, implementing the ten policies results in a GHG reduction of around 90%. Conclusions: The CRAFT tool quantifies the effects of city policies on reducing GHG emissions, decreasing environmental health hazards, and improving public health. The tool has potential value for policy makers through providing quantitative estimates of health impacts to support and prioritise policy options.

Do not underestimate the blood urea nitrogen-to-creatinine ratio in heart failure

Funding Acknowledgements

Type of funding sources: None.

Introduction

The blood urea nitrogen-to-creatinine ratio (BUN/SCr) has been proposed as a prognostic marker in heart failure (HF). We aimed to evaluate whether BUN/SCr predicts mortality outcomes in a real-world Southern European population with decompensated chronic HF.

Methods

We retrospectively studied 1057 patients with chronic HF admitted to our emergency department between November 2016 and December 2017 with acute decompensation. We excluded patients with a GFR &lt;15mL/min/m2 or on dialysis. The incidence of cardiovascular (CV) and all-cause death was evaluated through multivariable logistic regression models and by Kaplan-Meyer survival curves.

Results

1025 patients were included, median age 80 years (IQR 73-85), 52.4% male, mean LVEF 42.8 ± 12.7%, and mean GFR 57.2 ± 23.9 mL/min/m2. Mean BUN/SCr was 24.9 ± 8.2 and mean SBP was 139 ± 29mmHg (r=-0.17, p &lt; 0.001). After a median follow-up of 5 months (IQR 3-11 months), CV and all-cause death occurred in 8.0% and 21.6%, respectively. Mean BUN/SCr was higher in patients with fatal outcomes both for CV (31.3 vs. 24.3, p &lt; 0.001) and all-cause death (28.6 vs. 23.8, p &lt; 0.001). BUN/Scr was grouped by terciles: T1 (&lt;20.78), T2 (20.78-27.15), T3 (&gt;27.15). In the T3 group, the multivariable-adjusted  OR for CV and all-cause death was 5.43 (95% CI 2.20-13.37) and 2.72 (95% CI 1.66-4.46), respectively, compared to the T1 group. No significant differences between T1 and T2 groups.

Conclusions

BUN/SCr at admission predicts CV and all-cause death in patients with chronic HF after an episode of decompensation. BUN/SCr, as an easy-to-use tool, helps to identify those patients who benefit from tight monitoring both during hospitalization and after discharge.

Abstract Figure_1

Does lipoprotein(a) predict cardiovascular events in a long-term follow-up?

Funding Acknowledgements

Type of funding sources: None.

Background

Elevated plasma lipoprotein(a) [Lp(a)] concentrations are associated with an increased risk of atherosclerotic cardiovascular disease and its role in risk categorizing was recognized in the new ESC guidelines for the management of dyslipidaemias. We investigated 1) the association between baseline Lp(a) levels and incident long-term cardiovascular (CV) events and 2) its relationship with type 2 diabetes mellitus (T2DM) in a Southern European population.

Methods

We retrospectively assessed baseline Lp(a) concentrations in a total of 499 patients of a primary prevention cohort followed at the Lipidology Clinic of our hospital, with a median follow-up time of 15 (IQR 12-17) years. Lp(a) was analysed as a continuous variable, as a categorical variable with a 180mg/dL cut-off and by quartiles. We collected data on major CV events (CV death, myocardial infarction, stroke) as a composite outcome. Cox proportional hazard regression analyses were used to estimate hazard ratios (HR) and 95% confidence interval (CI).

Results

Mean age was 48.30 ± 14.41 years and 61.70% were male (n = 499). Median Lp(a) was 36.60 (IQR 0-396) mg/dL and 12.4% of patients had very high Lp(a) (≥180mg/dL); T2DM prevalence was 13.60%. The composite outcome incidence was 10%. At the baseline, individuals with T2DM had lower Lp(a) levels (11.85 IQR 3-330 mg/dL vs. 46.40 IQR 0-396, p &lt; 0.01 mg/dL). There was a moderate inverse correlation between Lp(a) and HbA1c (r = -0.67, p &lt; 0.01) but no significant correlations with lipid profile (total, LDL or HDL), risk scores (SCORE or the ACC pooled cohort equation), age nor gender. We found no relationship between baseline Lp(a) quartiles and composite outcome’s incidence (age-, sex-, and diabetes-adjusted HR: 1.15, 95%CI: 0.71-1.87, p = 0.57) (Figure 1), neither with the individual CV endpoints. Exploratory analysis showed that patients on aspirin had lower Lp(a) levels (29.55 IQR 0-264 mg/dL vs. 63.60 IQR 1-396 mg/dL, p &lt; 0.01).

Conclusion

In a single centre cohort of a primary prevention southern European population, we did not find an association between Lp(a) levels and incident CV events in a 15-year median follow-up time.

Myocardial infarction in young adults: are the risk profile and mortality outcomes different from older patients?

Funding Acknowledgements

Type of funding sources: None.

Introduction

The incidence of acute myocardial infarction (AMI) among young patients is increasing. The YOUNG-MI Registry reported that those under 40 years had similar risk profiles and outcomes compared to those aged 41 to 50. We aimed to evaluate cardiovascular risk factors and mortality outcomes in two age cohorts from southern European.

Methods

We retrospectively evaluated 4758 patients admitted to our coronary intensive care unit between 2004 and 2017 with AMI. We only included patients &lt;60 years in two subgroups: cohort A &lt; 50 years and cohort B 50-60 years. 

Results

From the 1233 patients included (mean age 50.5 ± 6.5 years, 82.2% male), 53% had STEMI. Cohort B had higher rates of hypertension (59.8 vs. 42.9%, p &lt; 0.001), diabetes (41.8 vs. 28.9%, p &lt; 0.001), and dyslipidemia (59.4 vs. 46.4%, p &lt; 0.001), while cohort A had higher rates of familial premature coronary artery disease (20.9 vs. 13.2%, p &lt; 0.001) and smoking habits (54.4 vs. 40.0%, p &lt; 0.001). Regarding coronary angiography, cohort B had higher rates of obstructive disease in each epicardial artery, except for left main involvement and non-obstructive disease (Fig. 1). Cohort A had lower all-cause mortality rates at the index hospitalization (1.3 vs. 3.2%, p = 0.045), 6-months (2.9 vs.5.4, p = 0.038), 1-year (3.1 vs. 6.3%, p = 0.014), and 3-years (3.6 vs 8.4, p = 0.001). After multivariable adjustment, we found no relationship between age cohorts and all-cause mortality for any follow-up timing: HR 1.57 (95% CI 0.56-4.37), 1.37 (95% CI 0.50-3.74), and 0.92 (95% CI 0.35-2.39) at 6-months, 1-year, and 3-years, respectively.

Conclusion

Among patients who suffer AMI, those under 50 years old have a different risk profile, compared to the 50-60 years cohort. However, there is no significant difference in all-cause mortality.

Abstract Figure.

The CUSSH programme: learning how to support cities’ transformational change towards health and sustainability

The Complex Urban Systems for Sustainability and Health (CUSSH) project is a global research programme on the complex systemic connections between urban development and health. Through transdisciplinary methods it will develop critical evidence on how to achieve the far-reaching transformation of cities needed to address vital environmental imperatives for planetary health in the 21st century. CUSSH’s core components include: (i) a review of evidence on the effects of climate actions (both mitigation and adaptation) and factors influencing their implementation in urban settings; (ii) the development and application of methods for tracking the progress of cities towards sustainability and health goals; (iii) the development and application of models to assess the impact on population health, health inequalities, socio-economic development and environmental parameters of urban development strategies, in order to support policy decisions; (iv) iterative in-depth engagements with stakeholders in partner cities in low-, middle- and high-income settings, using systems-based participatory methods, to test and support the implementation of the transformative changes needed to meet local and global health and sustainability objectives; (v) a programme of public engagement and capacity building. Through these steps, the programme will provide transferable evidence on how to accelerate actions essential to achieving population-level health and global climate goals through, amongst others, changing cities’ energy provision, transport infrastructure, green infrastructure, air quality, waste management and housing.

Climate action for health and wellbeing in cities: a protocol for the systematic development of a database of peer-reviewed studies using machine learning methods

Cities produce more than 70% of global greenhouse gas emissions. Action by cities is therefore crucial for climate change mitigation as well as for safeguarding the health and wellbeing of their populations under climate change. Many city governments have made ambitious commitments to climate change mitigation and adaptation and implemented a range of actions to address them. However, a systematic record and synthesis of the findings of evaluations of the effect of such actions on human health and wellbeing is currently lacking. This, in turn, impedes the development of robust knowledge on what constitutes high-impact climate actions of benefit to human health and wellbeing, which can inform future action plans, their implementation and scale-up. The development of a systematic record of studies reporting climate and health actions in cities is made challenging by the broad landscape of relevant literature scattered across many disciplines and sectors, which is challenging to effectively consolidate using traditional literature review methods. This protocol reports an innovative approach for the systematic development of a database of studies of climate change mitigation and adaptation actions implemented in cities, and their benefits (or disbenefits) for human health and wellbeing, derived from peer-reviewed academic literature. Our approach draws on extensive tailored search strategies and machine learning methods for article classification and tagging to generate a database for subsequent systematic reviews addressing questions of importance to urban decision-makers on climate actions in cities for human health and wellbeing.

Neighbourhood and path-based greenspace in three European countries: associations with objective physical activity

Background

Greenspace has been associated with health benefits in many contexts. An important pathway may be through outdoor physical activity. We use a novel approach to examine the link between greenspace microenvironments and outdoor physical activity levels in the HEALS study conducted in Edinburgh (UK), the Netherlands, and Athens and Thessaloniki (Greece).

Methods

Using physical activity tracker recordings, 118 HEALS participants with young children were classified with regard to daily minutes of moderate to vigorous physical activity (MVPA); 60 were classified with regard to the metabolic equivalent task (MET)-minutes for each of the 1014 active trips they made. Greenspace indicators were generated for Normalised Difference Vegetation Index (NDVI), tree cover density (TCD), and green land use (GLU). We employed linear mixed-effects models to analyse (1) daily MVPA in relation to greenspace within 300 m and 1000 m of residential addresses and (2) trip MET-minutes in relation to average greenspace within a 50 m buffer of walking/cycling routes. Models were adjusted for activity, walkability, bluespace, age, sex, car ownership, dog ownership, season, weekday/weekend day, and local meteorology.

Results

There was no clear association between MVPA-minutes and any residential greenspace measure. For example, in fully adjusted models, a 10 percentage point increase in NDVI within 300 m of home was associated with a daily increase of 1.14 (95% CI − 0.41 to 2.70) minutes of MVPA. However, we did find evidence to indicate greenspace markers were positively linked to intensity and duration of activity: in fully adjusted models, 10 percentage point increases in trip NDVI, TCD, and GLU were associated with increases of 10.4 (95% CI: 4.43 to 16.4), 10.6 (95% CI: 4.96 to 16.3), and 3.36 (95% CI: 0.00 to 6.72) MET-minutes, respectively. The magnitude of associations with greenspace tended to be greater for cycling.

Conclusions

More strenuous or longer walking and cycling trips occurred in environments with more greenspace, but levels of residential greenspace did not have a clear link with outdoor MVPA. To build on our research, we suggest future work examine larger, more diverse populations and investigate the influence of greenspace for trip purpose and route preference.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10259-0.

The public health implications of the Paris Agreement: a modelling study

BACKGROUND

nationally determined contributions (NDCs) serve to meet the goals of the Paris Agreement of staying "well below 2°C", which could also yield substantial health co-benefits in the process. However, existing NDC commitments are inadequate to achieve this goal. Placing health as a key focus of the NDCs could present an opportunity to increase ambition and realise health co-benefits. We modelled scenarios to analyse the health co-benefits of NDCs for the year 2040 for nine representative countries (ie, Brazil, China, Germany, India, Indonesia, Nigeria, South Africa, the UK, and the USA) that were selected for their contribution to global greenhouse gas emissions and their global or regional influence.

METHODS

Modelling the energy, food and agriculture, and transport sectors, and mortality related to risk factors of air pollution, diet, and physical activity, we analysed the health co-benefits of existing NDCs and related policies (ie, the current pathways scenario) for 2040 in nine countries around the world. We compared these health co-benefits with two alternative scenarios, one consistent with the goal of the Paris Agreement and the Sustainable Development Goals (ie, the sustainable pathways scenario), and one in line with the sustainable pathways scenario, but also placing health as a central focus of the policies (ie, the health in all climate policies scenario).

FINDINGS

Compared with the current pathways scenario, the sustainable pathways scenario resulted in an annual reduction of 1·18 million air pollution-related deaths, 5·86 million diet-related deaths, and 1·15 million deaths due to physical inactivity, across the nine countries, by 2040. Adopting the more ambitious health in all climate policies scenario would result in a further reduction of 462 000 annual deaths attributable to air pollution, 572 000 annual deaths attributable to diet, and 943 000 annual deaths attributable to physical inactivity. These benefits were attributable to the mitigation of direct greenhouse gas emissions and the commensurate actions that reduce exposure to harmful pollutants, as well as improved diets and safe physical activity.

INTERPRETATION

A greater consideration of health in the NDCs and climate change mitigation policies has the potential to yield considerable health benefits as well as achieve the "well below 2°C" commitment across a range of regional and economic contexts.

FUNDING

This work was in part funded through an unrestricted grant from the Wellcome Trust (award number 209734/Z/17/Z) and supported by an Engineering and Physical Sciences Research Council grant (grant number EP/R035288/1).

The 2020 report of The Lancet Countdown on health and climate change: responding to converging crises

For the Chinese, French, German, and Spanish translations of the abstract see Supplementary Materials section.

Telehealth Opportunities in the COVID-19 Pandemic Early Days: What Happened, Did Not Happen, Should Have Happened, and Must Happen in the Near Future?

The objective of this communication is to offer a better understanding of the value of telemedicine in health care, particularly its role in creating opportunities for continuity of care to patients in a complex and novel setting as were the circumstances of the early COVID-19 pandemic times. Crisis time is also a time for opportunities. With regard to telehealth, all players (providers, staff, and patients) should be informed about its benefits and should also become familiar with the use of the various telehealth options and this will only be achieved through large information campaigns necessary enriched by local teaching and training programs in both public and private institutions. The final aim is to launch the debate and foster ideas useful throughout the pandemic. This article covers the experiences of physicians as well as health professionals in the Iberian Peninsula (Spain and Portugal), to provide a clearer idea of what has happened and how we can improve it with the possibilities provided by telemedicine, while at the same time to put in evidence that public health systems need to be rethought to provide solutions to situations such as that we are experiencing.

A tool for assessing the climate change mitigation and health impacts of environmental policies: the Cities Rapid Assessment Framework for Transformation (CRAFT)

Background: A growing number of cities, including Greater London, have set ambitious targets, including detailed policies and implementation plans, to reach global goals on sustainability, health, and climate change. Here we present a tool for a rapid assessment of the magnitude of impact of specific policy initiatives to reach these targets. The decision-support tool simultaneously quantifies the environmental and health impacts of specified selected policies. Methods: The 'Cities Rapid Assessment Framework for Transformation (CRAFT)' tool was applied to Greater London. CRAFT quantifies the effects of ten environmental policies on changes in (1) greenhouse gas (GHG) emissions, (2) exposures to environmental hazards, (3) travel-related physical activity, and (4) mortality (the number of attributable deaths avoided in one typical year). Publicly available data and epidemiological evidence were used to make rapid quantitative estimates of these effects based on proportional reductions in GHG emissions and environmental exposures from current baseline levels and to compute the mortality impacts. Results: The CRAFT tool estimates that, of roughly 50,000 annual deaths in Greater London, the modelled hazards (PM 2.5 (from indoor and outdoor sources), outdoor NO 2, indoor radon, cold, overheating) and low travel-related physical activity are responsible for approximately 10,000 premature environment-related deaths. Implementing the selected polices could reduce the annual mortality number by about 20% (~1,900 deaths) by 2050. The majority of these deaths (1,700) may be avoided through increased uptake in active travel. Thus, out of ten environmental policies, the 'active travel' policy provides the greatest health benefit. Also, implementing the ten policies results in a GHG reduction of around 90%. Conclusions: The CRAFT tool quantifies the effects of city policies on reducing GHG emissions, decreasing environmental health hazards, and improving public health. The tool has potential value for policy makers through providing quantitative estimates of health impacts to support and prioritise policy options.

Inequalities after STEMI in National Health Service: is there really a postcode lottery?

Background and purpose

Failure to address the impact of social determinants of health attenuates efficacy of proven prevention recommendations, namely because important considerations related to socioeconomic disadvantage are not captured by existing cardiovascular disease (CDV) risk stratification methods. We aimed to assess how socioeconomic determinants influence recurrent MI and all-cause death after myocardial infarction (MI) in Portugal.

Methods

We conducted a retrospective, observational cohort study, including all patients with a ST-elevation MI (STEMI) admitted to and discharged alive from an intensive cardiac care unit between 2004 and 2017 (n=1809). The median (interquartile range) follow-up was 6 (4–9) years. We used survival models to assess the relationship between their municipal (i) income by purchasing power per capita (PPC), (ii) geographical accessibility to health care, (iii) illiteracy, iv) residential socioeconomic deprivation and recurrent MI and all-cause mortality. To assess residential socioeconomic deprivation, each individual's residential postcode was matched to the recently validated Portuguese version of European Deprivation Index (EDI). The index was categorized into quintiles (Q1-least deprived to Q5-most deprived).

Results

The mean age was 64±14 years; 74% were male. Regarding individual socioeconomic variables, PPC (HR 1.19; 95% CI 0.97–1.47 for Tertile 1 vs Tertile 2; HR 1.28; 95% CI 1.04–1.56 for Tertile 1 vs Tertile 3 and HR 1.07; 95% CI 0.85–1.34 for Tertile 2 vs Tertile 3) and medical appointments in primary health centers per inhabitant (HR 0.90; 95% CI 0.75–1.09 for Tertile 1 vs Tertile 2; HR 1.23; 95% CI 0.95–1.61 for Tertile 1 vs Tertile 3 and HR 1.37; 95% CI 1.06–1.76 for Tertile 2 vs Tertile 3) were predictors of all-cause mortality, but not recurrent MI; however, in multivariate analysis adjusted for sex, age and ejection fraction, this association was no longer significant (HR 1.00; 95% CI 0.99–1.00 and, HR 1.00; 95% CI 0.89–1.17, respectively). Additionally, no evident association between illiteracy and all-cause mortality or MI was present. Concerning EDI, demographic data was similar among the quintiles (Table 1). Although EDI quintiles were not associated with all-cause mortality (HR 1.17; 95% CI 0.82–1.66 for Q5 vs Q1), the EDI was an independent predictor of recurrent MI (Figure 1). On multivariate analysis, adjusted for age, sex, hypertension, diabetes and LDL cholesterol, the HR for the most deprived (Q5) to the least deprived (Q1) quintile was 1.91 (95% CI 1.05–3.49) for MI.

Conclusions

Our study shows clear socioeconomic differentials in cardiovascular outcomes in patients with STEMI which suggests that accounting for socioeconomic deprivation might improve risk prediction and therefore disease prognosis.

Funding Acknowledgement

Type of funding source: None

Strauss formula: a great and easy tool to manage congestion in acute heart failure

Background

Approaching the congestive patient is a complex task that requires the combination of different assessment methods. The Strauss formula uses variations in haemoglobin and haematocrit to estimate plasma volume variations (PVV) and haemoconcentration. However, this formula was only validated in outpatients followed with chronic heart failure. We aimed to assess the applicability of this formula to hospitalized patients for acute heart failure (AHF).

Methods

We conducted a single-centre, retrospective, observational study of 302 patients who were admitted to our hospital for AHF during 2016 and were discharged alive. Baseline clinical, laboratory and demographic characteristics were evaluated at admission and the Strauss formula was applied, as PVV (%) = 100 x [(Hb A / Hb D) x (1 − Hct D) / (1 − Hct A)] − 100), where A = admission and D = discharge. At discharge, we considered that a positive change (≥0%) in PV regarding the admission was linked to an increase in PV (haemodilution); a negative change (&lt;0%) correlated to a decrease in the PV (haemoconcentration). The primary endpoint was a composite of cardiovascular death (CV-death) and HF readmission at 3-months.

Results

Mean age was 76±11 years and 57% were male. At baseline, 92% were on clinical-haemodynamic profile B, with a median NT-proBNP of 2157 (IQR 1161–4242) pg/dL, a mean of glomerular filtration rate (GFR) of 63±57 mL/min/m2, a mean haemoglobin of 12±2 g/dL and a mean haematocrit of 38±6%. At discharge, the median plasma volume variation was −1.1% (IQR – 9.6 to 7.8) and the distribution of PVV values in the histogram reveals that a large proportion of patients (44%) increased or maintained plasma volume (PVV ≥0% – haemodilution). The group of patients who decreased plasma volume at discharge was slightly younger (75 vs 78 years, p=0.044), showing higher numerical decreases in NT-proBNP, gamma-glutamyl transferase (gGT) and bilirubin at discharge. A positive change in PV (PVV &gt;0%) during admission almost doubled the risk for readmission and CV-death at 3-months [OR 1.9 (95% CI: 1.1 to 3.1, p=0.026], after adjusting for age and sex.

Conclusions

In this work, we demonstrate that PVV, as calculated by the Strauss formula, increases or is unchanged in 44% of patients admitted with AHF and is strongly associated with a composite of 3-months CV death and HF readmission. Tools to guide the management of residual congestion are of great importance to assess the optimal discharge timing.

Funding Acknowledgement

Type of funding source: None

Guidelines for Modeling and Reporting Health Effects of Climate Change Mitigation Actions

BACKGROUND

Modeling suggests that climate change mitigation actions can have substantial human health benefits that accrue quickly and locally. Documenting the benefits can help drive more ambitious and health-protective climate change mitigation actions; however, documenting the adverse health effects can help to avoid them. Estimating the health effects of mitigation (HEM) actions can help policy makers prioritize investments based not only on mitigation potential but also on expected health benefits. To date, however, the wide range of incompatible approaches taken to developing and reporting HEM estimates has limited their comparability and usefulness to policymakers.

OBJECTIVE

The objective of this effort was to generate guidance for modeling studies on scoping, estimating, and reporting population health effects from climate change mitigation actions.

METHODS

An expert panel of HEM researchers was recruited to participate in developing guidance for conducting HEM studies. The primary literature and a synthesis of HEM studies were provided to the panel. Panel members then participated in a modified Delphi exercise to identify areas of consensus regarding HEM estimation. Finally, the panel met to review and discuss consensus findings, resolve remaining differences, and generate guidance regarding conducting HEM studies.

RESULTS

The panel generated a checklist of recommendations regarding stakeholder engagement: HEM modeling, including model structure, scope and scale, demographics, time horizons, counterfactuals, health response functions, and metrics; parameterization and reporting; approaches to uncertainty and sensitivity analysis; accounting for policy uptake; and discounting.

DISCUSSION

This checklist provides guidance for conducting and reporting HEM estimates to make them more comparable and useful for policymakers. Harmonization of HEM estimates has the potential to lead to advances in and improved synthesis of policy-relevant research that can inform evidence-based decision making and practice. https://doi.org/10.1289/EHP6745.

Can left atrial mechanics predict anticoagulation in cryptogenic stroke?

Introduction

Ischemic stroke is a leading cause of death and disability in the Western world, frequently due to cardioembolism and atherothromboembolism. Cryptogenic strokes occur without a well-defined aetiology after a standard vascular and cardiac evaluation, and secondary prevention may include antiplatelet therapy while awaiting results of long-term cardiac monitoring. In this study, we aimed to identify echocardiographic predictors of paroxysmal atrial fibrillation (AF) latter identified in follow-up of patients with cryptogenic stroke.

Methods

We retrospectively assessed all patients with cryptogenic stroke admitted in our hospital in the last 2 years. Only patients in normal sinus rhythm with a minimum of 24 hours of cardiac monitoring at admission and 24 hours Holter monitor within 6 months after discharge were included. Echocardiographic measures included left ventricle ejection fraction, left atrium (LA) volume, left and right atrium longitudinal strain, left and right ventricle longitudinal strain, E/A ratio, E/e' ratio, isovolumetric relaxation time (IVRT) and E wave deacceleration time. Echocardiographic data was assessed to determine its accuracy to identify AF.

Results

The study included 32 patients with a mean age of 72±10 years and a male preponderance (87.5%). AF was identified in 12 (37.5%) patients. This group of patients had a larger indexed LA volume (44.3 vs 29.1 mL/m2, p=0.043), a lower IVRT (87 vs 116 ms, p=0.028), and a lower LA longitudinal strain in contractile (6.7 vs 13.6%, p&lt;0.001) and in reservoir phase (17.1 vs 23.6%, p=0.042). All other variables were not significantly different among groups, including LA longitudinal strain in conduit phase. LA longitudinal strain in contractile phase showed the best predictive power with an area under the ROC curve of 0.925 (95% CI 0.82–1 p=0.001). The cut-off value that best predicted AF was 8.17% with a sensitivity of 1 and specificity of 0.9.

Conclusion

LA longitudinal strain in contractile phase is a powerful method to identify AF in cryptogenic stroke. When reduced, anticoagulation may be considered in order to prevent recurrence. Further studies are warranted to reproduce these results in larger cohorts.

Funding Acknowledgement

Type of funding source: None