2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

Jin-Xin-Kang alleviates heart failure by mitigating mitochondrial dysfunction through the Calcineurin/Dynamin-Related Protein 1 signaling pathway

ETHNOPHARMACOLOGICAL RELEVANCE

Chronic heart failure (CHF) is a severe consequence of cardiovascular disease, marked by cardiac dysfunction. Jin-Xin-Kang (JXK) is a traditional Chinese herbal formula used for the treatment of CHF. This formula consists of seven medicinal herbs, including Ginseng (Ginseng quinquefolium (L.) Alph.Wood), Astragali Radix (Astragalus membranaceus (Fisch.) Bunge), Salvia miltiorrhiza (Salvia miltiorrhiza Bunge), Descurainiae Semen Lepidii Semen (Descurainia sophia (L.) Webb ex Prantl), Leonuri Herba (Leonurus japonicus Houtt.), Cinnamomi Ramulus (Cinnamomum cassia (L.) J.Presl), and Ilex pubescens (Ilex pubescens Hook. & Arn.). Its clinical efficacy has been validated through prospective randomized controlled studies. However, the specific mechanisms of action for this formula have yet to be elucidated.

AIM OF THE STUDY

This study aimed to investigate the effect of JXK on mitochondrial function and its mechanism in the treatment of CHF.

METHODS

JXK components were qualitatively analyzed using UPLC-Q-Orbitrap-MS. HF was induced in mice via transverse aortic constriction (TAC). After successful model establishment, lyophilized JXK-L (4.38 g/kg) and JXK-H (13.14 g/kg) were administered for 8 weeks. In vitro, hypertrophic myocardium was induced using angiotensin II (Ang II) for 48 h, followed by JXK-L and JXK-H treatment. Network pharmacology and molecular docking techniques were used to predict the relevant targets of JXK. Cardiac function, serum markers, and histopathological changes were evaluated to assess cardiac function. Immunofluorescence of Tomm20, mitochondrial membrane potential, and ROS were measured to assess mitochondrial dysfunction. Protein expression of calcineurin (CaN) and Drp1 in the myocardium was assessed by Western blot analysis.

RESULTS

We detected that the active components of JXK include terpenes, glycosides, flavonoids, amino acids, and alkaloids, among others. In mice with CHF, JXK improved cardiac function and reversed ventricular remodeling. Network pharmacology indicated that JXK can inhibit the calcium signaling pathway. The molecular docking results demonstrated that the active components of JXK effectively bind with CaN. Both in vitro and in vivo experiments confirmed that JXK regulated the CaN/Drp1 pathway and alleviated mitochondrial dysfunction.

CONCLUSION

JXK can inhibit the CaN/Drp1 pathway to improve mitochondrial function, and consequently treat CHF.

Identification of active ingredients in Naomaitai capsules using high-resolution mass spectrometry unite molecular network analysis and prediction of their action mechanisms

RATIONALE

Although Naomaitai capsule (NMC) is widely used in clinical practice and has a good curative effect for cerebral infarction, its material basis and mechanism of action remain unclear.

METHODS

In this study, ultra-high-performance liquid chromatography (UHPLC) coupled with quadrupole Orbitrap MS technology was used to analyse the in vivo and in vitro components of NMC, and the Global Natural Products Social Molecular Networking website was used to further analyse the components of NMC. Next, systems biology approaches were employed to investigate the mechanism of action of NMC. Finally, molecular docking technology was used to verify the network pharmacological results.

RESULTS

In total, 177 compounds were identified in vitro, including 65 terpenoids, 62 flavonoids, 25 organic acids and 11 quinones. 64 compounds were identified in the blood of mice, and the main active components included ginkgolide C, ginkgolide A, ligustilide, tanshinone IIB, olmelin, emodin and puerarin. The main targets in vivo included TP53, SRC, STAT3, PIK3CA and PIK3R1.

CONCLUSIONS

In conclusion, this study has revealed that NMC acts on multiple targets in the body through various active components, exerting synergistic effects in the treatment of CI. Its mechanism of action may involve inhibiting neuronal apoptosis, oxidative stress and inflammatory responses as well as reducing cerebral vascular permeability and promoting cerebral vascular regeneration.

Pharmacotherapy of Weight-loss and Obesity with a Focus on GLP 1-Receptor Agonists

Obesity is a disease of epidemic proportions in the United States and contributes to morbidity and mortality for a large part of the population. In addition, the financial costs of this disease to society are high. Lifestyle modifications are key to prevention and treatment but adherence and long-term success have been challenging. Bariatric surgery has been available and pharmacologic approaches, first developed in the 1950s, continue to be an option; however, existing formulations have not provided optimal clinical efficacy and have had many concerning adverse effects. Over the last decade, glucagon-like peptide-1 (GLP-1) receptor agonists, a novel group of medications for the treatment of type 2 diabetes, were found to produce significant weight loss. Several formulations, at higher doses, received FDA approval for the treatment of obesity or those overweight with weight-related co-morbidities. More hormone-based therapies were and are being developed, some with dual or triple-receptor agonist activity. Their use, however, is not without questions and concerns as to long-term safety and efficacy, problems with cost and reimbursement, and how their use may intersect with public health efforts to manage the obesity epidemic. This review will focus on the GLP-1 receptor agonists currently used for weight loss and discuss their pharmacology, pertinent research findings establishing their benefits and risks, issues with prescribing these medications, and a perspective from a public health point of view.

Sulforaphane improves post-resuscitation myocardial dysfunction by inhibiting cardiomyocytes ferroptosis via the Nrf2/IRF1/GPX4 pathway

BACKGROUND

Ferroptosis is an important type of cell death contributing to myocardial dysfunction induced by whole body ischemia reperfusion following cardiac arrest (CA) and resuscitation. Sulforaphane (SFN), known as the activator of the nuclear factor E2-related factor 2 (Nrf2), has been proven to effectively alleviate regional myocardial ischemia reperfusion injury. The present study was designed to investigate whether SFN could improve post-resuscitation myocardial dysfunction by inhibiting cardiomyocytes ferroptosis and its potential regulatory mechanism.

METHODS AND RESULTS

An in vivo pig model of CA and resuscitation was established. Hypoxia/reoxygenation (H/R)-stimulated AC16 cardiomyocytes was constructed as an in vitro model to simulate the process of CA and resuscitation. In vitro experiment, SFN reduced ferroptosis-related ferrous iron, lipid reactive oxygen species, and malondialdehyde, increased glutathione, and further promoted cell survival after H/R stimulation in AC16 cardiomyocytes. Mechanistically, the activation of Nrf2 with the SFN decreased interferon regulatory factor 1 (IRF1) expression, then reduced its binding to the promoter of glutathione peroxidase 4 (GPX4), and finally recovered the latter's transcription after H/R stimulation in AC16 cardiomyocytes. In vivo experiment, SFN reversed abnormal expression of IRF1 and GPX4, inhibited cardiac ferroptosis, and improved myocardial dysfunction after CA and resuscitation in pigs.

CONCLUSIONS

SFN could effectively improve myocardial dysfunction after CA and resuscitation, in which the mechanism was potentially related to the inhibition of cardiomyocytes ferroptosis through the regulation of Nrf2/IRF1/GPX4 pathway.

Community-Based Physical Activity Programs for Blood Pressure Management in African Americans: A Scoping Review

BACKGROUND

Hypertension is a significant risk factor for cardiovascular disease, with a higher prevalence among African Americans (AA) than other racial groups. The impact of community-based interventions on managing blood pressure (BP) in AA communities is not fully understood. The purpose of this review was to synthesize literature on community-based physical activity (PA) programs designed to manage BP in AA populations.

METHODS

We conducted a scoping review by searching 4 databases (PubMed, CINAHL, MEDLINE, and APA PsycInfo) and reference lists of studies. Search terms included community PA, community-based, hypertension, high BP, AA, Black Americans, PA, and exercise. Inclusion criteria were studies (1) conducted in the United States and (2) published in English language from January 2013 to September 2023, with community-based interventions that included PA for BP management among AA aged ≥18 years.

RESULTS

Search results yielded 260 studies, of which 11 met the inclusion criteria. BP decreased over time in studies that incorporated PA, faith-based therapeutic lifestyle changes with nutritional education. The duration of the PA interventions varied, with moderate to vigorous PAs implemented for 12 weeks or longer having a greater impact on BP management.

CONCLUSIONS

Evidence suggests that community-based PA programs can potentially reduce BP among AA. PA programs incorporating faith-based therapeutic lifestyle change with nutritional education appear to reduce BP. Practitioners should consider multicomponent community-based PA initiatives to improve BP outcomes in AA communities.

Development and validation of a risk prediction model for short-term progression of carotid atherosclerosis among early middle age adults

AIM

We aimed at creating and validating a prognostic model incorporating easily accessible clinical and laboratory parameters to forecast the likelihood of short-term progression of carotid atherosclerosis.

METHODS

A prediction model was developed and validated for carotid plaque progression within 2 years in an early middle-age population in China. Progression was defined as the new appearance of carotid plaque or stenosis among participants who had normal carotid status at baseline. Leveraging data from a health check-up chain, predictors were identified using statistical methods including stepwise logistic regression, Markov Chain Monte Carlo (MCMC) simulation, random forest analysis and least absolute shrinkage selection operator (Lasso). Model performance was assessed. Bootstrap internal validation, validation on another check-up population and subgroup analysis were also conducted.

RESULTS

Among 7765 participants, predictors including age, diastolic blood pressure, uric acid levels, high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) were identified for carotid plaque progression in 2 years. The developed prediction model demonstrated good discrimination (AUC = 0.755, 95%CI:0.736-0.774) and calibration ability (slope = 0.922 and interception = 0.007) among development data, as well as among validation data (AUC = 0.759, 95%CI:0.674-0.770; slope = 1.076 and intercept = -0.014). Internal validation using bootstrap method yielded an adjusted AUC of 0.753. The model's performance remained consistent across different subgroups.

CONCLUSIONS

Our study presents a validated risk prediction model for carotid plaque progression in an early middle age population, offering a valuable tool for early identification and monitoring of cardiovascular risks. The model's robustness and applicability across different subgroups highlight its potential utility in preemptive cerebrovascular and cardiovascular disease management.

DCRM 2.0: Multispecialty practice recommendations for the management of diabetes, cardiorenal, and metabolic diseases

The spectrum of cardiorenal and metabolic diseases comprises many disorders, including obesity, type 2 diabetes (T2D), chronic kidney disease (CKD), atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), dyslipidemias, hypertension, and associated comorbidities such as pulmonary diseases and metabolism dysfunction-associated steatotic liver disease and metabolism dysfunction-associated steatohepatitis (MASLD and MASH, respectively, formerly known as nonalcoholic fatty liver disease and nonalcoholic steatohepatitis [NAFLD and NASH]). Because cardiorenal and metabolic diseases share pathophysiologic pathways, two or more are often present in the same individual. Findings from recent outcome trials have demonstrated benefits of various treatments across a range of conditions, suggesting a need for practice recommendations that will guide clinicians to better manage complex conditions involving diabetes, cardiorenal, and/or metabolic (DCRM) diseases. To meet this need, we formed an international volunteer task force comprising leading cardiologists, nephrologists, endocrinologists, and primary care physicians to develop the DCRM 2.0 Practice Recommendations, an updated and expanded revision of a previously published multispecialty consensus on the comprehensive management of persons living with DCRM. The recommendations are presented as 22 separate graphics covering the essentials of management to improve general health, control cardiorenal risk factors, and manage cardiorenal and metabolic comorbidities, leading to improved patient outcomes.

Electrochemical impedance spectroscopy unmasks high-risk atherosclerotic features in human coronary artery disease

Coronary plaque rupture remains the prominent mechanism of myocardial infarction. Accurate identification of rupture-prone plaque may improve clinical management. This study assessed the discriminatory performance of electrochemical impedance spectroscopy (EIS) in human cardiac explants to detect high-risk atherosclerotic features that portend rupture risk. In this single-center, prospective study, n = 26 cardiac explants were collected for EIS interrogation of the three major coronary arteries. Vessels in which advancement of the EIS catheter without iatrogenic plaque disruption was rendered impossible were not assessed. N = 61 vessels underwent EIS measurement and histological analyses. Plaques were dichotomized according to previously established high rupture-risk parameter thresholds. Diagnostic performance was determined via receiver operating characteristic areas-under-the-curve (AUC). Necrotic cores were identified in n = 19 vessels (median area 1.53 mm2) with a median fibrous cap thickness of 62 μm. Impedance was significantly greater in plaques with necrotic core area ≥1.75 mm2 versus <1.75 mm2 (19.8 ± 4.4 kΩ vs. 7.2 ± 1.0 kΩ, p = .019), fibrous cap thickness ≤65 μm versus >65 μm (19.1 ± 3.5 kΩ vs. 6.5 ± 0.9 kΩ, p = .004), and ≥20 macrophages per 0.3 mm-diameter high-power field (HPF) versus <20 macrophages per HPF (19.8 ± 4.1 kΩ vs. 10.2 ± 0.9 kΩ, p = .002). Impedance identified necrotic core area ≥1.75 mm2, fibrous cap thickness ≤65 μm, and ≥20 macrophages per HPF with AUCs of 0.889 (95% CI: 0.716-1.000) (p = .013), 0.852 (0.646-1.000) (p = .025), and 0.835 (0.577-1.000) (p = .028), respectively. Further, phase delay discriminated severe stenosis (≥70%) with an AUC of 0.767 (0.573-0.962) (p = .035). EIS discriminates high-risk atherosclerotic features that portend plaque rupture in human coronary artery disease and may serve as a complementary modality for angiography-guided atherosclerosis evaluation.

Advances in the Computational Assessment of Disturbed Coronary Flow and Wall Shear Stress: A Contemporary Review

Coronary artery blood flow is influenced by various factors including vessel geometry, hemodynamic conditions, timing in the cardiac cycle, and rheological conditions. Multiple patterns of disturbed coronary flow may occur when blood flow separates from the laminar plane, associated with inefficient blood transit, and pathological processes modulated by the vascular endothelium in response to abnormal wall shear stress. Current simulation techniques, including computational fluid dynamics and fluid-structure interaction, can provide substantial detail on disturbed coronary flow and have advanced the contemporary understanding of the natural history of coronary disease. However, the clinical application of these techniques has been limited to hemodynamic assessment of coronary disease severity, with the potential to refine the assessment and management of coronary disease. Improved computational efficiency and large clinical trials are required to provide an incremental clinical benefit of these techniques beyond existing tools. This contemporary review is a clinically relevant overview of the disturbed coronary flow and its associated pathological consequences. The contemporary methods to assess disturbed flow are reviewed, including clinical applications of these techniques. Current limitations and future opportunities in the field are also discussed.

Gender Differences in Defibrillator Practices in Out-of-Hospital Cardiac Arrest

OBJECTIVES

Disparities remain in survival after out-of-hospital cardiac arrest (OHCA) for women compared to men. Our objective was to evaluate differences in automated external defibrillator (AED) use before Emergency Medical Services (EMS) arrival and time from arrival to initial EMS defibrillation by EMS-assessed gender (women or men).

METHODS

This was a secondary analysis of adult non-traumatic, EMS-treated OHCA cases in the Portland Cardiac Arrest Epidemiologic Registry from 2018 to 2021. Emergency Medical Services-witnessed cardiac arrests were excluded and the primary outcomes were pre-EMS AED application and the time from EMS arrival to first defibrillation among patients in a shockable rhythm at first rhythm assessment without pre-EMS AED application. We examined pre-EMS AED application rates overall and separately for law enforcement, in cases where they were on-scene before EMS without a lay bystander AED applied, and lay responders, in cases where law enforcement had not applied an AED. We used multivariable logistic and linear regressions to adjust for potential confounders, including age, arrest location, witness status, bystander CPR, year, and time from dispatch to EMS arrival. We accounted for clustering by county of arrest using a mixed-effects approach.

RESULTS

Of the 3,135 adult, EMS-treated non-traumatic OHCAs that were not witnessed by EMS, 3,049 had all variables for analysis, of which 1,011 (33.2%) were women. The adjusted odds (adjusted odds ratio [95% CI]) for any pre-EMS placement of an AED was significantly higher for men compared to women (1.40 [1.05-1.86]). These odds favoring men remained when examining law enforcement AED application (1.89 [1.16-3.07]), but not lay bystander AED application (1.19 [0.83-1.71]). Among patients still in arrest on EMS arrival, with a shockable initial EMS rhythm, and without pre-EMS AED application, the time from EMS arrival on-scene to initial defibrillation was significantly longer for women compared to men (+0.81 min [0.22-1.41 min]).

CONCLUSIONS

Women with OHCA received lower rates of pre-EMS AED application and delays in initial EMS defibrillation compared to men.

Advancements in Incident Heart Failure Risk Prediction and Screening Tools

Heart failure (HF) is a major cause of mortality and morbidity in the United States that carries substantial healthcare costs. Multiple risk prediction models and strategies have been developed over the past 30 years with the aim of identifying those at high risk of developing HF and of implementing preventive therapies effectively. This review highlights recent developments in HF risk prediction tools including emerging risk factors, innovative risk prediction models, and novel screening strategies from artificial intelligence to biomarkers. These developments allow more accurate prediction, but their impact on clinical outcomes remains to be investigated. Implementation of these risk models in clinical practice is a considerable challenge, but HF risk prediction tools offer a promising opportunity to improve outcomes while maintaining value.

Computational Modeling Approach to Profile Hemodynamical Behavior in a Healthy Aorta

Cardiovascular diseases (CVD) remain the leading cause of mortality among older adults. Early detection is critical as the prognosis for advanced-stage CVD is often poor. Consequently, non-invasive diagnostic tools that can assess hemodynamic function, particularly of the aorta, are essential. Computational fluid dynamics (CFD) has emerged as a promising method for simulating cardiovascular dynamics efficiently and cost-effectively, using increasingly accessible computational resources. This study developed a CFD model to assess the aorta geometry using tetrahedral and polyhedral meshes. A healthy aorta was modeled with mesh sizes ranging from 0.2 to 1 mm. Key hemodynamic parameters, including blood pressure waveform, pressure difference, wall shear stress (WSS), and associated wall parameters like relative residence time (RRT), oscillatory shear index (OSI), and endothelial cell activation potential (ECAP) were evaluated. The performance of the CFD simulations, focusing on accuracy and processing time, was assessed to determine clinical viability. The CFD model demonstrated clinically acceptable results, achieving over 95% accuracy while reducing simulation time by up to 54%. The entire simulation process, from image construction to the post-processing of results, was completed in under 120 min. Both mesh types (tetrahedral and polyhedral) provided reliable outputs for hemodynamic analysis. This study provides a novel demonstration of the impact of mesh type in obtaining accurate hemodynamic data, quickly and efficiently, using CFD simulations for non-invasive aortic assessments. The method is particularly beneficial for routine check-ups, offering improved diagnostics for populations with limited healthcare access or higher cardiovascular disease risk.

Coagulation factor XII contributes to renin activation, heart failure progression, and mortality

Symptomatic heart failure (sHF) with cardiac dysfunction, edema, and mortality are driven by overactivation of the renin-angiotensin-aldosterone system (RAAS). Renin is widely recognized as a key initiator of RAAS function, yet the mechanisms that activate renin remain a mystery. We discovered that activated coagulation factor XII generates active renin in the circulation and is directly linked to pathological activation of the systemic RAAS, development of sHF, and increased mortality. These findings suggest a new paradigm for therapeutically modulating the RAAS in sHF and other pathological conditions.

Identification of potential therapeutic targets for nonischemic cardiomyopathy in European ancestry: an integrated multiomics analysis

BACKGROUND

Nonischemic cardiomyopathy (NISCM) is a clinical challenge with limited therapeutic targets. This study aims to identify promising drug targets for NISCM.

METHODS

We utilized cis-pQTLs from the deCODE study, which includes data from 35,559 Icelanders, and SNPs from the FinnGen study, which includes data from 1,754 NISCM cases and 340,815 controls of Finnish ancestry. Mendelian randomization (MR) analysis was performed to estimate the causal relationship between circulating plasma protein levels and NISCM risk. Proteins with significant associations underwent false discovery rate (FDR) correction, followed by Bayesian colocalization analysis. The expression of top two proteins, LILRA5 and NELL1, was further analyzed using various NISCM datasets. Descriptions from the Human Protein Atlas (HPA) validated protein expression. The impact of environmental exposures on LILRA5 was assessed using the Comparative Toxicogenomics Database (CTD), and molecular docking identified the potential small molecule interactions.

RESULTS

MR analysis identified 255 circulating plasma proteins associated with NISCM, with 16 remaining significant after FDR correction. Bayesian colocalization analysis identified LILRA5 and NELL1 as significant, with PP.H4 > 0.8. LILRA5 has a protective effect (OR = 0.758, 95% CI, 0.670-0.857) while NELL1 displays the risk effect (OR = 1.290, 95% CI, 1.199-1.387) in NISCM. Decreased LILRA5 expression was found in NISCM such as diabetic, hypertrophic, dilated, and inflammatory cardiomyopathy, while NELL1 expression increased in hypertrophic cardiomyopathy. HPA data indicated high LILRA5 expression in neutrophils, macrophages and endothelial cells within normal heart and limited NELL1 expression. Immune infiltration analysis revealed decreased neutrophil in diabetic cardiomyopathy. CTD analysis identified several small molecules that affect LILRA5 mRNA expression. Among these, Estradiol, Estradiol-3-benzoate, Gadodiamide, Topotecan, and Testosterone were found to stably bind to the LILRA5 protein at the conserved VAL-15 or THR-133 residues in the Ig-like C2 domain.

CONCLUSION

Based on European Ancestry Cohort, this study reveals that LILRA5 and NELL1 are potential therapeutic targets for NISCM, with LILRA5 showing particularly promising prospects in diabetic cardiomyopathy. Several small molecules interact with LILRA5, implying potential clinical implication.

Further Psychometric Testing of the Chest Pain Conception Questionnaire in a Racially and Ethnically Diverse Sample

BACKGROUND

The Chest Pain Conception Questionnaire was developed to measure the lay public's conceptions of chest pain related to acute coronary syndrome.

OBJECTIVE

The purpose of this study was to further test the Chest Pain Conception Questionnaire in a racially and ethnically diverse sample.

METHODS

Participants from across the United States completed an online survey. Confirmatory factor analysis and descriptive statistics were used to characterize the instrument's performance.

RESULTS

Participants (N = 597) were primarily women (59.6%), White (69.3%), and non-Hispanic (83.4%) with a mean age of 54.0 years (SD = 11.5). Confirmatory factor analysis supported the original 3-factor structure of the instrument, c2(58) = 132.32, P = .000, root mean square error of approximation = 0.04, confirmatory fit index = 0.95, Tucker-Lewis index = 0.93, standardized root mean square residual = 0.04. Other instrument characteristics from this validation study were similar to the initial development study.

CONCLUSIONS

This study further supports construct validity and internal consistency of the instrument in the target population.

The association between food environments and cardiovascular disease outcomes: A systematic review

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death worldwide, particularly affecting low- and middle-income countries. Food environments may be linked with the risk of CVD; however, current study findings regarding their relationship are inconsistent. A systematic review of their associations is needed to guide interventions to improve cardiovascular health.

OBJECTIVE

This systematic review aimed to comprehensively assess the relationship between food environments and CVD outcomes, including incidence, hospitalization, mortality, and recurrence rates.

METHOD

According to PRISMA guidelines, a systematic search was conducted until 28th March 2024, using eight databases, including PubMed, Embase, Ovid, CINAHL, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), and Wanfang Data. The review quality was assessed according to the Agency for Healthcare Research and Quality (AHRQ) and Newcastle-Ottawa Scale (NOS). The included studies were categorized based on their exposure factors into unhealthy, healthy, and comprehensive food environments, encompassing facilities that offer healthy and unhealthy foods. The findings were narratively synthesized according to this classification.

RESULT

A total of 23 studies, encompassing 13 cross-sectional studies and 10 cohort-longitudinal studies, were included in this review. Among the 20 studies on unhealthy food environments, 13 found a positive association with CVD outcomes. Of the seven studies on healthy food environments, 3 found a negative association with CVD outcomes. Additionally, 4 out of 8 studies on comprehensive food environments found a significant but inconsistent association with CVD outcomes.

CONCLUSION

This study suggested that unhealthy food environments are probably associated with CVD outcomes. At the same time, there is currently no conclusive evidence to indicate a relationship between healthy food environments or comprehensive food environments and CVD outcomes.

Brain Ischemic Tolerance Triggered by Preconditioning Involves Modulation of Tumor Necrosis Factor-α-Stimulated Gene 6 (TSG-6) in Mice Subjected to Transient Middle Cerebral Artery Occlusion

Ischemic preconditioning (PC) induced by a sub-lethal cerebral insult triggers brain tolerance against a subsequent severe injury through diverse mechanisms, including the modulation of the immune system. Tumor necrosis factor (TNF)-α-stimulated gene 6 (TSG-6), a hyaluronate (HA)-binding protein, has recently been involved in the regulation of the neuroimmune response following ischemic stroke. Thus, we aimed at assessing whether the neuroprotective effects of ischemic PC involve the modulation of TSG-6 in a murine model of transient middle cerebral artery occlusion (MCAo). The expression of TSG-6 was significantly elevated in the ischemic cortex of mice subjected to 1 h MCAo followed by 24 h reperfusion, while this effect was further potentiated (p < 0.05 vs. MCAo) by pre-exposure to ischemic PC (i.e., 15 min MCAo) 72 h before. By immunofluorescence analysis, we detected TSG-6 expression mainly in astrocytes and myeloid cells populating the lesioned cerebral cortex, with a more intense signal in tissue from mice pre-exposed to ischemic PC. By contrast, levels of TSG-6 were reduced after 24 h of reperfusion in plasma (p < 0.05 vs. SHAM), but were dramatically elevated when severe ischemia (1 h MCAo) was preceded by ischemic PC (p < 0.001 vs. MCAo) that also resulted in significant neuroprotection. In conclusion, our data demonstrate that neuroprotection exerted by ischemic PC is associated with the elevation of TSG-6 protein levels both in the brain and in plasma, further underscoring the beneficial effects of this endogenous modulator of the immune system.

Protection of blood-brain barrier by endothelial DAPK1 deletion after stroke

Death-associated protein kinase (DAPK) 1 is a critical mediator for neuronal cell death in cerebral ischemia, but its role in blood-brain barrier (BBB) disruption is incompletely understood. Here, we found that endothelial-specific deletion of Dapk1 using Tie2 Cre protected the brain of Dapk1fl/fl mice against middle cerebral artery occlusion (MCAO), characterized by mitigated Evans blue dye (EBD) extravasation, reduced infarct size and improved behavior. In vitro experiments also indicated that DAPK1 deletion inhibited oxygen-glucose deprivation (OGD)-induced tight junction alteration between cerebral endothelial cells (CECs). Mechanistically, we revealed that DAPK1-DAPK3 interaction activated cytosolic phospholipase A2 (cPLA2) in OGD-stimulated CECs. Our results thus suggest that inhibition of endothelial DAPK1 specifically prevents BBB damage after stroke.

Cutting-edge advances in nano/biomedicine: A review on transforming thrombolytic therapy

Thrombotic blockages within blood vessels give rise to critical cardiovascular disorders, including ischemic stroke, venous thromboembolism, and myocardial infarction. The current approach to the therapy of thrombolysis involves administering Plasminogen Activators (PA), but it is hindered by fast drug elimination, narrow treatment window, and the potential for bleeding complications. Leveraging nanomedicine to encapsulate and deliver PA offers a solution by improving the efficacy of therapy, safeguarding the medicine from proteinase biodegradation, and reducing unwanted effects in in vivo trials. In this review, we delve into the underlying venous as well as arterial thrombus pathophysiology and provide an overview of clinically approved PA used to address acute thrombotic conditions. We explore the existing challenges and potential directions within recent pivotal research on a variety of targeted nanocarriers, such as lipid, polymeric, inorganic, and biological carriers, designed for precise delivery of PA to specific sites. We also discuss the promising role of microbubbles and ultrasound-assisted Sono thrombolysis, which have exhibited enhanced thrombolysis in clinical studies. Furthermore, our review delves into approaches for the strategic development of nano-based carriers tailored for targeting thrombolytic action and efficient encapsulation of PA, considering the intricate interaction in biology systems as well as nanomaterials. In conclusion, the field of nanomedicine offers a valuable method for the exact and effective therapy of severe thrombus conditions, presenting a pathway toward improved patient outcomes and reduced complications.

Sex disparities of clinical manifestations in acute pulmonary embolism and predictive value for in-hospital mortality: Insights from CURES

BACKGROUND

Pulmonary embolism (PE) is a common and potentially fatal disease, with differences in mortality rates among PE patients of different sexes. This study aims to investigate the disparities in clinical manifestations and in-hospital mortality rates between sexes in PE patients, as well as the association of clinical symptoms with in-hospital mortality.

METHODS

We analyzed data from the China pUlmonary thromboembolism REgistry Study (CURES), a nationwide, multicenter, prospective registry focusing on patients with acute PE. Using propensity score matching (PSM) to pair male and female patients with PE, we explored the correlation between clinical symptoms and in-hospital mortality through multivariable regression analysis.

RESULTS

A total of 15,203 patients with acute PE were enrolled, and 380 died during hospitalization. The incidence of chest pain, hemoptysis, and palpitations was significantly higher in males compared to females. The incidence of dyspnea, fever, and syncope was higher in females. Hemoptysis and dyspnea were associated with increased in-hospital mortality in males, whereas dyspnea, fever, and palpitations were linked to higher mortality in females. Overall, males exhibited a higher in-hospital mortality than females (2.9 % vs. 2.1 %, p = 0.002). After matching 13,130 patients using the PSM method, the mortality rate of males remained higher than that of females (2.7 % vs. 2.1 %, p = 0.020).

CONCLUSIONS

Our study demonstrates that male patients with PE have a higher risk of in-hospital mortality than females. Significant differences in clinical symptoms between sexes are associated with increased mortality risk, emphasizing the need for clinical awareness.

Accelerated Chemical Shift Encoded Cardiac MRI with Use of Resolution Enhancement Network

BACKGROUND

Cardiovascular magnetic resonance (CMR) chemical shift encoding (CSE) enables myocardial fat imaging. We sought to develop a deep learning network (FastCSE) to accelerate CSE.

METHODS

FastCSE was built on a super-resolution generative adversarial network extended to enhance complex-valued image sharpness. FastCSE enhances each echo image independently before water-fat separation. FastCSE was trained with retrospectively identified cines from 1519 patients (56 ± 16 years; 866 men) referred for clinical 3T CMR. In a prospective study of 16 participants (58 ± 19 years; 7 females) and 5 healthy individuals (32 ± 17 years; 5 females), dual-echo CSE images were collected with 1.5 × 1.5mm2, 2.5 × 1.5 mm2, and 3.8 × 1.9mm2 resolution using generalized autocalibrating partially parallel acquisition (GRAPPA). FastCSE was applied to images collected with resolution of 2.5 × 1.5mm2 and 3.8 × 1.9 mm2 to restore sharpness. Fat images obtained from two-point Dixon reconstruction were evaluated using a quantitative blur metric and analyzed with 5-way analysis of variance.

RESULTS

FastCSE successfully reconstructed CSE images inline. FastCSE acquisition, with a resolution of 2.5 × 1.5mm² and 3.8 × 1.9 mm², reduced the number of breath-holds without impacting visualization of fat by approximately 1.5-fold and 3-fold compared to GRAPPA acquisition with a resolution of 1.5 × 1.5 mm², from 3.0 ± 0.8 breath-holds to 2.0 ± 0.2 and 1.1 ± 0.4 breath-holds, respectively. FastCSE improved image sharpness and removed ringing artifacts in GRAPPA fat images acquired with a resolution of 2.5 × 1.5 mm2 (0.31 ± 0.03 vs. 0.35 ± 0.04, P < 0.001) and 3.8 × 1.9 mm2 (0.31 ± 0.03 vs. 0.42 ± 0.06, P < 0.001). Blurring in FastCSE images was similar to blurring in images with 1.5 × 1.5 mm² resolution (0.32 ±0.03 vs. 0.31 ± 0.03, P = 0.78; 0.32 ± 0.03 vs. 0.31 ± 0.03, P = 0.90).

CONCLUSION

We showed that a deep learning-accelerated CSE technique based on complex-valued resolution enhancement can reduce the number of breath-holds in CSE imaging without impacting the visualization of fat. FastCSE showed similar image sharpness compared to a standardized parallel imaging method.

Adjunctive Intravenous Argatroban or Eptifibatide for Ischemic Stroke

BACKGROUND

Intravenous thrombolysis is a standard treatment of acute ischemic stroke. The efficacy and safety of combining intravenous thrombolysis with argatroban (an anticoagulant agent) or eptifibatide (an antiplatelet agent) are unclear.

METHODS

We conducted a phase 3, three-group, adaptive, single-blind, randomized, controlled clinical trial at 57 sites in the United States. Patients with acute ischemic stroke who had received intravenous thrombolysis within 3 hours after symptom onset were assigned to receive intravenous argatroban, eptifibatide, or placebo within 75 minutes after the initiation of thrombolysis. The primary efficacy outcome, the utility-weighted 90-day modified Rankin scale score (range, 0 to 10, with higher scores reflecting better outcomes), was assessed by means of centralized adjudication. The primary safety outcome was symptomatic intracranial hemorrhage within 36 hours after randomization.

RESULTS

A total of 514 patients were assigned to receive argatroban (59 patients), eptifibatide (227 patients), or placebo (228 patients). All the patients received intravenous thrombolysis (70% received alteplase, and 30% received tenecteplase), and 225 patients (44%) underwent endovascular thrombectomy. At 90 days, the mean (±SD) utility-weighted modified Rankin scale scores were 5.2±3.7 with argatroban, 6.3±3.2 with eptifibatide, and 6.8±3.0 with placebo. The posterior probability that argatroban was better than placebo was 0.002 (posterior mean difference in utility-weighted modified Rankin scale score, -1.51±0.51) and that eptifibatide was better than placebo was 0.041 (posterior mean difference, -0.50±0.29). The incidence of symptomatic intracranial hemorrhage was similar in the three groups (4% with argatroban, 3% with eptifibatide, and 2% with placebo). Mortality at 90 days was higher in the argatroban group (24%) and the eptifibatide group (12%) than in the placebo group (8%).

CONCLUSIONS

In patients with acute ischemic stroke treated with intravenous thrombolysis within 3 hours after symptom onset, adjunctive treatment with intravenous argatroban or eptifibatide did not reduce poststroke disability and was associated with increased mortality. (Funded by the National Institute of Neurological Disorders and Stroke; MOST ClinicalTrials.gov number, NCT03735979.).

Transcriptomic Alterations in Spliceosome Components in Advanced Heart Failure: Status of Cardiac-Specific Alternative Splicing Factors

Heart failure (HF) is associated with global changes in gene expression. Alternative mRNA splicing (AS) is a key regulatory mechanism underlying these changes. However, the whole status of molecules involved in the splicing process in human HF is unknown. Therefore, we analysed the spliceosome transcriptome in cardiac tissue (n = 36) from control subjects and HF patients (with ischaemic (ICM) and dilated (DCM) cardiomyopathies) using RNA-seq. We found greater deregulation of spliceosome machinery in ICM. Specifically, we showed widespread upregulation of the E and C complex components, highlighting an increase in SNRPD2 (FC = 1.35, p < 0.05) and DHX35 (FC = 1.34, p < 0.001) mRNA levels. In contrast, we observed generalised downregulation of the A complex and cardiac-specific AS factors, such as the multifunctional protein PCBP2 (FC = -1.29, p < 0.001) and the RNA binding proteins QKI (FC = -1.35, p < 0.01). In addition, we found a relationship between SNPRD2 (an E complex component) and the left ventricular mass index in ICM patients (r = 0.779; p < 0.01). On the other hand, we observed the specific underexpression of DDX46 (FC = -1.29), RBM17 (FC = -1.33), SDE2 (FC = -1.35) and RBFOX1 (FC = -1.33), p < 0.05, in DCM patients. Therefore, these aetiology-related alterations may indicate the differential involvement of the splicing process in the development of ICM and DCM.

Keratinocyte-Derived Exosomes in Painful Diabetic Neuropathy

Painful diabetic neuropathy (PDN) is a challenging complication of diabetes with patients experiencing a painful and burning sensation in their extremities. Existing treatments provide limited relief without addressing the underlying mechanisms of the disease. PDN involves the gradual degeneration of nerve fibers in the skin. Keratinocytes, the most abundant epidermal cell type, are closely positioned to cutaneous nerve terminals, suggesting the possibility of bi-directional communication. Exosomes are small extracellular vesicles released from many cell types that mediate cell to cell communication. The role of keratinocyte-derived exosomes (KDEs) in influencing signaling between the skin and cutaneous nerve terminals and their contribution to the genesis of PDN has not been explored. In this study, we characterized KDEs in a well-established high-fat diet (HFD) mouse model of PDN using primary adult mouse keratinocyte cultures. We obtained highly enriched KDEs through size exclusion chromatography and then analyzed their molecular cargo using proteomic analysis and small RNA sequencing. We found significant differences in the protein and microRNA content of HFD KDEs compared to KDEs obtained from control mice on a regular diet (RD), including pathways involved in axon guidance and synaptic transmission. Additionally, using an in vivo conditional extracellular vesicle (EV) reporter mouse model, we demonstrated that epidermal-originating GFP-tagged KDEs are retrogradely trafficked into the DRG neuron cell body. Overall, our study presents a potential novel mode of communication between keratinocytes and DRG neurons in the skin, revealing a possible role for KDEs in contributing to the axonal degeneration that underlies neuropathic pain in PDN. Moreover, this study presents potential therapeutic targets in the skin for developing more effective, disease-modifying, and better-tolerated topical interventions for patients suffering from PDN, one of the most common and untreatable peripheral neuropathies.

Metabolic dysfunction and incidence of heart failure subtypes among Black individuals: The Jackson Heart Study

AIMS

The extent to which metabolic syndrome (MetS) severity influences subclinical myocardial remodelling, heart failure (HF) incidence and subtypes, remains unclear. We assessed the association of MetS with incident HF (including ejection fraction subtypes) among Black individuals.

METHODS AND RESULTS

We included 4069 Jackson Heart Study participants (mean age 54.4 years, 63.8% women, 37.2% with MetS) without HF. We categorized participants based on MetS status and MetS severity scores (based on waist circumference [MetS-Z-WC] and body mass index [MetS-Z-BMI]). We assessed the associations of MetS indices with echocardiographic parameters, biomarkers of myocardial damage (high-sensitivity cardiac troponin I [hs-cTnI] and B-type natriuretic peptide [BNP]) and incident HF hospitalizations including HF with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF). MetS severity was associated with subclinical cardiac remodelling (assessed by echocardiographic measures and biomarkers of myocardial damage). Over a median of 12 years, 319 participants developed HF (157 HFpEF, 149 HFrEF and 13 HF of unknown type). MetS was associated with a twofold greater risk of HF (hazard ratio [HR] 2.07, 95% confidence interval [CI] 1.64-2.61). Compared to the lowest quartile (Q1) of MetS-Z-WC, the highest quartile (Q4) conferred a higher risk of HF (HR 2.35, 95% CI 1.67-3.30), with a stronger association for HFpEF (Q4 vs. Q1: HR 4.94, 95% CI 2.67-9.14) vs. HFrEF (HR 1.69, 95% CI 1.06-2.70).

CONCLUSIONS

Metabolic syndrome severity was associated with both HF subtypes among Black individuals, highlighting the importance of optimal metabolic health for preventing HF.

The Quality of Short Videos as a Source of Coronary Heart Disease Information on TikTok: Cross-Sectional Study

BACKGROUND

Coronary heart disease (CHD) is a leading cause of death worldwide and imposes a significant economic burden. TikTok has risen as a favored platform within the social media sphere for disseminating CHD-related information and stands as a pivotal resource for patients seeking knowledge about CHD. However, the quality of such content on TikTok remains largely unexplored.

OBJECTIVE

This study aims to assess the quality of information conveyed in TikTok CHD-related videos.

METHODS

A comprehensive cross-sectional study was undertaken on TikTok videos related to CHD. The sources of the videos were identified and analyzed. The comprehensiveness of content was assessed through 6 questions addressing the definition, signs and symptoms, risk factors, evaluation, management, and outcomes. The quality of the videos was assessed using 3 standardized evaluative instruments: DISCERN, the Journal of the American Medical Association (JAMA) benchmarks, and the Global Quality Scale (GQS). Furthermore, correlative analyses between video quality and characteristics of the uploaders and the videos themselves were conducted.

RESULTS

The search yielded 145 CHD-related videos from TikTok, predominantly uploaded by health professionals (n=128, 88.3%), followed by news agencies (n=6, 4.1%), nonprofit organizations (n=10, 6.9%), and for-profit organizations (n=1, 0.7%). Content comprehensiveness achieved a median score of 3 (IQR 2-4). Median values for the DISCERN, JAMA, and GQS evaluations across all videos stood at 27 (IQR 24-32), 2 (IQR 2-2), and 2 (IQR 2-3), respectively. Videos from health professionals and nonprofit organizations attained significantly superior JAMA scores in comparison to those of news agencies (P<.001 and P=.02, respectively), whereas GQS scores for videos from health professionals were also notably higher than those from news agencies (P=.048). Within health professionals, cardiologists demonstrated discernibly enhanced performance over noncardiologists in both DISCERN and GQS assessments (P=.02). Correlative analyses unveiled positive correlations between video quality and uploader metrics, encompassing the positive correlations between the number of followers; total likes; average likes per video; and established quality indices such as DISCERN, JAMA, or GQS scores. Similar investigations relating to video attributes showed correlations between user engagement factors-likes, comments, collections, shares-and the aforementioned quality indicators. In contrast, a negative correlation emerged between the number of days since upload and quality indices, while a longer video duration corresponded positively with higher DISCERN and GQS scores.

CONCLUSIONS

The quality of the videos was generally poor, with significant disparities based on source category. The content comprehensiveness coverage proved insufficient, casting doubts on the reliability and quality of the information relayed through these videos. Among health professionals, video contributions from cardiologists exhibited superior quality compared to noncardiologists. As TikTok's role in health information dissemination expands, ensuring accurate and reliable content is crucial to better meet patients' needs for CHD information that conventional health education fails to fulfill.

Development and external validation of a risk prediction model for depression in patients with coronary heart disease

BACKGROUND

Depression is an independent risk factor for adverse outcomes of coronary heart disease (CHD). This study aimed to develop a depression risk prediction model for CHD patients.

METHODS

This study utilized data from the National Health and Nutrition Examination Survey (NHANES). In the training set, reference literature, logistic regression, LASSO regression, optimal subset algorithm, and machine learning random forest algorithm were employed to screen prediction variables, respectively. The optimal prediction model was selected based on the C-index, Net Reclassification Improvement (NRI), and Integrated Discrimination Improvement (IDI). A nomogram for the optimal prediction model was constructed. 3 external validations were performed.

RESULTS

The training set comprised 1375 participants, with a depressive symptoms prevalence of 15.2 %. The optimal prediction model was constructed using predictors obtained from optimal subsets algorithm (C-index = 0.774, sensitivity = 0.751, specificity = 0.685). The model includes age, gender, education, marriage, diabetes, tobacco use, antihypertensive drugs, high-density lipoprotein cholesterol (HDLC), and aspartate aminotransferase (AST). The model demonstrated consistent discrimination ability, accuracy, and clinical utility across the 3 external validations.

LIMITATIONS

The applicable population of the model is CHD patients. And the clinical benefits of interventions based on the prediction results are still unknown.

CONCLUSION

We developed a depression risk prediction model for CHD patients, which was presented in the form of a nomogram for clinical application.

Association of overweight and obesity with coronary risk factors and the presence of multivessel disease in patients with obstructive coronary artery disease - A nationwide registry study

Background

The growing prevalence of obesity is expected to increase the burden of coronary artery disease. This study examined the prevalence of overweight and obesity in patients with a first-time diagnosis of obstructive coronary artery disease in a contemporary population. The association of body-mass-index (BMI) with age, traditional risk factors, and the presence of multivessel disease were explored.

Methods and results

Using the Danish Nationwide registries, we identified 49,733 patients with a first-time diagnosis of obstructive coronary artery disease in the period 2012-2018. We investigated the association between BMI and coronary risk factors by multivariate logistic regression. Mean age was 65.8 ± 11.8 years, mean BMI was 27.5 kg/m2 ± 7.2, and 73.2 % were men. 66.3 % had a BMI ≥25 kg/m2 and 1.3 % were underweight. The prevalence of patients with BMI ≥25 kg/m2 decreased with increasing age and was 69 % in patients <50 year vs. 46.2 % in patients ≥80 years (p < 0.001). In all age groups, higher odds of BMI ≥25 kg/m2 were observed in males, former smokers, and patients with hypertension. In multivariate logistic regression, BMI ≥25 kg/m2 was not associated with presence of multivessel disease (p = 0.74).

Conclusion

In this large, nationwide study, 66.3 % of patients with first time diagnosis of obstructive coronary disease had BMI ≥25 kg/m2. Young patients had higher BMI and were more likely to be current smokers. Overweight or obesity was independently associated with the presence of diabetes and hypertension. BMI ≥25 kg/m2 was not independently associated with the presence of multivessel disease.

Improving diversity in cardiac surgery clinical trials with ROMA:Women as an exemplar

PURPOSE OF REVIEW

To describe methods to improve representation of women in cardiac surgery clinical trials.

RECENT FINDINGS

Cardiovascular disease risk among women is high. Historically, women have been excluded from cardiac surgery trials, in part due to restrictive inclusion criteria. Surgical outcomes, specifically after coronary artery bypass grafting, are consistently worse among female patients, and these outcomes have not improved over the last decade. Addressing treatment effects and clinical benefit among women requires accurate representation in cardiovascular surgery trials. ROMA:Women, is the first cardiac surgery trial to focus solely on women, with the goal of addressing underrepresentation. Through utilizing specific strategies, ROMA:Women is a promising first step in advancing health equity.

SUMMARY

Strategies to ensure effective recruitment and representation among women in cardiac surgery clinical trials, such as tailored eligibility criteria and comprehensive strategies to improve communication and increase trust, are two of many potential approaches to address the structural barriers to female representation in cardiac surgery clinical trials. To date, ROMA:Women is an example of a trial that has shown extraordinary preliminary success enrolling women. Designing trials exclusively for women is one strategy to improve the diversity of clinical trial participation.

Physical exercise in hypertensive heart disease: From the differential diagnosis to the complementary role of exercise

Arterial hypertension (AH) is one of the most common pathologic conditions and uncontrolled AH is a leading risk factor for cardiovascular disease and mortality. AH chronically causes myocardial and arterial remodelling with hemodynamic changes affecting the heart and other organs, with potentially irreversible consequences leading to poor outcomes. Therefore, a proper and early treatment of AH is crucial after the diagnosis. Beyond medical treatment, physical exercise also plays a therapeutic role in reducing blood pressure, given its potential effects on sympathetic tone, renin-angiotensin-aldosterone system, and endothelial function. International scientific societies recommend physical exercise among lifestyle modifications to treat AH in the first stages of the disease. Moreover, some studies have also shown its usefulness in addition to drugs to reduce blood pressure further. Therefore, an accurate, personalized exercise prescription is recommended to optimize the prevention and treatment of hypertension. On the other hand, uncontrolled AH in athletes requires proper risk stratification and careful evaluation to practice competitive sports safely. Moreover, the differential diagnosis between hypertensive heart disease and athlete's heart is sometimes challenging and requires a careful and comprehensive interpretation in order not to misinterpret the clinical findings. The present review aims to discuss the relationship between hypertensive heart disease and physical exercise, from diagnostic tools to prevention and treatment strategies.

Latent profiles of global electrical heterogeneity: the Hispanic Community Health Study/Study of Latinos

Aims

Despite the highest prevalence of stroke, obesity, and diabetes across races/ethnicities, paradoxically, Hispanic/Latino populations have the lowest prevalence of atrial fibrillation and major Minnesota code-defined ECG abnormalities. We aimed to use Latent Profile Analysis in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) population to obtain insight into epidemiological discrepancies.

Methods and results

We conducted a cross-sectional analysis of baseline HCHS/SOL visit. Global electrical heterogeneity (GEH) was measured as spatial QRS-T angle (QRSTa), spatial ventricular gradient azimuth (SVGaz), elevation (SVGel), magnitude (SVGmag), and sum absolute QRST integral (SAIQRST). Statistical analysis accounted for the stratified two-stage area probability sample design. We fitted a multivariate latent profile generalized structural equation model adjusted for age, sex, ethnic background, education, hypertension, diabetes, smoking, dyslipidaemia, obesity, chronic kidney disease, physical activity, diet quality, average RR' interval, median beat type, and cardiovascular disease (CVD) to gain insight into the GEH profiles. Among 15 684 participants (age 41 years; 53% females; 6% known CVD), 17% had an increased probability of likely abnormal GEH profile (QRSTa 80 ± 27°, SVGaz -4 ± 21°, SVGel 72 ± 12°, SVGmag 45 ± 12 mVms, and SAIQRST 120 ± 23 mVms). There was a 23% probability for a participant of being in Class 1 with a narrow QRSTa (40.0 ± 10.2°) and large SVG (SVGmag 108.3 ± 22.6 mVms; SAIQRST 203.4 ± 39.1 mVms) and a 60% probability of being in intermediate Class 2.

Conclusion

A substantial proportion (17%) in the Hispanic/Latino population had an increased probability of altered, likely abnormal GEH profile, whereas 83% of the population was resilient to harmful risk factors exposures.

Advances in targeting LDL cholesterol: PCSK9 inhibitors and beyond

There is a direct relationship between the duration and level of exposure to low density lipoprotein cholesterol (LDL-C) levels over one's lifespan and cardiovascular events. Early treatment to lower elevated LDL-C is crucial for better outcomes with multiple therapies currently available to reduce atherogenic lipoproteins. Statins remain the foundation of LDL-C lowering therapy as one of the most cost-effective drugs to reduce atherosclerotic events (ASCVD) and mortality. Nonetheless, LDL-driven goal attainment remains suboptimal globally, highlighting a considerable need for non-statin therapies to address residual risk related to statin intolerance, non-adherence, and inherited lipoprotein disorders. LDL-C lowering interventions beyond statins include ezetimibe, PCSK9 monoclonal antibodies, inclisiran and bempedoic acid with specific guideline recommendations as to when to consider each. For patients with homozygous familial hypercholesterolemia requiring more advanced therapy, lomitapide and evinacumab are available, providing mechanisms that are not LDL receptor dependent. Lipoprotein apheresis remains an effective option for clinical familial hypercholesterolemia as well as elevated lipoprotein (a). There are investigational therapies being explored to add to our current armamentarium including CETP inhibitors, a third-generation PCSK9 inhibitor (small recombinant fusion protein oral PCSK9 inhibitor) and gene editing which aims to directly restore or disrupt genes of interest at the DNA level. This article is a brief review of the pharmacotherapy options beyond statins for lowering LDL-C and their impact on ASCVD risk reduction. Our primary aim is to guide physicians on the role these therapies play in achieving appropriate LDL-C goals, with an algorithm of when to consider each based on efficacy, safety and outcomes.

Community-level bystander treatment and outcomes for witnessed out-of-hospital cardiac arrest in the state of Connecticut

Background

Prior reports have demonstrated underutilization of bystander cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use in patients with witnessed out-of-hospital cardiac arrest (OHCA) in Connecticut. This study aimed to identify community-level risk factors that contribute to low rates of bystander intervention to improve statewide OHCA outcomes.

Methods

We analyzed 2,789 adult patients with witnessed, non-traumatic OHCA submitted to the Connecticut Cardiac Arrest Registry to Enhance Survival (CARES) between 2013-2022. Patients were grouped by zip code, and associated municipal characteristics were acquired from 2022 United States Census Bureau data. Use of bystander CPR, attempted bystander AED defibrillation, and patient survival with favorable neurological function were determined for 19 of the 20 most populous cities and towns. Pearson correlation tests and linear regression were used to determine associations between OHCA treatment and outcomes with population size, racial/ethnic demographics, language use, income, and educational level.

Results

Bystander CPR was lower in municipalities with population size > 100,000 and in communities where > 40% of residents are non-English-speaking. AED use was also lower in these municipalities, as well as those with per capita incomes < $40,000 or > 1/3 Hispanic residents. Communities with populations > 100,000, > 40% non-English-speaking, per capita income < $40,000, and > 1/3 Hispanic residents were all associated with lower survival rates.

Conclusions

OHCA pre-hospital treatment and outcomes vary significantly by municipality in Connecticut. Community outcomes might be improved by specifically targeting urban population centers and Hispanic communities with culturally sensitive, low, or no-cost CPR and AED educational programs, using instructional languages other than English.

Prediction of presence and severity of metabolic syndrome using regional body volumes measured by a multisensor white-light 3D scanner and validation using a mobile technology

Aims

To test whether an index based on the combination of demographics and body volumes obtained with a multisensor 3D body volume (3D-BV) scanner and biplane imaging using a mobile application (myBVI®) will reliably predict the severity and presence of metabolic syndrome (MS).

Methods and results

We enrolled 1280 consecutive subjects who completed study protocol measurements, including 3D-BV and myBVI®. Body volumes and demographics were screened using the least absolute shrinkage and selection operator to select features associated with an MS severity score and prevalence. We randomly selected 80% of the subjects to train the models, and performance was assessed in 20% of the remaining observations and externally validated on 133 volunteers who prospectively underwent myBVI® measurements. The mean ± SD age was 43.7 ± 12.2 years, 63.7% were women, body mass index (BMI) was 28.2 ± 6.2 kg/m2, and 30.2% had MS and an MS severity z-score of -0.2 ± 0.9. Features β coefficients equal to zero were removed from the model, and 14 were included in the final model and used to calculate the body volume index (BVI), demonstrating an area under the receiving operating curve (AUC) of 0.83 in the validation set. The myBVI® cohort had a mean age of 33 ± 10.3 years, 61% of whom were women, 10.5% MS, an average MS severity z-score of -0.8, and an AUC of 0.88.

Conclusion

The described BVI model was associated with an increased severity and prevalence of MS compared with BMI and waist-to-hip ratio. Validation of the BVI had excellent performance when using myBVI®. This model could serve as a powerful screening tool for identifying MS.

Post cardiac arrest left ventricular ejection fraction associated with survival to discharge

Background

Post cardiac arrest left ventricular ejection fraction (LVEF) is routinely assessed, but the implications of this are unknown. This study aimed to assess the association between post cardiac arrest LVEF and survival to hospital discharge.

Methods

In this retrospective cohort study, all in-hospital and out of hospital cardiac arrests at our tertiary care center between January 2012 and September 2015 were included. Baseline demographics, clinical data, characteristics of the arrest, and interventions performed were collected. Earliest post cardiac arrest echocardiograms were reviewed with LVEF documented. The primary outcome was survival to discharge.

Results

A total of 736 patients were included in the analysis (mean age 58 years, 44% female). 15% were out of hospital cardiac arrest (24% shockable rhythm). After adjusting for covariates, patients with LVEF < 30% had 36% lower odds of surviving to hospital discharge than those with LVEF ≥ 52% (p = 0.014). Shockable initial rhythm and targeted temperature management were associated with improved survival.

Conclusion

After a cardiac arrest, an initial LVEF < 30% is associated with significantly lower odds of survival to hospital discharge.

Stroke Risk After Emergency Department Treat-and-Release Visit for a Fall

BACKGROUND

Previous cohort studies of hospitalized patients with a delayed diagnosis of ischemic stroke found that these patients often had an initial emergency department (ED) diagnosis of a fall. We sought to evaluate whether ED visits for a fall resulting in discharge to home (ie, treat-and-release visits) were associated with increased short-term ischemic stroke risk.

METHODS

A case-crossover design was used to compare ED visits for falls during case periods (0-15, 16-30, 31-90, and 91-180 days before stroke) and control periods (equivalent time periods exactly 1 year before stroke) using administrative data from the Healthcare Cost and Utilization Project on all hospital admissions and ED visits across 10 states from 2016 to 2020. To identify ED treat-and-release visits for a fall and patients hospitalized for acute ischemic stroke, we used previously validated International Classification of Diseases, Tenth Revision, Clinical Modification codes. Odds ratios and 95% CIs were calculated using conditional logistic regression.

RESULTS

Among 90 592 hospitalized patients with ischemic stroke, 5230 (5.8%) had an ED treat-and-release visit for a fall within 180 days before their stroke. Patients with an ED treat-and-release visit for a fall were older (mean age, 74.7 [SD, 14.6] versus 70.8 [SD, 15.1] years), more often female (61.9% versus 53.4%), and had higher rates of vascular comorbidities than other patients with stroke. ED treat-and-release visits for a fall were significantly more common in the 15 days before stroke compared with the 15-day control period 1 year earlier (odds ratio, 2.7 [95% CI, 2.4-3.1]). The association between stroke and a preceding ED treat-and-release visit for a fall decreased in magnitude with increasing temporal distance from stroke.

CONCLUSIONS

ED treat-and-release visits for a fall are associated with significantly increased short-term ischemic stroke risk. These visits may be opportunities to improve stroke diagnostic accuracy and treatment in the ED.

A cross-sectional study of Hispanic and Latina/o/x/e individuals' acute coronary syndrome symptom knowledge, attitudes, and beliefs

BACKGROUND

Little attention has been placed on language proficiency as a potential variable affecting ACS symptom knowledge, attitudes, and beliefs.

OBJECTIVES

To compare the ACS symptom knowledge, attitudes, and beliefs of Hispanic and Latina/o/x/e individuals proficient in English and in those only proficient in Spanish. Secondary aims were to determine if there were differences in ACS symptom knowledge, attitudes, or beliefs based on participants' previous exposure to ACS symptom information and to evaluate instrument characteristics of the new Spanish version of the ACS Response Index.

METHODS

This cross-sectional, comparative study included participants (N = 99) from a community-based clinic in Illinois. Knowledge, attitudes, and beliefs related to ACS symptoms were measured using the ACS Response Index.

RESULTS

The average participant was 39.8 (SD 15.6) years of age, female (n = 56, 56.6 %), and had a high school education or less (n = 61, 61.6 %). Participants correctly classified a mean 57.5 % (SD 12.8) of symptoms and had mean attitude and belief scores of 12.1 (SD 3.3) and 17.5 (SD 2.9), respectively. There were no significant differences in knowledge, attitudes, and beliefs based on language proficiency. However, there were some statistically significant differences for knowledge and attitude scores based on exposure to ACS symptom information. The ACS Response Index (Spanish Version) also demonstrated favorable internal consistency.

CONCLUSIONS

Overall knowledge, attitude, and belief scores were modest in this sample. Higher knowledge and attitude scores were observed for some types of ACS information exposure, supporting the importance of future educational efforts in this population.

Atrial Fibrillation and Heart Failure With Reduced Ejection Fraction: New Assessment of an Old Problem

Atrial fibrillation (AF) and heart failure (HF)-specifically, heart failure with reduced ejection fraction (HFrEF)-often coexist, and each contributes to the propagation of the other. This relationship extends from the mechanistic and physiological to clinical syndromes, quality of life, and long-term cardiovascular outcomes. The risk factors for AF and HF overlap and create a critical opportunity to prevent adverse outcomes among patients at greatest risk for either condition. Increasing recognition of the linkages between AF and HF have led to widespread interest in designing diagnostic, predictive, and interventional strategies targeting all aspects of disease, from identifying genetic predisposition to addressing social determinants of health. Advances across this spectrum culminated in updated multisociety guidelines for management of AF, which includes specific consideration of comorbid AF and HF. This review expands on these guidelines by further highlighting relevant clinical trial findings and providing additional context for the evolving recommendations for management in this important and growing population.

TRIM25-mediated XRCC1 ubiquitination accelerates atherosclerosis by inducing macrophage M1 polarization and programmed death

BACKGROUND

Macrophage-mediated cleaning up of dead cells is a crucial determinant in reducing coronary artery inflammation and maintaining vascular homeostasis. However, this process also leads to programmed death of macrophages. So far, the role of macrophage death in the progression of atherosclerosis remains controversial. Also, the underlying mechanism by which transcriptional regulation and reprogramming triggered by macrophage death pathways lead to changes in vascular inflammation and remodeling are still largely unknown. TRIM25-mediated RIG-I signaling plays a key role in regulation of macrophages fate, however the role of TRIM25 in macrophage death-mediated atherosclerotic progression remains unclear. This study aims to investigate the relationship between TRIM25 and macrophage death in atherosclerosis.

METHODS

A total of 34 blood samples of patients with coronary stent implantation, including chronic total occlusion (CTO) leisions (n = 14) or with more than 50% stenosis of a coronary artery but without CTO leisions (n = 20), were collected, and the serum level of TRIM25 was detected by ELISA. Apoe-/- mice with or without TRIM25 gene deletion were fed with the high-fat diet (HFD) for 12 weeks and the plaque areas, necrotic core size, aortic fibrosis and inflammation were investigated. TRIM25 wild-type and deficient macrophages were isolated, cultured and stimulated with ox-LDL, RNA-seq, real-time PCR, western blot and FACS experiments were used to screen and validate signaling pathways caused by TRIM25 deletion.

RESULTS

Downregulation of TRIM25 was observed in circulating blood of CTO patients and also in HFD-induced mouse aortas. After HFD for 12 weeks, TRIM25-/-ApoeE-/- mice developed smaller atherosclerotic plaques, less inflammation, lower collagen content and aortic fibrosis compared with TRIM25+/+ApoeE-/- mice. By RNA-seq and KEGG enrichment analysis, we revealed that deletion of TRIM25 mainly affected pyroptosis and necroptosis pathways in ox-LDL-induced macrophages, and the expressions of PARP1 and RIPK3, were significantly decreased in TRIM25 deficient macrophages. Overexpression of TRIM25 promoted M1 polarization and necroptosis of macrophages, while inhibition of PARP1 reversed this process. Further, we observed that XRCC1, a repairer of DNA damage, was significantly upregulated in TRIM25 deficient macrophages, inhibiting PARP1 activity and PARP1-mediated pro-inflammatory change, M1 polarization and necroptosis of macrophages. By contrast, TRIM25 overexpression mediated ubiquitination of XRCC1, and the inhibition of XRCC1 released PARP1, and activated macrophage M1 polarization and necroptosis, which accelerated aortic inflammation and atherosclerotic plaque progression.

CONCLUSIONS

Our study has uncovered a crucial role of the TRIM25-XRCC1Ub-PARP1-RIPK3 axis in regulating macrophage death during atherosclerosis, and we highlight the potential therapeutic significance of macrophage reprogramming regulation in preventing the development of atherosclerosis.

Spatially clustered type I interferon responses at injury borderzones

Sterile inflammation after myocardial infarction is classically credited to myeloid cells interacting with dead cell debris in the infarct zone1,2. Here we show that cardiomyocytes are the dominant initiators of a previously undescribed type I interferon response in the infarct borderzone. Using spatial transcriptomics analysis in mice and humans, we find that myocardial infarction induces colonies of interferon-induced cells (IFNICs) expressing interferon-stimulated genes decorating the borderzone, where cardiomyocytes experience mechanical stress, nuclear rupture and escape of chromosomal DNA. Cardiomyocyte-selective deletion of Irf3 abrogated IFNIC colonies, whereas mice lacking Irf3 in fibroblasts, macrophages, neutrophils or endothelial cells, Ccr2-deficient mice or plasmacytoid-dendritic-cell-depleted mice did not. Interferons blunted the protective matricellular programs and contractile function of borderzone fibroblasts, and increased vulnerability to pathological remodelling. In mice that died after myocardial infarction, IFNIC colonies were immediately adjacent to sites of ventricular rupture, while mice lacking IFNICs were protected from rupture and exhibited improved survival3. Together, these results reveal a pathological borderzone niche characterized by a cardiomyocyte-initiated innate immune response. We suggest that selective inhibition of IRF3 activation in non-immune cells could limit ischaemic cardiomyopathy while avoiding broad immunosuppression.