European Society of Cardiology: Cardiovascular Disease Statistics 2019

Essen Stroke Risk Score Predicts Carotid Atherosclerosis in Chinese Community Populations

BACKGROUND

Carotid atherosclerosis (CA) is closely related to stroke, and Framingham Risk Score (FRS) has been used for CA risk evaluation. However, FRS could only be used for subjects of up to 74 years old. The present study was to determine if Essen Stroke Risk Score (ESRS) could be used to estimate CA risk in community populations without age limits.

METHODS

In the present prospective multi-community screening study, we evaluated the prevalence of CA using high-resolution ultrasound in 521 males and 1039 females (35 to 91 years old). Both FRS and ESRS were calculated for the subjects. Multivariate logistic regression analysis was used to determine the predictive values of FRS and ESRS for CA in these subjects.

RESULTS

Ultrasound data showed that CA was present in 56.2% of the participants (total of 1560). Multivariate logistic regression analysis showed that ESRS was associated with CA with odds ratio (OR): 1.34 (95% confidence interval (CI), 1.12-1.60, p=0.001). Central obesity (OR: 1.40, CI: 1.07-1.83, p=0.015), female (OR: 0.55, CI: 0.39-0.77, p <0.001) and age (OR: 2.63, CI: 2.27-3.06, p <0.001) were also associated with CA. Based on the estimated area under curve (AUC), FRS (AUC 0.775) was better than ESRS (AUC 0.693) (z statistic 6.774, p <0.001) for CA prediction for individuals of ≤74 years old. However, receiver operating characteristic analysis showed ESRS was a good CA predictor for all subjects (AUC of 0.715).

CONCLUSION

ESRS could be used as an alternative to FRS to predict CA in community population of all age.

VCAM-1 Target in Non-Invasive Imaging for the Detection of Atherosclerotic Plaques

Simple Summary

Cardiovascular diseases are the first cause of morbimortality worldwide. They are mainly caused by atherosclerosis, with progressive plaque formation in the arterial wall. In this context, several imaging techniques have been developed to screen, detect and quantify atherosclerosis. Early screening improves primary prevention and promotes the prescription of adequate medication before adverse clinical events. In this review, we focus on the imaging of vascular cell adhesion molecule-1, an adhesion molecule involved in the first stages of the development of atherosclerosis. This molecule could therefore be a promising target to detect early atherosclerosis non-invasively. Potential clinical applications are critically discussed.

Abstract

Atherosclerosis is a progressive chronic arterial disease characterised by atheromatous plaque formation in the intima of the arterial wall. Several invasive and non-invasive imaging techniques have been developed to detect and characterise atherosclerosis in the vessel wall: anatomic/structural imaging, functional imaging and molecular imaging. In molecular imaging, vascular cell adhesion molecule-1 (VCAM-1) is a promising target for the non-invasive detection of atherosclerosis and for the assessment of novel antiatherogenic treatments. VCAM-1 is an adhesion molecule expressed on the activated endothelial surface that binds leucocyte ligands and therefore promotes leucocyte adhesion and transendothelial migration. Hence, for several years, there has been an increase in molecular imaging methods for detecting VCAM-1 in MRI, PET, SPECT, optical imaging and ultrasound. The use of microparticles of iron oxide (MPIO), ultrasmall superparamagnetic iron oxide (USPIO), microbubbles, echogenic immunoliposomes, peptides, nanobodies and other nanoparticles has been described. However, these approaches have been tested in animal models, and the remaining challenge is bench-to-bedside development and clinical applicability.

Lifelong voluntary aerobic exercise prevents age- and Western diet- induced vascular dysfunction, mitochondrial oxidative stress and inflammation in mice

KEY POINTS

The results of the present study establish the temporal pattern of age-related vascular dysfunction across the adult lifespan in sedentary mice consuming a non-Western diet, and the underlying mechanisms The results demonstrate that consuming a Western diet accelerates and exacerbates vascular ageing across the lifespan in sedentary mice They also show that lifelong voluntary aerobic exercise has remarkable protective effects on vascular function throughout the lifespan, in the setting of ageing alone, as well as ageing compounded by Western diet consumption Overall, the results indicate that amelioration of mitochondrial oxidative stress and inflammation are key mechanisms underlying the voluntary aerobic exercise-associated preservation of vascular function across the lifespan in both the presence and absence of a Western dietary pattern ABSTRACT: Advancing age is the major risk factor for cardiovascular diseases, driven largely by vascular endothelial dysfunction (impaired endothelium-dependent dilatation, EDD) and aortic stiffening (increased aortic pulse wave velocity, aPWV). In humans, vascular ageing occurs in the presence of differences in diet and physical activity, but the interactive effects of these factors are unknown. We assessed carotid artery EDD and aPWV across the lifespan in mice consuming standard (normal) low-fat chow (NC) or a high-fat/high-sucrose Western diet (WD) in the absence (sedentary, SED) or presence (voluntary wheel running, VWR) of aerobic exercise. Ageing impaired nitric oxide-mediated EDD (peak EDD 88 ± 12% 6 months P = 0.003 vs. 59 ± 9% 27 months NC-SED), which was accelerated by WD (60 ± 18% 6 months WD-SED). In NC mice, aPWV increased 32% with age (423 ± 13 cm/s at 24 months P < 0.001 vs. 321 ± 12 cm/s at 6 months) and absolute values were an additional ∼10% higher at any age in WD mice (P = 0.042 vs. NC-SED). Increases in aPWV with age in NC and WD mice were associated with 30-65% increases in aortic intrinsic wall stiffness (6 vs. 19-27 months, P = 0.007). Lifelong aerobic exercise prevented age- and WD-related vascular dysfunction across the lifespan, and this protection appeared to be mediated by mitigation of vascular mitochondrial oxidative stress and inflammation. Our results depict the temporal impairment of vascular function over the lifespan in mice, acceleration and exacerbation of that dysfunction with WD consumption, the remarkable protective effects of voluntary aerobic exercise, and the underlying mechanisms.

Women’s Cardiac Health in 2020: A Systematic Review

Although substantial progress has been made toward improving gender- and sex-specific cardiovascular disease (CVD) management and outcomes, contemporary reports indicate a persistent knowledge gap with regard to optimal risk-stratification and management in female cardiac heart disease (CHD) patients. Prominent patient and system delays in diagnosing CHD are, in part, due to the limited awareness for the latent CVD risk in women, a lack of sex-specific thresholds within clinical guidelines, and subsequent limited performance of contemporary diagnostic approaches in women. Several traditional risk factors for CHD affect both women and men. But other factors can play a bigger role in the development of heart disease in women. In addition, little is known about the influence of socioenvironmental and contextual factors on gender-specific disease manifestation and outcomes. It is imperative that we understand the mechanisms that contribute to worsening risk factors profiles in young women to reduce future atherosclerotic CVD morbidity and mortality. This comprehensive review focuses on the novel aspects of cardiovascular health in women and sex differences as they relate to clinical practice and prevention, diagnosis, and treatment of CVD. Increased recognition of the prevalence of traditional cardiovascular risk factors and their differential impact in women, as well as emerging nontraditional risk factors unique to or more common in women, contribute to new understanding mechanisms, leading to worsening outcome for women.

BRD4 (Bromodomain-Containing Protein 4) Interacts with GATA4 (GATA Binding Protein 4) to Govern Mitochondrial Homeostasis in Adult Cardiomyocytes

BACKGROUND

Gene regulatory networks control tissue homeostasis and disease progression in a cell type-specific manner. Ubiquitously expressed chromatin regulators modulate these networks, yet the mechanisms governing how tissue specificity of their function is achieved are poorly understood. BRD4 (bromodomain-containing protein 4), a member of the BET (bromo- and extraterminal domain) family of ubiquitously expressed acetyl-lysine reader proteins, plays a pivotal role as a coactivator of enhancer signaling across diverse tissue types in both health and disease and has been implicated as a pharmacological target in heart failure. However, the cell-specific role of BRD4 in adult cardiomyocytes remains unknown.

METHODS

We combined conditional mouse genetics, unbiased transcriptomic and epigenomic analyses, and classic molecular biology and biochemical approaches to understand the mechanism by which BRD4 in adult cardiomyocyte homeostasis.

RESULTS

Here, we show that cardiomyocyte-specific deletion of Brd4 in adult mice leads to acute deterioration of cardiac contractile function with mutant animals demonstrating a transcriptomic signature characterized by decreased expression of genes critical for mitochondrial energy production. Genome-wide occupancy data show that BRD4 enriches at many downregulated genes (including the master coactivators Ppargc1a, Ppargc1b, and their downstream targets) and preferentially colocalizes with GATA4 (GATA binding protein 4), a lineage-determining cardiac transcription factor not previously implicated in regulation of adult cardiac metabolism. BRD4 and GATA4 form an endogenous complex in cardiomyocytes and interact in a bromodomain-independent manner, revealing a new functional interaction partner for BRD4 that can direct its locus and tissue specificity.

CONCLUSIONS

These results highlight a novel role for a BRD4-GATA4 module in cooperative regulation of a cardiomyocyte-specific gene program governing bioenergetic homeostasis in the adult heart.

Medical Treatment in Coronary Patients: Is there Still a Gender Gap? Results from European Society of Cardiology EUROASPIRE V Registry

PURPOSE

This study is aimed at investigating gender differences in the medical management of patients with coronary heart disease (CHD).

METHODS

Analyses were based on the ESC EORP EUROASPIRE V (European Survey Of Cardiovascular Disease Prevention And Diabetes) survey. Consecutive patients between 18 and 80 years, hospitalized for a coronary event, were included in the study. Information on cardiovascular medication intake at hospital discharge and at follow-up (≥ 6 months to < 2 years after hospitalization) was collected.

RESULTS

Data was available for 8261 patients (25.8% women). Overall, no gender differences were observed in the prescription and use of cardioprotective medication like aspirin, beta-blockers, and ACE-I/ARBs (P > 0.01) at discharge and follow-up respectively. However, a statistically significant difference was found in the use of statins at follow-up, in disfavor of women (82.8% vs. 77.7%; P < 0.001). In contrast, at follow-up, women were more likely to use diuretics (31.5% vs. 39.5%; P < 0.001) and calcium channel blockers (21.2% vs. 28.8%; P < 0.001), whereas men were more likely to use anticoagulants (8.8% vs. 7.0%; P < 0.001). Overall, no gender differences were found in total daily dose intake (P > 0.01). Furthermore, women were less likely than men to have received a CABG (20.4% vs. 13.2%; P < 0.001) or PCI (82.1% vs. 74.9%; P < 0.001) at follow-up. No gender differences were observed in prescribed (P = 0.10) and attended (P = 0.63) cardiac rehabilitation programs.

CONCLUSION

The EUROASPIRE V results show only limited gender differences in the medical management of CHD patients. Current findings suggest growing awareness about risk in female CHD patients.

Angiogenesis after acute myocardial infarction

Acute myocardial infarction (MI) inflicts massive injury to the coronary microcirculation leading to vascular disintegration and capillary rarefication in the infarct region. Tissue repair after MI involves a robust angiogenic response that commences in the infarct border zone and extends into the necrotic infarct core. Technological advances in several areas have provided novel mechanistic understanding of postinfarction angiogenesis and how it may be targeted to improve heart function after MI. Cell lineage tracing studies indicate that new capillary structures arise by sprouting angiogenesis from pre-existing endothelial cells (ECs) in the infarct border zone with no meaningful contribution from non-EC sources. Single-cell RNA sequencing shows that ECs in infarcted hearts may be grouped into clusters with distinct gene expression signatures, likely reflecting functionally distinct cell populations. EC-specific multicolour lineage tracing reveals that EC subsets clonally expand after MI. Expanding EC clones may arise from tissue-resident ECs with stem cell characteristics that have been identified in multiple organs including the heart. Tissue repair after MI involves interactions among multiple cell types which occur, to a large extent, through secreted proteins and their cognate receptors. While we are only beginning to understand the full complexity of this intercellular communication, macrophage and fibroblast populations have emerged as major drivers of the angiogenic response after MI. Animal data support the view that the endogenous angiogenic response after MI can be boosted to reduce scarring and adverse left ventricular remodelling. The improved mechanistic understanding of infarct angiogenesis therefore creates multiple therapeutic opportunities. During preclinical development, all proangiogenic strategies should be tested in animal models that replicate both cardiovascular risk factor(s) and the pharmacotherapy typically prescribed to patients with acute MI. Considering that the majority of patients nowadays do well after MI, clinical translation will require careful selection of patients in need of proangiogenic therapies.

[Statement of the Spanish Interdisciplinary Vascular Prevention Committee on the updated European Cardiovascular Prevention Guidelines]

We present the adaptation for Spain of the updated European Cardiovascular Prevention Guidelines. In this update, greater stress is laid on the population approach, and especially on the promotion of physical activity and healthy diet through dietary, leisure and active transport policies in Spain. To estimate vascular risk, note should be made of the importance of recalibrating the tables used, by adapting them to population shifts in the prevalence of risk factors and incidence of vascular diseases, with particular attention to the role of chronic kidney disease. At an individual level, the key element is personalised support for changes in behaviour, adherence to medication in high-risk individuals and patients with vascular disease, the fostering of physical activity, and cessation of smoking habit. Furthermore, recent clinical trials with PCSK9 inhibitors are reviewed, along with the need to simplify pharmacological treatment of arterial hypertension to improve control and adherence to treatment. In the case of patients with type 2 diabetes mellitus and vascular disease or high vascular disease risk, when lifestyle changes and metformin are inadequate, the use of drugs with proven vascular benefit should be prioritised. Lastly, guidelines on peripheral arterial disease and other specific diseases are included, as is a recommendation against prescribing antiaggregants in primary prevention.

Men and COVID-19: the aftermath

The global pandemic as a result of the SARS-CoV2 virus has seen over 16 m people infected and over 650,000 deaths, with men at double the risk of both developing the severe form of the disease and mortality. There are both biological (sex) and socio-cultural (gender) factors, compounded by socio-economic factors and ethnicity, that impact on the aftermath of what has occurred over the short time that this novel coronavirus has been circulating the world. The potential life-long morbidity as a result of the infection and as a consequence of highly invasive critical care treatment needs to be factored into the rehabilitation of survivors. There are also many men whose lives will have been severely affected both physically and emotionally by the pandemic without ever contracting the disease, with the widespread disruption to normal existence and its impact on their social world and the economy. The implications of the closure of many healthcare services over the initial lockdown will also have both a shorter- and longer-term impact on other diseases due to missed early diagnosis and disrupted treatment regimes. Getting effective public health messages out to the population is critical and this current pandemic is demonstrating that there needs to be a more focused view on men's health behavior. Without effective public support for preventative action, the more likely the disease will continue its path unabated. This review explores the wider ramifications of the disease both for those men who have survived the disease and those that have been affected by the wider social effects of the pandemic. The pandemic should be a wake-up call for all involved in the planning and delivery of health and social care for the greater attention to the central role of sex and gender.

Role of CMR Mapping Techniques in Cardiac Hypertrophic Phenotype

Non-ischemic cardiomyopathies represent a heterogeneous group of myocardial diseases potentially leading to heart failure, life-threatening arrhythmias, and eventually death. Myocardial dysfunction is associated with different underlying pathological processes, ultimately inducing changes in morphological appearance. Thus, classification based on presenting morphological phenotypes has been proposed, i.e., dilated, hypertrophic, restrictive, and right ventricular cardiomyopathies. In light of the key diagnostic and prognostic role of morphological and functional features, cardiovascular imaging has emerged as key element in the clinical workflow of suspected cardiomyopathies, and above all, cardiovascular magnetic resonance (CMR) represents the ideal technique to be used: thanks to its physical principles, besides optimal spatial and temporal resolutions, incomparable contrast resolution allows to assess myocardial tissue abnormalities in detail. Traditionally, weighted images and late enhancement images after gadolinium-based contrast agent administration have been used to perform tissue characterization, but in the last decade quantitative assessment of pre-contrast longitudinal relaxation time (native T1), post-contrast longitudinal relaxation time (post-contrast T1) and transversal relaxation time (T2), all displayed with dedicated pixel-wise color-coded maps (mapping), has contributed to give precious knowledge insight, with positive influence of diagnostic accuracy and prognosis assessment, mostly in the setting of the hypertrophic phenotype. This review aims to describe the available evidence of the role of mapping techniques in the assessment of hypertrophic phenotype, and to suggest their integration in the routine CMR evaluation of newly diagnosed cardiomyopathies with increased wall thickness.

Roles and mechanisms of renalase in cardiovascular disease: A promising therapeutic target

Cardiovascular disease (CVD) is prevalent worldwide and remains a leading cause of death. Although substantial progress has been made in the diagnosis and treatment of CVD, the prognosis remains unsatisfactory. Renalase is a newly discovered cytokine that is synthesized by the kidney and then secreted into blood. Numerous studies have suggested the efficacy of renalase in treating CVD by metabolizing catecholamines in the circulatory system. As a new biomarker of heart disease, renalase is normally recognized as a signalling molecule that activates cytoprotective intracellular signals to lower blood pressure, protect ischaemic heart muscle and promote atherosclerotic plaque stability in CVD, which subsequently improves cardiac function. Due to its important regulatory role in the circulatory system, renalase has gradually become a potential target in the treatment of CVD. This review summarizes the structure, mechanism and function of renalase in CVD, thereby providing preclinical evidence for alternative approaches and new prospects in the development of renalase-related drugs against CVD.

Coronary Microvascular Dysfunction

Many patients with chest pain undergoing coronary angiography do not show significant obstructive coronary lesions. A substantial proportion of these patients have abnormalities in the function and structure of coronary microcirculation due to endothelial and smooth muscle cell dysfunction. The coronary microcirculation has a fundamental role in the regulation of coronary blood flow in response to cardiac oxygen requirements. Impairment of this mechanism, defined as coronary microvascular dysfunction (CMD), carries an increased risk of adverse cardiovascular clinical outcomes. Coronary endothelial dysfunction accounts for approximately two-thirds of clinical conditions presenting with symptoms and signs of myocardial ischemia without obstructive coronary disease, termed "ischemia with non-obstructive coronary artery disease" (INOCA) and for a small proportion of "myocardial infarction with non-obstructive coronary artery disease" (MINOCA). More frequently, the clinical presentation of INOCA is microvascular angina due to CMD, while some patients present vasospastic angina due to epicardial spasm, and mixed epicardial and microvascular forms. CMD may be associated with focal and diffuse epicardial coronary atherosclerosis, which may reinforce each other. Both INOCA and MINOCA are more common in females. Clinical classification of CMD includes the association with conditions in which atherosclerosis has limited relevance, with non-obstructive atherosclerosis, and with obstructive atherosclerosis. Several studies already exist which support the evidence that CMD is part of systemic microvascular disease involving multiple organs, such as brain and kidney. Moreover, CMD is strongly associated with the development of heart failure with preserved ejection fraction (HFpEF), diabetes, hypertensive heart disease, and also chronic inflammatory and autoimmune diseases. Since coronary microcirculation is not visible on invasive angiography or computed tomographic coronary angiography (CTCA), the diagnosis of CMD is usually based on functional assessment of microcirculation, which can be performed by both invasive and non-invasive methods, including the assessment of delayed flow of contrast during angiography, measurement of coronary flow reserve (CFR) and index of microvascular resistance (IMR), evaluation of angina induced by intracoronary acetylcholine infusion, and assessment of myocardial perfusion by positron emission tomography (PET) and magnetic resonance (CMR).

The effect of feedback on cardiovascular risk factors on optimization of primary prevention: The PharmLines initiative

BACKGROUND

It is unknown whether population based single assessment of cardiovascular disease (CVD) risk and feedback to individuals and general practitioners results in initiation of preventive cardiovascular pharmacotherapy in those at risk.

METHODS

The population based cohort study Lifelines was linked to the IADB.nl pharmacy database to assess information on the initiation of preventive medication (N = 48,770). At the baseline visit, information on cardiovascular risk factors was collected and reported to the participants and their general practitioners. An interrupted-time-series-analysis was plotted, in which the start year of blood pressure and lipid lowering medication was displayed in years before or after the baseline visit. Subsequently, predictors of the initiation of pharmacotherapy were determined and possible reduction in cardiovascular events that could be achieved by optimal treatment of individuals at risk.

RESULTS

Before the Lifelines baseline visit, 34% (out of 1,527, 95% Confidence interval (CI) 32%-36%) and 30% (out of 1,991, 95%CI 28%-32%) of the individuals at risk had a blood pressure or lipid lowering drug prescription, respectively. In those at risk, the use of blood pressure lowering medication, increased substantially during the year of the baseline visit. Treating individuals at increased risk (≥5% 10-year risk) with lipid or blood pressure lowering medication (N = 8515 and N = 6899) would have prevented 162 and 183 CVD events, respectively, in the upcoming five years.

CONCLUSION

Primary prevention of CVD in the general population appears suboptimal. Feedback of cardiovascular risk factors resulted in a substantial increase of blood pressure lowering medication and extrapolated health benefits.

Efficacy and tolerability of alirocumab in Austrian clinical practice - results of the non-interventional PEARL-AT study

OBJECTIVE

Proprotein convertase subtilisin/kexin type 9 inhibition can be an effective treatment in patients with primary hypercholesterolemia, particularly in cases with concomitant coronary heart disease, peripheral artery occlusive disease or cerebrovascular occlusive disease for secondary prevention after an acute atherosclerotic ischemic event. The primary objective of the PEARL-AT study was to assess effectiveness and safety of alirocumab in a real-world setting in Austria.

METHODS

Non-interventional, prospective study conducted across Austria between September 2016 and July 2018. 113 patients, for whom the decision for treatment with alirocumab according to the Austrian Summary of Product Characteristics (SmPC) was made, were enrolled and were followed-up over 24 weeks. The primary endpoint of the study was the average change of low density lipoprotein cholesterol (LDL-C) levels by week 24.

RESULTS

In total, 112 patients with at least one post-baseline visit were included. Alirocumab was initiated using 75 mg (57.1%) and 150 mg (42.9%) every two weeks. Average LDL-C levels decreased by 75.0 mg/dl at week 24 in 87 patients with available LDL-C at baseline and week 24 (in 25 patients LDL-C was missing at least at one time point). The mean relative change of LDL-C was -50.0% (median: 57.8%, SD: 28.4). Throughout the study, 46 adverse events were documented in 21 (18.6%) patients. The most frequent adverse events were gastrointestinal disorders.

CONCLUSIONS

The present data indicate a good overall efficacy of alirocumab in a real-world Austrian population. Effectiveness and safety were both in line with the clinical trial program as well as previous real-world observations.

Telemedicine consultation for the clinical cardiologists in the era of COVID-19: present and future. Consensus document of the Spanish Society of Cardiology

The coronavirus disease 2019 (COVID-19) pandemic has changed how we view our consultations. To reduce the risk of spread in the most vulnerable patients (those with heart disease) and health personnel, most face-to-face consultations have been replaced by telemedicine consultations. Although this change has been rapidly introduced, it will most likely become a permanent feature of clinical practice. Nevertheless, there remain serious doubts about organizational and legal issues, as well as the possibilities for improvement etc. In this consensus document of the Spanish Society of Cardiology, we attempt to provide some keys to improve the quality of care in this new way of working, reviewing the most frequent heart diseases attended in the cardiology outpatient clinic and proposing some minimal conditions for this health care process. These heart diseases are ischemic heart disease, heart failure, and arrhythmias. In these 3 scenarios, we attempt to clarify the basic issues that must be checked during the telephone interview, describe the patients who should attend in person, and identify the criteria to refer patients for follow-up in primary care. This document also describes some improvements that can be introduced in telemedicine consultations to improve patient care.

The risk of cardiovascular complications in inflammatory bowel disease

Inflammatory bowel disease (IBD) is a chronic, relapsing disease of unknown etiology involving gastrointestinal tract. IBD comprises two main entities: ulcerative colitis and Crohn's disease. Several studies showed increased risk of cardiovascular complications in chronic inflammatory disorders, especially during IBD relapses. Endothelium plays a role in physiologic regulation of vascular tone, cell adhesion, migration and resistance to thrombosis. Also, its dysfunction is associated with increased risk of atherosclerosis development. There are several potential links between chronic IBD-related inflammatory processes and the risk of cardiovascular disease, but insight into pathogenetic pathways remains unclear. We present the current concepts and review of adult and pediatric studies on the risk of CVD in IBD.

Personalized medicine for cardiovascular diseases

Personalized medicine is an emerging concept involving managing the health of patients based on their individual characteristics, including particular genotypes. Cardiovascular diseases are heritable traits, and family history information is useful for risk prediction. As such, determining genetic information (germline genetic mutations) may also be applied to risk prediction. Furthermore, accumulating evidence suggests that genetic background can provide guidance for selecting effective treatments and preventive strategies in individuals with particular genotypes. These concepts may be applicable both to rare Mendelian diseases and to common complex traits. In this review, we define the concept and provide examples of personalized medicine based on human genetics for cardiovascular diseases, including coronary artery disease, arrhythmia, and cardiomyopathies. We also provide a particular focus on Mendelian randomization studies, especially those examining loss-of function genetic variations, for identifying high-risk individuals, as well as signaling pathways that may be useful targets for improving healthy living without cardiovascular events.

Update Lebensstil – Was funktioniert in der Praxis?

Aktuelle Versorgungsstudien zeigen eine alarmierende Zunahme Lebensstil-assoziierter kardiovaskulärer Risikofaktoren, wie Adipositas und körperliche Inaktivität, in der Gesamtbevölkerung und bei Patienten mit Herz-Kreislauf-Erkrankungen. Um dem entgegenzuwirken, ist es wichtig, Patienten nach Koronarereignissen langfristig zu Verhaltensänderungen zu motivieren. Eine kürzlich publizierte Studie zeigte, dass ein intensives Präventionsprogramm (IPP) für 12 Monate, das primär von nicht ärztlichen Präventionsassistenten durchgeführt wurde und auf engmaschigen Kontakten zu den Patienten beruhte, die kardiovaskulären Risikofaktoren nachhaltig besser einstellen konnte. In der Gesamtbevölkerung ist eine Anleitung zu Lebensstilmodifikationen in verschiedenen Lebensphasen wichtig: beginnend im Kindes- und Jugendalter, über das Berufsleben, bis hin zum Rentenalter. Ein besonders hoher Bedarf besteht in Bevölkerungsschichten mit niedrigem sozioökonomischen Status. Durch präventive Maßnahmen, wie Aufklärung zu mehr Bewegung, gesunder Ernährung und Nicht-Rauchen, kann hier ein großer Beitrag geleistet werden, die kardiovaskuläre Morbidität und Letalität zu senken.

Rosuvastatin/Ezetimibe: A Review in Hypercholesterolemia

Rosuvastatin/ezetimibe combines two lipid-lowering agents: rosuvastatin, an HMG-CoA reductase inhibitor (i.e. statin) with particularly strong inhibitory effects on hepatic cholesterol synthesis, and ezetimibe, which inhibits the intestinal absorption of cholesterol. A fixed-dose combination (FDC) of rosuvastatin/ezetimibe is indicated as an adjunctive therapy to diet for the management of primary hypercholesterolemia in adults in numerous countries worldwide. In well-designed clinical trials evaluating the therapeutic efficacy of rosuvastatin/ezetimibe administered as either separate agents or as an FDC, rosuvastatin/ezetimibe was significantly more effective than rosuvastatin monotherapy (including at double the dose of rosuvastatin) or simvastatin/ezetimibe in reducing low-density lipoprotein cholesterol (LDL-C) and total cholesterol in adults with hypercholesterolemia. Furthermore, rosuvastatin/ezetimibe enabled significantly higher proportions of patients to achieve recommended LDL-C levels than rosuvastatin monotherapy or simvastatin/ezetimibe. Rosuvastatin/ezetimibe did not significantly differ from rosuvastatin monotherapy with respect to incidences of treatment-related or serious adverse events in these short-term trials and displayed a similar safety profile to simvastatin/ezetimibe. While additional cardiovascular outcomes data and head-to-head comparisons with atorvastatin/ezetimibe would be of interest, rosuvastatin/ezetimibe is a potent and generally well-tolerated drug combination that extends the range of options available for the pharmacological management of primary hypercholesterolemia in adults.

Is the Retinol-Binding Protein 4 a Possible Risk Factor for Cardiovascular Diseases in Obesity?

Although many preventive and treatment approaches have been proposed, cardiovascular disease (CVD) remains one of the leading causes of deaths worldwide. Current epidemiological data require the specification of new causative factors, as well as the development of improved diagnostic tools to provide better cardiovascular management. Excessive accumulation of adipose tissue among patients suffering from obesity not only constitutes one of the main risk factors of CVD development but also alters adipokines. Increased attention is devoted to bioactive adipokines, which are also produced by the adipose tissue. The retinol-binding protein 4 (RBP4) has been associated with numerous CVDs and is presumably associated with an increased cardiovascular risk. With this in mind, exploring the role of RBP4, particularly among patients with obesity, could be a promising direction and could lead to better CVD prevention and management in this patient group. In our review, we summarized the current knowledge about RBP4 and its association with essential aspects of cardiovascular disease-lipid profile, intima-media thickness, atherosclerotic process, and diet. We also discussed the RBP4 gene polymorphisms essential from a cardiovascular perspective.

Two early rehabilitation training models in male patients after coronary artery bypass surgery: application of continuous walking training as an alternative to interval cycle ergometer training

Introduction

Walking training is a good alternative to the commonly used cycle ergometer training. It is still necessary to develop rehabilitation programs based on walking characterized by a high degree of safety and effectiveness.

Aim

Application of continuous walking training as an alternative to interval cycle ergometer training in men after coronary artery bypass graft (CABG) surgery, using the 6-minute walk test (6-MWT) to determine the initial training load.

Material and methods

Forty-four men aged 45 to 76 years, up to 3 months after CABG surgery, were randomly assigned to continuous training on a treadmill (study group) or interval training on a cycle ergometer (control group), performed 6 times per week (12-15 sessions). Participants underwent the treadmill exercise stress test (TEST) and 6-MWT at the begining and after completion of the rehabilitation program. Before and 3 minutes after the 6^th and 12^th training session blood lactate concentration was determined.

Results

Energy expenditure in TEST increased from 4.4 to 6.3 MET in the study group and from 5.0 to 6.5 MET in the control group. Distance walked in 6-MWT increased from 420 to 519 m and from 438 to 510 m, respectively. Resting heart rate (HR) and double product (DP) decreased only in the study group as well as systolic blood pressure (SBP), HR and DP at peak exercise load in baseline TEST. Mean energy expenditure during training sessions was 2.6 MET in the study group and 2.8 MET in the control group (NS). Exercise blood lactate concentration did not exceed 2.0 mmol/l in both groups.

Conclusions

Both rehabilitation programs were of similar effectiveness and their intensity did not exceed the anaerobic threshold.

Lost in circulation

BACKGROUND

Device complications in complex percutaneous coronary interventions are rare but potentially deadly. Surgical removal is often required. However, an evaluation of surgical therapy beyond case reports is practically not existent.

METHODS

We prospectively followed all cases of retained guide wires and/or other devices referred to us for surgical removal between 2015 and 2019 and retrospectively searched our database for such cases between 2010 and 2014.

RESULTS

From 2015 on, eight cases were referred for surgical removal from six different cardiology departments. In the 5 years before, there was not a single case. Six patients were operated emergently. Patients were 60.5 ± 5.42 years old, overweight (body mass index 30.1 ± 3.77) and except for one case (left ventricular-assist device) showed preserved ejection fraction (EF) (mean EF 57 ± 18.01). The retained devices were mostly located in the right coronary artery (50%), followed by the circumflex artery (37.5%) and diagonal branch (12.5%). The devices were remnants of guide wires (n = 4), balloon catheters (n = 3), and in one case a rotablator. Full sternotomy was performed in six patients and two received a left-sided minithoracotomy (n = 2). The operations were performed on-pump in five (62.5%) and off-pump in three patients. Complete extraction of the foreign bodies was possible in all patients. Two patients died; one in unrelated multiorgan failure and one due to retained-device-related right heart failure. The other patients survived and had uneventful postoperative courses.

CONCLUSIONS

Retained foreign bodies from cardiac interventions can be completely removed surgically using individualized approaches. There appears to be a trend toward a rising incidence of such interventional complications.

[Telemedicine consultation for the clinical cardiologists in the era of COVID-19: present and future. Consensus document of the Spanish Society of Cardiology]

La pandemia producida por la infección por el coronavirus SARS-CoV-2 (COVID-19) ha cambiado la forma de entender nuestras consultas. Para reducir el riesgo de contagio de los pacientes más vulnerables (aquellos con cardiopatías) y del personal sanitario, se han suspendido la mayoría de las consultas presenciales y se han puesto en marcha las consultas telemáticas. Este cambio se ha implementado en muy poco tiempo, pero parece que ha venido para quedarse. No obstante, hay grandes dudas sobre aspectos organizativos, legales, posibilidades de mejora, etc. En este documento de consenso de la Sociedad Española de Cardiología, tratamos de dar las claves para mejorar la calidad asistencial en nuestras nuevas consultas telemáticas, revisando las afecciones que el cardiólogo clínico atiende con más frecuencia en su consulta ambulatoria y proponiendo unos mínimos en ese proceso asistencial. Estas enfermedades son la cardiopatía isquémica, la insuficiencia cardiaca y las arritmias. En los 3 escenarios tratamos de clarificar los aspectos fundamentales que hay que revisar en la entrevista telefónica, a qué pacientes habrá que atender en una consulta presencial y cuáles serán los criterios para su seguimiento en atención primaria. El documento también recoge distintas mejoras que pueden introducirse en la consulta telemática para mejorar la asistencia de nuestros pacientes.

Targeting mitochondrial fitness as a strategy for healthy vascular aging

Cardiovascular diseases (CVD) are the leading cause of death worldwide and aging is the primary risk factor for CVD. The development of vascular dysfunction, including endothelial dysfunction and stiffening of the large elastic arteries (i.e., the aorta and carotid arteries), contribute importantly to the age-related increase in CVD risk. Vascular aging is driven in large part by oxidative stress, which reduces bioavailability of nitric oxide and promotes alterations in the extracellular matrix. A key upstream driver of vascular oxidative stress is age-associated mitochondrial dysfunction. This review will focus on vascular mitochondria, mitochondrial dysregulation and mitochondrial reactive oxygen species (ROS) production and discuss current evidence for prevention and treatment of vascular aging via lifestyle and pharmacological strategies that improve mitochondrial health. We will also identify promising areas and important considerations ('research gaps') for future investigation.

Mapping interventional cardiology in Europe: the European Association of Percutaneous Cardiovascular Interventions (EAPCI) Atlas Project

Aims

The European Association of Percutaneous Cardiovascular Interventions (EAPCI) Atlas of Interventional Cardiology has been developed to map interventional practice across European Society of Cardiology (ESC) member countries. Here we present the main findings of a 16-country survey in which we examine the national availability of interventional infrastructure, human resource, and procedure volumes.

Methods and results

Sixteen ESC member countries participated in the EAPCI Atlas survey. Interventional data were collected by the National Cardiac Society of each participating country. An annual median of 5131 [interquartile range (IQR) 4013–5801] diagnostic heart procedures per million people were reported, ranging from &lt;2500 in Egypt and Romania to &gt;7000 in Turkey and Germany. Procedure rates showed significant correlation (r = 0.67, P = 0.013) with gross national income (GNI) per capita. An annual median of 2478 (IQR 1690–2633) percutaneous coronary interventions (PCIs) per million people were reported, ranging from &lt;1000 in Egypt and Romania to &gt;3000 in Switzerland, Poland, and Germany. Procedure rates showed significant correlation with GNI per capita (r = 0.62, P = 0.014). An annual median of 48.2 (IQR 29.1–105.2) transcatheter aortic valve implantation procedures per million people were performed, varying from &lt;25 per million people in Egypt, Romania, Turkey, and Poland to &gt;100 per million people in Denmark, France, Switzerland, and Germany. Procedure rates showed significant correlation with national GNI per capita (r = 0.92, P &lt; 0.001).

Conclusion

The first report from the EAPCI Atlas has shown considerable international heterogeneity in interventional cardiology procedure volumes. The heterogeneity showed association with national economic resource, a reflection no doubt of the technological costs of developing an interventional cardiology service.

Late-life voluntary wheel running reverses age-related aortic stiffness in mice: a translational model for studying mechanisms of exercise-mediated arterial de-stiffening

Aortic stiffening, assessed as pulse-wave velocity (PWV), increases with age and is an important antecedent to, and independent predictor of, cardiovascular diseases (CVD) and other clinical disorders of aging. Aerobic exercise promotes lower levels of aortic stiffness in older adults, but the underlying mechanisms are incompletely understood, largely due to inherent challenges of mechanistic studies of large elastic arteries in humans. Voluntary wheel running (VWR) is distinct among experimental animal exercise paradigms in that it allows investigation of the physiologic effects of aerobic training without potential confounding influences of aversive molecular signaling related to forced exercise. In this study, we investigated whether VWR in mice may be a suitable model for mechanistic studies (i.e., "reverse translation") of the beneficial effects of exercise on arterial stiffness in humans. We found that 10 weeks of VWR in old mice (~ 28 months) reversed age-related elevations in aortic PWV assessed in vivo (Old VWR: 369 ± 19 vs. old sedentary: 439 ± 20 cm/s, P < 0.05). The de-stiffening effects of VWR were accompanied by normalization of age-related increases in ex vivo mechanical stiffness of aortic segments and aortic accumulation of collagen-I and advanced glycation end products, as well as lower levels of aortic superoxide and nitrotyrosine. Our results suggest that late-life VWR in mice recapitulates the aortic de-stiffening effects of exercise in humans and indicates important mechanistic roles for decreased oxidative stress and extracellular matrix remodeling. Therefore, VWR is a suitable model for further study of the mechanisms underlying beneficial effects of exercise on arterial stiffness.

COVID-19 and Congenital Heart Disease: Results from a Nationwide Survey

BACKGROUND

The pandemic of Novel Coronavirus Disease 2019 (COVID-19) is challenging, given the large number of hospitalized patients. Cardiovascular co-morbidities are linked to a higher mortality risk. Thus, patients with Congenital Heart Disease (CHD) might represent a high-risk population. Nevertheless, no data about them are available, yet. Hence, we conducted a nationwide survey to assess clinical characteristics and outcomes in patients with congenital heart disease affected by COVID-19.

METHODS AND RESULTS

This is a multi-centre, observational, nationwide survey, involving high-volume Italian CHD centres. COVID-19 diagnosis was defined as either "clinically suspected" or "confirmed", where a severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) test had been performed and was positive. Cardiovascular comorbidities were observed among adult patients-atrial fibrillation (seven; 9%), hypertension (five; 7%), obesity (seven; 9%) and diabetes (one; 1%)-but were absent among children. Cardiovascular complications were mainly observed in the "confirmed" COVID-19+ group, consisting of heart failure (9%), palpitations/arrhythmias (3%), stroke/TIA (3%) and pulmonary hypertension (3%). Cardiovascular symptoms such as chest pain (1%), myocardial injury (1%) and pericardial effusion (1%) were also recorded. On the contrary, CHD patients from the clinically suspected COVID-19 group presented no severe symptoms or complications.

CONCLUSIONS

Despite previous reports pointing to a higher case-fatality rate among patients with cardiovascular co-morbidities, we observed a mild COVID-19 clinical course in our cohort of CHD patients. Although these results should be confirmed in larger cohorts to investigate the underlying mechanisms, the findings of low cardiovascular complications rates and no deaths are reassuring for CHD patients.

Deep learning for automated exclusion of cardiac CT examinations negative for coronary artery calcium

PURPOSE

Coronary artery calcium (CAC) score has shown to be an accurate predictor of future cardiovascular events. Early detection by CAC scoring might reduce the number of deaths by cardiovascular disease (CVD). Automatically excluding scans which test negative for CAC could significantly reduce the workload of radiologists. We propose an algorithm that both excludes negative scans and segments the CAC.

METHOD

The training and internal validation data were collected from the ROBINSCA study. The external validation data were collected from the ImaLife study. Both contain annotated low-dose non-contrast cardiac CT scans. 60 scans of participants were used for training and 2 sets of 50 CT scans of participants without CAC and 50 CT scans of participants with an Agatston score between 10 and 20 were collected for both internal and external validation. The effect of dilated convolutional layers was tested by using 2 CNN architectures. We used the patient-level accuracy as metric for assessing the accuracy of our pipeline for detection of CAC and the Dice coefficient score as metric for the segmentation of CAC.

RESULTS

Of the 50 negative cases in the internal and external validation set, 62 % and 86 % were classified correctly, respectively. There were no false negative predictions. For the segmentation task, Dice Coefficient scores of 0.63 and 0.84 were achieved for the internal and external validation datasets, respectively.

CONCLUSIONS

Our algorithm excluded 86 % of all scans without CAC. Radiologists might need to spend less time on participants without CAC and could spend more time on participants that need their attention.

Hypercholesterolemia Interferes with Induction of miR-125b-1-3p in Preconditioned Hearts

Ischemic preconditioning (IPre) reduces ischemia/reperfusion (I/R) injury in the heart. The non-coding microRNA miR-125b-1-3p has been demonstrated to play a role in the mechanism of IPre. Hypercholesterolemia is known to attenuate the cardioprotective effect of preconditioning; nevertheless, the exact underlying mechanisms are not clear. Here we investigated, whether hypercholesterolemia influences the induction of miR-125b-1-3p by IPre. Male Wistar rats were fed with a rodent chow supplemented with 2% cholesterol and 0.25% sodium-cholate hydrate for 8 weeks to induce high blood cholesterol levels. The hearts of normo- and hypercholesterolemic animals were then isolated and perfused according to Langendorff, and were subjected to 35 min global ischemia and 120 min reperfusion with or without IPre (3 × 5 min I/R cycles applied before index ischemia). IPre significantly reduced infarct size in the hearts of normocholesterolemic rats; however, IPre was ineffective in the hearts of hypercholesterolemic animals. Similarly, miR-125b-1-3p was upregulated by IPre in hearts of normocholesterolemic rats, while in the hearts of hypercholesterolemic animals IPre failed to increase miR-125b-1-3p significantly. Phosphorylation of cardiac Akt, ERK, and STAT3 was not significantly different in any of the groups at the end of reperfusion. Based on these results we propose here that hypercholesterolemia attenuates the upregulation of miR-125b-1-3p by IPre, which seems to be associated with the loss of cardioprotection.

Unravelling the Biology of Adult Cardiac Stem Cell-Derived Exosomes to Foster Endogenous Cardiac Regeneration and Repair

Cardiac remuscularization has been the stated goal of the field of regenerative cardiology since its inception. Along with the refreshment of lost and dysfunctional cardiac muscle cells, the field of cell therapy has expanded in scope encompassing also the potential of the injected cells as cardioprotective and cardio-reparative agents for cardiovascular diseases. The latter has been the result of the findings that cell therapies so far tested in clinical trials exert their beneficial effects through paracrine mechanisms acting on the endogenous myocardial reparative/regenerative potential. The endogenous regenerative potential of the adult heart is still highly debated. While it has been widely accepted that adult cardiomyocytes (CMs) are renewed throughout life either in response to wear and tear and after injury, the rate and origin of this phenomenon are yet to be clarified. The adult heart harbors resident cardiac/stem progenitor cells (CSCs/CPCs), whose discovery and characterization were initially sufficient to explain CM renewal in response to physiological and pathological stresses, when also considering that adult CMs are terminally differentiated cells. The role of CSCs in CM formation in the adult heart has been however questioned by some recent genetic fate map studies, which have been proved to have serious limitations. Nevertheless, uncontested evidence shows that clonal CSCs are effective transplantable regenerative agents either for their direct myogenic differentiation and for their paracrine effects in the allogeneic setting. In particular, the paracrine potential of CSCs has been the focus of the recent investigation, whereby CSC-derived exosomes appear to harbor relevant regenerative and reparative signals underlying the beneficial effects of CSC transplantation. This review focuses on recent advances in our knowledge about the biological role of exosomes in heart tissue homeostasis and repair with the idea to use them as tools for new therapeutic biotechnologies for "cell-less" effective cardiac regeneration approaches.

Association of triglyceride glucose index and its combination of obesity indices with prehypertension in lean individuals: A cross-sectional study of Chinese adults

For normal-weight population, the management of prehypertension may be more beneficial by identifying insulin resistance (IR) status than relying solely on traditional indicators of obesity. We investigated the association of triglyceride glucose (TyG) index, a simple surrogate marker of IR, and its combination of obesity indices with prehypertension in lean individuals. A total of 105 070 lean adults without hypertension were included in this analysis. Body mass index (BMI), waist circumference (WC), waist-to-height ratio (WtHR), and TyG were calculated according to the corresponding formula; TyG-BMI, TyG-WC, and TyG-WHtR were calculated by multiplying the corresponding two parameters. Gardner-Altman plots, partial correlation, and logistic regression analyses were applied to explore the associations in continuous variables and quartiles. The prehypertensive ones had higher mean values of TyG, TyG-BMI, TyG-WC, and TyG-WHtR than normotensive individuals. All the four indicators showed positive correlations with systolic blood pressure and diastolic blood pressure. After full adjustment, only TyG-BMI and TyG-WC were significantly associated with prehypertension in both genders. Furthermore, TyG-BMI had the highest OR for prehypertension. Our study showed that TyG-BMI might be an accessible and complementary monitor in the hierarchical management of non-obese prehypertensive patients.

Effectiveness of Trimetazidine in Patients with Stable Angina Pectoris of Various Durations: Results from ODA

INTRODUCTION

Trimetazidine (TMZ) is an antianginal agent that acts directly at the myocardial cell level and which is now available in a once-daily (od) formulation.

METHODS

ODA, a 3-month, observational, multicenter study in Russia, assessed the effectiveness and tolerability of TMZ 80 mg od in patients with stable angina and persisting symptoms, in real-life settings. The present analysis explored the effects of adding TMZ to background antianginal treatment with respect to the duration of stable angina.

RESULTS

A total of 3032 patients were divided into four groups according to stable angina pectoris duration since diagnosis, ranging from less than 1 year to more than 10 years. A decrease in frequency of angina attacks was observed, including in patients with angina duration < 1 year, in whom the frequency of weekly angina attacks decreased from 3.8 ± 2.9 to 1.4 ± 1.7 at 1 month and 0.6 ± 1.0 at 3 months. Short-acting nitrate consumption and proportion of angina-free patients decreased, and self-reported physical activity and adherence to antianginal therapy improved in all patient groups, including recently diagnosed patients and starting already at month 1.

CONCLUSIONS

Addition of TMZ 80 mg od to antianginal treatment was effective in reducing the frequency of angina attacks and the use of short-acting nitrates, improving Canadian Cardiovascular Society (CCS) class, self-reported physical activity, and adherence to antianginal therapy. These beneficial effects were observed in patient groups with different durations of stable angina, suggesting an opportunity for decreasing angina burden even in recently diagnosed patients.

TRIAL REGISTRATION

ISRCTN registry Identifier, ISRCTN97780949.

30-year trends in major cardiovascular risk factors in the Czech population, Czech MONICA and Czech post-MONICA, 1985 - 2016/17

Background

Compared with Western Europe, the decline in cardiovascular (CV) mortality has been delayed in former communist countries in Europe, including the Czech Republic. We have assessed longitudinal trends in major CV risk factors in the Czech Republic from 1985 to 2016/17, covering the transition from the totalitarian regime to democracy.

Methods

There were 7 independent cross-sectional surveys for major CV risk factors conducted in the Czech Republic in the same 6 country districts within the WHO MONICA Project (1985, 1988, 1992) and the Czech post-MONICA study (1997/98, 2000/01, 2007/08 and 2016/2017), including a total of 7,606 males and 8,050 females. The population samples were randomly selected (1%, aged 25–64 years).

Results

Over the period of 31/32 years, there was a significant decrease in the prevalence of smoking in males (from 45.0% to 23.9%; p < 0.001) and no change in females. BMI increased only in males. Systolic and diastolic blood pressure decreased significantly in both genders, while the prevalence of hypertension declined only in females. Awareness of hypertension, the proportion of individuals treated by antihypertensive drugs and consequently hypertension control improved in both genders. A substantial decrease in total cholesterol was seen in both sexes (males: from 6.21 ± 1.29 to 5.30 ± 1.05 mmol/L; p < 0.001; females: from 6.18 ± 1.26 to 5.31 ± 1.00 mmol/L; p < 0.001).

Conclusions

The significant improvement in most CV risk factors between 1985 and 2016/17 substantially contributed to the remarkable decrease in CV mortality in the Czech Republic.

Ferritin: An Inflammatory Player Keeping Iron at the Core of Pathogen-Host Interactions

Iron is an essential element for virtually all cell types due to its role in energy metabolism, nucleic acid synthesis and cell proliferation. Nevertheless, if free, iron induces cellular and organ damage through the formation of free radicals. Thus, iron levels must be firmly controlled. During infection, both host and microbe need to access iron and avoid its toxicity. Alterations in serum and cellular iron have been reported as important markers of pathology. In this regard, ferritin, first discovered as an iron storage protein, has emerged as a biomarker not only in iron-related disorders but also in inflammatory diseases, or diseases in which inflammation has a central role such as cancer, neurodegeneration or infection. The basic research on ferritin identification and functions, as well as its role in diseases with an inflammatory component and its potential as a target in host-directed therapies, are the main considerations of this review.

What do we know about the role of lipoprotein(a) in atherogenesis 57 years after its discovery?

Elevated circulating concentrations of lipoprotein(a) [Lp(a)] is strongly associated with increased risk of atherosclerotic cardiovascular disease (CVD) and degenerative aortic stenosis. This relationship was first observed in prospective observational studies, and the causal relationship was confirmed in genetic studies. Everybody should have their Lp(a) concentration measured once in their lifetime. CVD risk is elevated when Lp(a) concentrations are high i.e. > 50 mg/dL (≥100 mmol/L). Extremely high Lp(a) levels >180 mg/dL (≥430 mmol/L) are associated with CVD risk similar to that conferred by familial hypercholesterolemia. Elevated Lp(a) level was previously treated with niacin, which exerts a potent Lp(a)-lowering effect. However, niacin is currently not recommended because, despite the improvement in lipid profile, no improvements on clinical outcomes have been observed. Furthermore, niacin use has been associated with severe adverse effects. Post hoc analyses of clinical trials with proprotein convertase subtilisin/kexin type-9 (PCSK9) inhibitors have shown that these drugs exert clinical benefits by lowering Lp(a), independent of their potent reduction of low-density lipoprotein cholesterol (LDL-C). It is not yet known whether PCSK9 inhibitors will be of clinical use in patients with elevated Lp(a). Apheresis is a very effective approach to Lp(a) reduction, which reduces CVD risk but is invasive and time-consuming and is thus reserved for patients with very high Lp(a) levels and progressive CVD. Studies are ongoing on the practical application of genetic approaches to therapy, including antisense oligonucleotides against apolipoprotein(a) and small interfering RNA (siRNA) technology, to reduce the synthesis of Lp(a).

Effects of Probiotics on Patients with Hypertension: a Systematic Review and Meta-Analysis

PURPOSE OF REVIEW

This meta-analysis and systematic review was conducted to evaluate the effect of probiotics on blood pressure, body mass index (BMI), and blood glucose changes in patients with hypertension.

RECENT FINDINGS

We searched the PubMed, Cochrane, Embase, and ProQuest databases using a combination of MeSH and free text, from the inception of these databases to 20 January 2020, with no language restrictions. The quantitative PEDro scale method was used to assess the quality of the included studies. We used the random effects models to estimate the outcomes, with heterogeneity among the studies assessed using Cochran's Q statistic. Fourteen included studies published between 2002 and 2019 were included in the meta-analysis, reporting results of 846 hypertension participants. A significant reduction in SBP by - 2.05 mmHg (95% CI - 3.87, -0.24, P = 0.03), DBP by - 1.26 mmHg (95% CI - 2.51, - 0.004, P = 0.047), BMI by - 1.03 (95% CI - 1.28, - 0.97, P < 0.01), and blood glucose by - 0.18 mmol/L (95% CI - 0.30 - 0.05, P = 0.007) was observed following probiotics intervention. Our meta-analysis showed a modest but a significant reduction in SBP and DBP in patients with hypertension, particularly in those with diabetes mellitus, following probiotic supplementation. This effect was associated with treatment duration, dosage, and the age of subject but was not associated with single or multiple strains usage. Additionally, probiotic supplement had a beneficial effect in reducing BMI and blood glucose.