Quantifying Importance of Major Risk Factors for Coronary Heart Disease

Age-Specific Relation of Cardiovascular Health Metrics With Incident Cardiovascular Disease

We examined the age-related differences in cardiovascular health (CVH) metrics for incident cardiovascular disease (CVD). Analyses were conducted using data from the JMDC Claims Database from 2005 to 2020 (n = 2,728,427; mean age 44.9 ± 11.0 years; 56.2% men). Participants were categorized on the basis of age: 20 to 49 years (n = 1,800,161), 50 to 59 years (n = 644,703), and 60 to 75 years (n = 283,563). Ideal CVH metrics included nonsmoking, body mass index <25 kg/m², physical activity at goal, not skipping breakfast, blood pressure <120/80 mm Hg, fasting plasma glucose <100 mg/dL, and total cholesterol <200 mg/dL. Over a mean follow-up of 1,194 ± 917 days, 5,988 myocardial infarction (MI), 53,409 angina pectoris, 26,530 stroke, and 52,712 heart failure (HF) events were recorded. Number of the nonideal CVH metrics was associated with incident MI, angina pectoris, stroke, and HF in all age categories. However, the association of the number of nonideal CVH metrics with incident CVD was modified by age categories and was more pronounced in participants aged 20 to 49 years. Similarly, the relative risk reduction at 1 year for each CVD event under the virtual condition that an individual with 2 nonideal CVH metrics has decreased them to zero, decreased with age. For example, relative risk reduction for MI was 0.51 in participants aged 20 to 49 years, 0.48 in those aged 50 to 59 years, and 0.40 in those aged 60 to 75 years. In conclusion, CVH metrics were more strongly associated with incident CVD including HF among younger individuals suggesting the importance of optimizing modifiable risk factors and lifestyles in young participants for the primary CVD prevention.

Preexisting coronary artery disease among coronavirus disease 2019 patients: a systematic review and meta-analysis

AIMS

The prevalence and prognostic implications of coronary artery disease (CAD) in patients infected by the novel coronavirus 2019 (COVID-19) disease remain unclear.

METHODS

We conducted a systematic review and meta-analysis to investigate the prevalence and mortality risk in COVID-19 patients with preexisting CAD. We searched Medline and Scopus to locate all articles published up to December 8, 2021, reporting data of COVID-19 survivors and nonsurvivors with preexisting CAD. Data were pooled using the Mantel-Haenszel random effects models with odds ratio (OR) as the effect measure with the related 95% confidence interval (CI).

RESULTS

Thirty-eight studies including 27 435 patients (mean age 61.5 and 70.9 years) were analysed. The pooled prevalence of preexisting CAD was 12.6% (95% CI: 11.2-16.5%, I2 : 95.6%), and resulted as higher in intensive care unit patients (17.5%, 95% CI: 11.9-25.1, I2 : 88.4%) and in European cohorts (13.1%, 95% CI: 7.8-21.6%, P  < 0.001, I2 : 98.4%). COVID-19 patients with preexisting CAD had a two-fold risk of short-term mortality (OR 2.61, 95% CI 2.10-3.24, P  < 0.001, I2  = 73.6%); this risk was higher among Asian cohorts (OR: 2.66, 95% CI: 1.79-3.90, P  < 0.001, I2 : 77.3%) compared with European (OR: 2.44, 95% CI: 1.90-3.14, P  < 0.001, I2 : 56.9%) and American (OR: 1.86, 95% CI: 1.41-2.44, P  < 0.001, I2 : 0%) populations. The association between CAD and poor short-term prognosis was influenced by age, prevalence of hypertension (HT), DM and CKD.

CONCLUSIONS

Preexisting CAD is present in approximately 1 in 10 patients hospitalized for COVID-19 and significantly associated with an increased risk of short-term mortality, which is influenced by age, HT, DM and CKD.

Cardiovascular disease risk factors distribution and clustering across different geographic levels in Nepal

BACKGROUND

In an effort to reduce the burgeoning problem of cardiovascular diseases (CVD), it is imperative to understand the variation of risk factors across different geographic regions. This study aims to shed light on examining the leading risk factors of CVD and it's clustering across Nepal.

METHODS

Data from a nationally representative survey were analyzed to estimate the distribution of four major risk factors (high blood pressure, overweight, obesity, and smoking) of cardiovascular diseases. Similarly, this study also assessed the intra-cluster correlation coefficients (ICCs) of CVD risk factors at the household, community (urban/rural), district, and province level.

RESULTS

This study included 14 418 adult population with age of 15 years and above of which 41.7% were male and 58.3% were female. Higher prevalence of all four CVD risk factors was found in the richest quintile, people living in hilly region, most noticeably among residents of metropolitan city and in Gandaki, Bagmati, and Province 1. The ICC decreased as the socio-geographic clustering units decreased in size from province, district, and household level clustering. The ICC was highest at province level for "province 1" for raised blood pressure than other provinces.

CONCLUSIONS

Risk factors of CVD in Nepal are concentrated prominent in highly urbanized areas and ICC is low as the level of geography decreased from province, district, and household. The findings can be applied in directing prevention activities at different levels to mitigate the higher burden of risk factors of CVD in Nepal.

The association between dietary intake and cardiometabolic risk factors among obese adolescents in Indonesia

BACKGROUND AND OBJECTIVE

Poor diets, characterized by excess fat, sugar and sodium intakes, are considered to be one of the most important modifiable risk factors for cardiovascular disease. Diet patterns and intakes during adolescence may persist into adulthood and impact on risk for chronic disease later in life. We aimed to evaluate the dietary intake of obese adolescents and its relationship to cardiometabolic health including lipid status and glycemic control.

METHODS AND STUDY DESIGN

This was a cross-sectional study of obese children aged 15 to < 18 years in Yogyakarta, Indonesia. All children had a medical history performed including a physical examination and fasting blood sample. Dietary intake was assessed using a semi-quantitative recall food frequency questionnaire. Multivariable linear regression model was performed to determine the relationship between dietary intakes and cardiovascular disease risks and to adjust for potential confounders.

RESULTS

Of 179 adolescents, 101 (57.4%) were male and median age was 16.4 (15.0-17.9) years. The majority of adolescents (98%) had inadequate intake of fibre and exceeded intakes of total fat (65%) and total sugar (36%). There was statistically significant correlation found in the multivariable linear regression analysis between fibre intake and HDL cholesterol after adjusting for potential confounders (β = 0.165; p = 0.033).

CONCLUSIONS

This study demonstrates that there is a high proportion of obese Indonesian adolescents with poor dietary intakes. There was relationship observed between intake of nutrients of concern (fibre) and cardiometabolic risk factor among this sample of obese adolescents. Future research should examine overall dietary patterns in more detail among this population to elucidate the role of poor diet intakes in development of cardiovascular disease risk factors in young people transitioning into adulthood.

Increased Risk to Develop Hypertension and Carotid Plaques in Patients with Long-Lasting Helicobacter pylori Gastritis

Helicobacter pylori infection has been reported to be positively associated with hypertension, although with conflicting results. In this study, the relationship between H. pylori infection and hypertension, as well as atherosclerotic carotid lesions, was analyzed. Methods. Clinical records of patients referred to undergo upper endoscopy and gastric biopsy were retrieved. Information regarding the presence of H. pylori infection with atrophy/metaplasia/dysplasia (interpreted as a long-lasting infection), and current or past H. pylori infection was collected, as well as demographic variables, smoking habits, body mass index (BMI), dyslipidemia, diabetes, hypertension, presence of carotid lesions, and current treatment, and analyzed by multivariable regression models. Results. A total of 7152 clinical records from patients older than 30 years (63.4% women) were available for the study. Hypertension was present in 2039 (28.5%) patients and the risk was significantly increased in those with long-lasting H. pylori infection after adjusting for age decades, sex, BMI, cigarette smoking, diabetes, and dyslipidemia (OR 1.17, 95% CI 1.02–1.35). In addition, the long-lasting H. pylori infection was an independent risk for carotid plaques (OR 2.15, 95% CI 1.14–4.09). Conclusions. Our retrospective study demonstrated that long-lasting H. pylori infection is an independent risk factor for hypertension and the presence of carotid lesions after adjusting for potential confounders, although further validation our findings is needed from prospective studies.

Alterations in pro- and anti-inflammatory mediators are involved in microvascular dysfunction in postmenopausal women with type 2 diabetes mellitus

Evidence has shown that women with type 2 diabetes mellitus (T2DM) have a greater risk of cardiovascular complications compared with men, but this sex difference is not clearly understood. This study assessed the microvascular function and circulatory biomarkers in postmenopausal women (PMW) with T2DM compared with diabetic men and their non-diabetic counterparts. Sixty participants were divided into nondiabetic PMW, PMW with T2DM, non-diabetic men, and diabetic men. Microvascular function was assessed using non-invasive equipment (EndoPAT^®) and reported as reactive hyperemia index (RHI). Anthropometric and cardiovascular parameters were also measured. Two-way ANOVA was performed using sex (women or men) and T2DM (non-diabetic and diabetic) as the two factors. RHI impairment (1.97±0.14) was detected in diabetic PMW compared with women without T2DM (2.5±0.13) accompanied by lower adiponectin levels (T2DM: 9.3±1.2 and CTL: 13.8±1.8 ug/mL, P<0.05). An increase in the Nε-carboxymethyllysine (CML), nitrate/nitrite, and C-reactive protein (CRP) levels were observed in diabetic PMW compared to the other groups. Although a poor glycemia control was seen in diabetic men, neither RHI nor circulatory biomarkers were affected by T2DM. Multiple linear regression stratified by sex and T2DM identified some variables with RHI only in PMW with T2DM: HbA1c (P=0.003), body mass index (P=0.029), CML (P=0.032), and CRP (P=0.006). Diabetic PMW were more susceptible to the deleterious effects of hyperglycemia than men, showing microvascular dysfunction with high levels of pro-inflammatory mediators (CML and CRP) and a lower adiponectin concentration.

Not Quite Out of the Woods: Overall Health and Chronic Disease Risk Factors among Maine Logging Workers

OBJECTIVE

This research reports on the health status, including chronic disease risk factors, among Maine loggers.

METHODS

Loggers completed a survey and health screenings were held across Maine, collecting data on a variety of health endpoints.

RESULTS

Seventy-five loggers participated. The majority were men (97.1%) with a median age of 46, and a mean BMI of 30.6 kg/m2 (SD 4.9). Nearly half of those screened (45.9%) had blood pressure at the level of stage II hypertension. Loggers with at least a single joint abnormality were 38.4%. The health screening cohort was similar to the non-health screening cohort for many attributes.

CONCLUSIONS

Future research should focus on tailored interventions to improve cardiovascular and musculoskeletal risk factors among loggers.

European Society of Cardiology: cardiovascular disease statistics 2021

AIMS

This report from the European Society of Cardiology (ESC) Atlas Project updates and expands upon the widely cited 2019 report in presenting cardiovascular disease (CVD) statistics for the 57 ESC member countries.

METHODS AND RESULTS

Statistics pertaining to 2019, or the latest available year, are presented. Data sources include the World Health Organization, the Institute for Health Metrics and Evaluation, the World Bank, and novel ESC sponsored data on human and capital infrastructure and cardiovascular healthcare delivery. New material in this report includes sociodemographic and environmental determinants of CVD, rheumatic heart disease, out-of-hospital cardiac arrest, left-sided valvular heart disease, the advocacy potential of these CVD statistics, and progress towards World Health Organization (WHO) 2025 targets for non-communicable diseases. Salient observations in this report: (i) Females born in ESC member countries in 2018 are expected to live 80.8 years and males 74.8 years. Life expectancy is longer in high income (81.6 years) compared with middle-income (74.2 years) countries. (ii) In 2018, high-income countries spent, on average, four times more on healthcare than middle-income countries. (iii) The median PM2.5 concentrations in 2019 were over twice as high in middle-income ESC member countries compared with high-income countries and exceeded the EU air quality standard in 14 countries, all middle-income. (iv) In 2016, more than one in five adults across the ESC member countries were obese with similar prevalence in high and low-income countries. The prevalence of obesity has more than doubled over the past 35 years. (v) The burden of CVD falls hardest on middle-income ESC member countries where estimated incidence rates are ∼30% higher compared with high-income countries. This is reflected in disability-adjusted life years due to CVD which are nearly four times as high in middle-income compared with high-income countries. (vi) The incidence of calcific aortic valve disease has increased seven-fold during the last 30 years, with age-standardized rates four times as high in high-income compared with middle-income countries. (vii) Although the total number of CVD deaths across all countries far exceeds the number of cancer deaths for both sexes, there are 15 ESC member countries in which cancer accounts for more deaths than CVD in males and five-member countries in which cancer accounts for more deaths than CVD in females. (viii) The under-resourced status of middle-income countries is associated with a severe procedural deficit compared with high-income countries in terms of coronary intervention, ablation procedures, device implantation, and cardiac surgical procedures.

CONCLUSION

Risk factors and unhealthy behaviours are potentially reversible, and this provides a huge opportunity to address the health inequalities across ESC member countries that are highlighted in this report. It seems clear, however, that efforts to seize this opportunity are falling short and present evidence suggests that most of the WHO NCD targets for 2025 are unlikely to be met across ESC member countries.

Compound Danshen dripping pills in treating with coronary heart disease: A protocol for systematic review and meta-analysis

BACKGROUND

Coronary heart disease (CHD) patients are categorized by occlusion or vascular stenosis leading to myocardial ischemia, hypoxia, and necrosis. In clinical cardiovascular, CHD remains as a leading disease that is primarily prevalent among older people and mid-aged groups. CHD has a drastic impact on their life standard, and is known to have debilitating effects on both mental and physical wellbeing. As a Chinese patent medicine, compound Danshen dripping pills (CDDPs) are commonly administered to treat CHD in China. Despite the common intake of CDDPs, there is a lack of evidence-based clinical practice to inform its efficacy and safety through related systematic reviews. Therefore, the present protocol proposes to conduct a meta-analysis aiming to evaluate the effectivity and safeness of using CDDP for treating CHD patients.

METHODS

Randomized controlled trials that have evaluated the efficacy and safety of CDDP for treating CHD patients will be searched in MEDLINE, Cochrane Library, EMBASE, China National Knowledge Infrastructure, and WanFang databases. The search will include all related articles published till January 3, 2022. The extracted data will include information on study design, characteristics of the participants, details on intervention, and outcomes. Cochrane risk of bias tool will be employed to assess the quality of the trials. We will use either a random-effects model or fixed-effects model to pool the data. We will present the results as a risk ratio for dichotomous data and weighted mean difference for continuous data. We will visualize publication bias using funnel plots. Disagreements shall be resolved through discussion.

ETHICS AND DISSEMINATION

Not required.

OSF REGISTRATION NUMBER

10.17605/OSF.IO/HJTP8.

Driver Cardiovascular Disease Detection Using Seismocardiogram

This article deals with the treatment and application of cardiac biosignals, an excited accelerometer, and a gyroscope in the prevention of accidents on the road. Previously conducted studies say that the seismocardiogram is a measure of cardiac microvibration signals that allows for detecting rhythms, heart valve opening and closing disorders, and monitoring of patients' breathing. This article refers to the seismocardiogram hypothesis that the measurements of a seismocardiogram could be used to identify drivers' heart problems before they reach a critical condition and safely stop the vehicle by informing the relevant departments in a nonclinical manner. The proposed system works without an electrocardiogram, which helps to detect heart rhythms more easily. The estimation of the heart rate (HR) is calculated through automatically detected aortic valve opening (AO) peaks. The system is composed of two micro-electromechanical systems (MEMSs) to evaluate physiological parameters and eliminate the effects of external interference on the entire system. The few digital filtering methods are discussed and benchmarked to increase seismocardiogram efficiency. As a result, the fourth adaptive filter obtains the estimated HR = 65 beats per min (bmp) in a still noisy signal (SNR = −11.32 dB). In contrast with the low processing benefit (3.39 dB), 27 AO peaks were detected with a 917.56-ms peak interval mean over 1.11 s, and the calculated root mean square error (RMSE) was 0.1942 m/s2 when the adaptive filter order is 50 and the adaptation step is equal to 0.933.

Evaluation of the long-term prognostic ability of triglyceride-glucose index for elderly acute coronary syndrome patients: a cohort study

Background

With the advancement of the world population aging, more attention should be paid to the prognosis of elderly patients with acute coronary syndrome (ACS). Triglyceride-glucose (TyG) index is a reliable indicator of insulin resistance (IR) and is closely related to traditional risk factors of cardiovascular disease (CVD). However, the effect of TyG index on the prognosis of long-term adverse events in elderly ACS patients has not been reported. This study evaluated the prognostic power of TyG index in predicting adverse events in elderly ACS patients.

Methods

In this study, 662 ACS patients > 80 years old who were hospitalized from January 2006 to December 2012 were enrolled consecutively and the general clinical data and baseline blood biochemical indicators were collected. The follow-up time after discharge was 40–120 months (median, 63 months; interquartile range, 51‒74 months). In addition, the following formula was used to calculate the TyG index: Ln [fasting TG (mg/dL) × FBG (mg/dL)/2], and patients were divided into three groups according to the tertile of the TyG index.

Results

The mean age of the subjects was 81.87 ± 2.14 years, the proportion of females was 28.10%, and the mean TyG index was 8.76 ± 0.72. The TyG index was closely associated with the traditional risk factors of CVD. In the fully-adjusted Cox regression model, the Hazard ratio (95% CI) of all-cause mortality (in tertile 3) was 1.64 (1.06, 2.54) and major adverse cardiac event (MACE) (in tertile 3) was 1.36 (1.05, 1.95) for each SD increase in the TyG index. The subgroup analyses also confirmed the significant association of the TyG index and long-term prognosis.

Conclusion

The TyG index is an independent predictor of long-term all-cause mortality and MACE in elderly ACS patients.

Microbiome and Cardiovascular Disease

Atherosclerotic cardiovascular disease (ASCVD) is a prime example of a systems disease. In the initial phase, apolipoprotein B-containing cholesterol-rich lipoproteins deposit excess cholesterol in macrophage-like cells that subsequently develop into foam cells. A multitude of systemic as well as environmental factors are involved in further progression of atherosclerotic plaque formation. In recent years, both oral and gut microbiota have been proposed to play an important role in the process at different stages. Particularly bacteria from the oral cavity may easily reach the circulation and cause low-grade inflammation, a recognized risk factor for ASCVD. Gut-derived microbiota on the other hand can influence host metabolism on various levels. Next to translocation across the intestinal wall, these prokaryotes produce a great number of specific metabolites such as trimethylamine and short-chain fatty acids but can also metabolize endogenously formed bile acids and convert these into metabolites that may influence signal transduction pathways. In this overview, we critically discuss the novel developments in this rapidly emerging research field.

Prediction of first cardiovascular disease event in 2.9 million individuals using Danish administrative healthcare data: a nationwide, registry-based derivation and validation study

Aims

The aim of this study was to derive and validate a risk prediction model with nationwide coverage to predict the individual and population-level risk of cardiovascular disease (CVD).

Methods and results

All 2.98 million Danish residents aged 30–85 years free of CVD were included on 1 January 2014 and followed through 31 December 2018 using nationwide administrative healthcare registries. Model predictors and outcome were pre-specified. Predictors were age, sex, education, use of antithrombotic, blood pressure-lowering, glucose-lowering, or lipid-lowering drugs, and a smoking proxy of smoking-cessation drug use or chronic obstructive pulmonary disease. Outcome was 5-year risk of first CVD event, a combination of ischaemic heart disease, heart failure, peripheral artery disease, stroke, or cardiovascular death. Predictions were computed using cause-specific Cox regression models. The final model fitted in the full data was internally-externally validated in each Danish Region. The model was well-calibrated in all regions. Area under the receiver operating characteristic curve (AUC) and Brier scores ranged from 76.3% to 79.6% and 3.3 to 4.4. The model was superior to an age-sex benchmark model with differences in AUC and Brier scores ranging from 1.2% to 1.5% and −0.02 to −0.03. Average predicted risks in each Danish municipality ranged from 2.8% to 5.9%. Predicted risks for a 66-year old ranged from 2.6% to 25.3%. Personalized predicted risks across ages 30–85 were presented in an online calculator (https://hjerteforeningen.shinyapps.io/cvd-risk-manuscript/).

Conclusion

A CVD risk prediction model based solely on nationwide administrative registry data provided accurate prediction of personal and population-level 5-year first CVD event risk in the Danish population. This may inform clinical and public health primary prevention efforts.

The importance of child abuse and neglect in adult medicine

The risk for adverse consequences and disease due to the trauma of child abuse or neglect is easily assessed using the self-administered modified ACEs questionnaire. Exposure to child maltreatment is endemic and common. At least one out of every ten USA adults has a significant history of childhood maltreatment. This is a review of the literature documenting that a past history of childhood abuse and neglect (CAN) makes substantial contributions to physical disease in adults, including asthma, chronic obstructive pulmonary disease, lung cancer, hypertension, stroke, kidney disease, hepatitis, obesity, diabetes, coronary artery disease, pelvic pain, endometriosis, chronic fatigue syndrome, irritable bowel syndrome, fibromyalgia, and auto immune diseases. Adults who have experienced child maltreatment have a shortened life expectancy. The contribution of CAN trauma to these many pathologies remains largely underappreciated and neglected compared to the attention given to the array of mental illnesses associated with child maltreatment. Specific pathophysiolologic pathways have yet to be defined. Clinical recognition of the impact of past CAN trauma will contribute to the healing process in any disease but identifying specific effective therapies based on this insight remains to be accomplished. Recommendations are made for managing these patients in the clinic. It is important to incorporate screening for CAN throughout adult medical practice now.

Cardiovascular risk and functional burden at midlife: Prospective associations of isotemporal reallocations of accelerometer-measured physical activity and sedentary time in the CARDIA study

Cardiovascular risk and functional burden, or the accumulation of cardiovascular risk factors coupled with functional decline, may be an important risk state analogy to multimorbidity. We investigated prospective associations of sedentary time (ST), light intensity physical activity (LPA), and moderate to vigorous intensity physical activity (MVPA) with cardiovascular risk and functional burden at midlife. Participants were 1648 adults (mean ± SD age = 45 ± 4 years, 61% female, 39% Black) from Coronary Artery Risk Development in Young Adults (CARDIA) who wore accelerometers in 2005-2006 and 2015-2016. Cardiovascular risk and functional burden was defined as ≥2 cardiovascular risk factors (untreated/uncontrolled hypertension and hypercholesterolemia, type 2 diabetes, reduced kidney function) and/or functional decline conditions (reduced physical functioning and depressive symptoms). Prospective logistic regression models tested single activity, partition, and isotemporal substitution associations of accelerometer-measured ST, LPA, and MVPA with cardiovascular risk and functional burden 10 years later. In isotemporal models of baseline activity, reallocating 24 min of ST to MVPA was associated with 15% lower odds of cardiovascular risk and functional burden (OR: 0.85; CI: 0.75, 0.96). Reallocating 24 min of LPA to MVPA was associated with a 14% lower odds of cardiovascular risk and functional burden (OR: 0.86; CI: 0.75, 0.99). In longitudinal isotemporal models, similar beneficial associations were observed when 10-year increases in MVPA replaced time in ST or LPA. Findings suggest that maintaining an MVPA dose reflecting daily physical activity recommendations in early midlife is associated with lower odds of cardiovascular risk and functional burden later in midlife.

Mapping gene and gene pathways associated with coronary artery disease: a CARDIoGRAM exome and multi-ancestry UK biobank analysis

Coronary artery disease (CAD) genome-wide association studies typically focus on single nucleotide variants (SNVs), and many potentially associated SNVs fail to reach the GWAS significance threshold. We performed gene and pathway-based association (GBA) tests on publicly available Coronary ARtery DIsease Genome wide Replication and Meta-analysis consortium Exome (n = 120,575) and multi ancestry pan UK Biobank study (n = 442,574) summary data using versatile gene-based association study (VEGAS2) and Multi-marker analysis of genomic annotation (MAGMA) to identify novel genes and pathways associated with CAD. We included only exonic SNVs and excluded regulatory regions. VEGAS2 and MAGMA ranked genes and pathways based on aggregated SNV test statistics. We used Bonferroni corrected gene and pathway significance threshold at 3.0 × 10^-6 and 1.0 × 10^-5, respectively. We also report the top one percent of ranked genes and pathways. We identified 17 top enriched genes with four genes (PCSK9, FAM177, LPL, ARGEF26), reaching statistical significance (p ≤ 3.0 × 10^-6) using both GBA tests in two GWAS studies. In addition, our analyses identified ten genes (DUSP13, KCNJ11, CD300LF/RAB37, SLCO1B1, LRRFIP1, QSER1, UBR2, MOB3C, MST1R, and ABCC8) with previously unreported associations with CAD, although none of the single SNV associations within the genes were genome-wide significant. Among the top 1% non-lipid pathways, we detected pathways regulating coagulation, inflammation, neuronal aging, and wound healing.

Risk Prediction Using Polygenic Risk Scores for Prevention of Stroke and Other Cardiovascular Diseases

Early prediction of risk of cardiovascular disease (CVD), including stroke, is a cornerstone of disease prevention. Clinical risk scores have been widely used for predicting CVD risk from known risk factors. Most CVDs have a substantial genetic component, which also has been confirmed for stroke in recent gene discovery efforts. However, the role of genetics in prediction of risk of CVD, including stroke, has been limited to testing for highly penetrant monogenic disorders. In contrast, the importance of polygenic variation, the aggregated effect of many common genetic variants across the genome with individually small effects, has become more apparent in the last 5 to 10 years, and powerful polygenic risk scores for CVD have been developed. Here we review the current state of the field of polygenic risk scores for CVD including stroke, and their potential to improve CVD risk prediction. We present findings and lessons from diseases such as coronary artery disease as these will likely be useful to inform future research in stroke polygenic risk prediction.

Bayesian Analysis for Cardiovascular Risk Factors in Ischemic Heart Disease

Ischemic heart disease (or Coronary Artery Disease) is the most common cause of death in various countries, characterized by reduced blood supply to the heart. Statistical models make an impact in evaluating the risk factors that are responsible for mortality and morbidity during IHD (Ischemic heart disease). In general, geometric or Poisson distributions can underestimate the zero-count probability and hence make it difficult to identify significant effects of covariates for improving conditions of heart disease due to regional wall motion abnormalities. In this work, a flexible class of zero inflated models is introduced. A Bayesian estimation method is developed as an alternative to traditionally used maximum likelihood-based methods to analyze such data. Simulation studies show that the proposed method has a better small sample performance than the classical method, with tighter interval estimates and better coverage probabilities. Although the prevention of CAD has long been a focus of public health policy, clinical medicine, and biomedical scientific investigation, the prevalence of CAD remains high despite current strategies for prevention and treatment. Various comprehensive searches have been performed in the MEDLINE, HealthSTAR, and Global Health databases for providing insights into the effects of traditional and emerging risk factors of CAD. A real-life data set is illustrated for the proposed method using WinBUGS.

Working towards full eradication of lipid-driven cardiovascular risk?

Lipid-driven cardiovascular disease (CVD) risk is caused by atherogenic apolipoprotein B (apoB) particles containing low-density lipoprotein cholesterol (LDL-C), triglycerides and lipoprotein(a) [Lp(a)] and resembles a large and modifiable proportion of the total CVD risk. While a surplus of novel lipid-lowering therapies has been developed in recent years, management of lipid-driven CVD risk in the Netherlands remains suboptimal. To lower LDL‑C levels, statins, ezetimibe and proprotein convertase subtilisin/kexin type 9 inhibiting antibodies are the current standard of therapy. With the approval of bempedoic acid and the silencing RNA inclisiran, therapeutic options are expanding continuously. Although the use of triglyceride-lowering therapies remains a matter of debate, post hoc analyses consistently show a benefit in subsets of patients with high triglyceride or low high-density lipoprotein cholesterol levels. Pemafibrate and novel apoC-III could be efficacious options when approved for clinical use. Lp(a)-lowering therapies such as pelacarsen are under clinical investigation, offering a potent Lp(a)-lowering effect. If proven effective in reducing cardiovascular endpoints, Lp(a) lowering holds promise to be the third axis of effective lipid-lowering therapies. Using these three components of lipid-lowering treatment, the contribution of apoB-containing lipid particles to the CVD risk may be fully eradicated in the next decade.

Interaction between eNOS gene polymorphism and current smoking on susceptibility to coronary heart disease in Chinese people

OBJECTIVE

This study aims to explore the relation between endothelial nitric oxide synthase (eNOS) single-nucleotide polymorphisms (SNPs) and the risk of coronary heart disease (CHD).

METHODS

SNPstats (online software: http://bioinfo.iconcologia.net/SNPstats) was performed to test Hardy-Weinberg equilibrium in controls. Generalized multifactor dimensionality reduction (GMDR) was adopted to screen the preferable interaction between eNOS SNPs and smoking.

RESULTS

The frequency for the rs1799983-T allele was 31.1% in CHD patients, which was significantly higher than that of 19.8% in controls (P < 0.05). The frequency for the rs891512-A allele was 28.8% in cases, which was also significantly higher than that of 20.1% in controls (P < 0.05). Logistic regression analysis showed that both rs1799983-T and rs891512-A alleles were related with increased risk of CHD, and the odds ratios (ORs) [95% confidence interval (CI)] were 1.71 (1.31-2.15) and 1.57 (1.14-2.07), respectively. High-order interactions were investigated among SNPs and environmental factors using the GMDR method. The data showed that a two-locus model (rs1799983 × smoking) had a testing accuracy of 0.60 (P = 0.001). We found that current smokers with rs1799983-GT or TT within eNOS gene have the highest CHD risk, compared to never smokers with rs1799983-GG genotype, OR (95% CI) = 2.74 (1.78-3.85), after covariates adjustment for age, gender, BMI, and alcohol drinking.

CONCLUSION

The rs1799983-T and rs891512-A alleles and interaction between rs1799983 and smoking were all risk factors of CHD.

The emotional heart: prospective associations of anger, depression, and anxiety as risk factors for myocardial infarction in a 22-year follow-up of a working cohort of middle-aged men

Aim

The study aim was to further clarify the relationship between psychological factors and myocardial infarction (MI) by simultaneously examining anger, depression, and anxiety as risk factors for incident MI in a healthy working sample.

Subject and method

Baseline measurements of psychological variables were assessed through a self-reported questionnaire in a healthy cohort of 968 middle-aged men working at the Volvo Corporation. Single-item questions assessed depression and anxiety. Anger was assessed by the Trait Anger subscale of the Spielberger State-Trait Anger Expression Inventory. The endpoint was incident MI verified by national registers or medical records with follow up after 22 years. The main outcome was computed through logistic regression, reported as odds ratios. Additional correlation analyses were performed between psychological variables and coronary risk factors.

Results

None of the psychological variables was significantly associated with the outcome; thus, the results failed to show an association between anger, depression, or anxiety and incident MI in this sample. There were some significant, but weak, correlations between psychological factors and negative health behaviors. Other components of traditional risk scoring instruments did not correlate with the psychological factors.

Conclusion

A cohort restricted to middle-age healthy men limits applicability. However, our failure to replicate earlier results of population samples suggests a need for further research on associations between psychological factors and MI in healthy samples.

Contribution of lncRNA CASC8, CASC11, and PVT1 Genetic Variants to the Susceptibility of Coronary Heart Disease

ABSTRACT

The purpose of this study was to explore the relationship between lncRNA CASC8, CASC11, and plasmacytoma variant translocation 1 (PVT1). genetic variants and coronary heart disease (CHD) susceptibility among a Chinese Han population. Five single nucleotide polymorphisms were genotyped by Agena MassARRAY platform among 464 CHD patients and 510 healthy controls. Binary logistic regression models by calculating odds ratios (ORs) with 95% confidence intervals (CIs) were used to assess the association between selected single nucleotide polymorphisms and CHD risk. Multifactor dimensionality reduction analysis was performed to analyze gene-gene interaction. PVT1 rs4410871 (OR = 0.77, P = 0.040) was associated with a reduced risk of CHD occurrence in the Chinese population. CASC11 rs9642880 (OR = 1.49, P = 0.021) was a risk factor for increased CHD susceptibility in subjects over 60 years old, and PVT1 rs4410871 was a protective factor for CHD susceptibility in males (OR = 0.67, P = 0.015) and smokers (OR = 0.62, P = 0.047). Complications (hypertension or diabetes) of CHD influenced the association between CASC8, CASC11, and PVT1 genetic polymorphisms and CHD predisposition. Moreover, CASC8, CASC11, and PVT1 polymorphisms were related to the number of pathological branches and Gensini score in CHD patients. The study displayed the contribution of CASC8, CASC11, and PVT1 genetic polymorphisms to CHD predisposition, and these variants could serve as potential biomarkers of CHD susceptibility. These findings contribute to enhancing the understanding of the role of lncRNA polymorphisms in CHD risk.

Pooled prevalence of three major cardiovascular risk factors in patients undergoing left main bifurcation stenting: a systematic review and meta-analysis

BACKGROUND

Prevalence of the major risk factors in patients with Left Main (LM) bifurcation disease has not been yet clearly assessed, although it would important for building up bifurcation computational models. We perform a systematic review and metaanalysis on the three major cardiovascular risk factors in patients treated for LM bifurcation disease using either single or 2-stent strategy.

MEHTODS

In accordance with the PRISMA guidelines, Cochrane Library, Embase, PubMed and Google Scholar were queried to locate articles published between January 2015 to October 2020, comparing single- versus 2-stent strategy and reporting the prevalence of arterial hypertension (HT), hyperlipidaemia (HyperL) and diabetes mellitus (DM).

RESULTS

Out of a total of 230 articles, 7 articles were included into the final analysis. A total of 4559 patients were enrolled: 2666 (58.4%, mean age 60.4 years, 2318 males) and 1933 patients (42.3%, mean age 64.8 years, 1763 males) received a single- and 2-stent stenting strategies, respectively. A random effect model revealed a pooled prevalence of HT, HyperL and DM in 69.4%, 38.9% and in 31% of cases, respectively. Prevalence of HT was lower in patients treated with single versus 2-stent strategy (63 versus 66.7% of patients, p=0.01) while HyperL and DM were more represented in single versus 2-stent strategy: 41.6 versus 34.1% (p<0.001), and 32.5 versus 31.8% of patients (p=0.61), respectively.

CONCLUSIONS

In patients with LM bifurcation disease undergoing either single or 2- stent strategy, HT, HyperL and DM are frequent comorbidities. In severe LM disease requiring 2-stent technique, HT is the most prevalent risk factor.

Clinical reasoning and prevention of cardiovascular disease

All the major lipid prevention guidelines agree that the 10-year risk of a cardiovascular event should be the primary method to select individuals for statin prevention of a cardiovascular event. They also all rely on LDL cholesterol (LDL-C) as the primary metric to monitor lipid lowering therapy. These two principles form the major instruments on which primary prevention of cardiovascular disease is based worldwide. Their application is based on decades of prospective observational studies and large numbers of randomized clinical trials. Their development and application are milestones in medical progress. But are there limits, which were unseen and unintended, that need to be identified and overcome so that cardiovascular prevention can improve? Based on new insights and old knowledge, this Viewpoint will apply Clinical Reasoning, the process by which we integrate all the relevant knowledge, including the knowledge we have gained from physiology, pathology, epidemiology, metabolism, experimental models of disease, and our clinical experience as well as the results of randomized clinical trials to the analysis of a single case to answer these questions. Moreover, this Viewpoint will challenge the universal practice of relating the clinical outcomes of the major successful lipid lowering trials to the decrease in LDL-C and argue that cardiovascular prevention should move from the Risk model to the Causal Benefit model. This Viewpoint will be framed around a single case because, as caregivers, we make decisions case by case and because, as caregivers, the individual is the true object of our concern.

Guideline-Driven Management of Hypertension: An Evidence-Based Update

Several important findings bearing on the prevention, detection, and management of hypertension have been reported since publication of the 2017 American College of Cardiology/American Heart Association Blood Pressure Guideline. This review summarizes and places in context the results of relevant observational studies, randomized clinical trials, and meta-analyses published between January 2018 and March 2021. Topics covered include blood pressure measurement, patient evaluation for secondary hypertension, cardiovascular disease risk assessment and blood pressure threshold for drug therapy, lifestyle and pharmacological management, treatment target blood pressure goal, management of hypertension in older adults, diabetes, chronic kidney disease, resistant hypertension, and optimization of care using patient, provider, and health system approaches. Presenting new information in each of these areas has the potential to increase hypertension awareness, treatment, and control which remain essential for the prevention of cardiovascular disease and mortality in the future.

Association of Lipid, Inflammatory, and Metabolic Biomarkers With Age at Onset for Incident Coronary Heart Disease in Women

Importance

Risk profiles for premature coronary heart disease (CHD) are unclear.

Objective

To examine baseline risk profiles for incident CHD in women by age at onset.

Design, Setting, and Participants

A prospective cohort of US female health professionals participating in the Women's Health Study was conducted; median follow-up was 21.4 years. Participants included 28 024 women aged 45 years or older without known cardiovascular disease. Baseline profiles were obtained from April 30, 1993, to January 24, 1996, and analyses were conducted from October 1, 2017, to October 1, 2020.

Exposures

More than 50 clinical, lipid, inflammatory, and metabolic risk factors and biomarkers.

Main Outcomes and Measures

Four age groups were examined (<55, 55 to <65, 65 to <75, and ≥75 years) for CHD onset, and adjusted hazard ratios (aHRs) were calculated using stratified Cox proportional hazard regression models with age as the time scale and adjusting for clinical factors. Women contributed to different age groups over time.

Results

Of the clinical factors in the women, diabetes had the highest aHR for CHD onset at any age, ranging from 10.71 (95% CI, 5.57-20.60) at CHD onset in those younger than 55 years to 3.47 (95% CI, 2.47-4.87) at CHD onset in those 75 years or older. Risks that were also noted for CHD onset in participants younger than 55 years included metabolic syndrome (aHR, 6.09; 95% CI, 3.60-10.29), hypertension (aHR, 4.58; 95% CI, 2.76-7.60), obesity (aHR, 4.33; 95% CI, 2.31-8.11), and smoking (aHR, 3.92; 95% CI, 2.32-6.63). Myocardial infarction in a parent before age 60 years was associated with 1.5- to 2-fold risk of CHD in participants up to age 75 years. From approximately 50 biomarkers, lipoprotein insulin resistance had the highest standardized aHR: 6.40 (95% CI, 3.14-13.06) for CHD onset in women younger than 55 years, attenuating with age. In comparison, weaker but significant associations with CHD in women younger than 55 years were noted (per SD increment) for low-density lipoprotein cholesterol (aHR, 1.38; 95% CI, 1.10-1.74), non-high-density lipoprotein cholesterol (aHR, 1.67; 95% CI, 1.36-2.04), apolipoprotein B (aHR, 1.89; 95% CI, 1.52-2.35), triglycerides (aHR, 2.14; 95% CI, 1.72-2.67), and inflammatory biomarkers (1.2- to 1.8-fold)-all attenuating with age. Some biomarkers had similar CHD age associations (eg, physical inactivity, lipoprotein[a], total high-density lipoprotein particles), while a few had no association with CHD onset at any age. Most risk factors and biomarkers had associations that attenuated with increasing age at onset.

Conclusions and Relevance

In this cohort study, diabetes and insulin resistance, in addition to hypertension, obesity, and smoking, appeared to be the strongest risk factors for premature onset of CHD. Most risk factors had attenuated relative rates at older ages.

Evaluation of physician's knowledge in Jordan about the ACC/AHA blood cholesterol guidelines

BACKGROUND

Elevated levels of blood lipids are considered a major modifiable risk factor for the development of cardiovascular diseases. The optimal management of dyslipidaemia remains inadequate worldwide. Accordingly, there is an increasing need to evaluate the basis that health care providers are using to control dyslipidaemia.

AIM

To evaluate the awareness of Jordanian physicians about the American College of Cardiology/American Heart Association (ACC/AHA) guidelines for dyslipidaemia management.

METHOD

A written questionnaire was distributed to 250 physicians from different areas of Jordan during 7 months period (from February 2018 until the end of August 2018). The target population is composed of the following categories: juniors, residents, fellows and consultants who were recruited from private, government and military practice settings. The validated developed questionnaire was distributed by trained medical personnel.

RESULTS

A total of 207 physicians filled and handed back the questionnaire. The response rate was 82.8%. Generally, there was a difference in the level of knowledge between physicians (juniors/ residents/ consultants) while there was no difference between genders or practice settings (private or government). The current study showed that the awareness of physicians in different areas of Jordan regarding the 2013 (ACC/AHA) dyslipidaemia guidelines is suboptimal.

CONCLUSION

Results indicated low levels of knowledge of 2013 ACC/AHA guidelines for the management of dyslipidaemia among physicians in Jordan. Hence, multiple interventions are needed to be implemented in order to increase the level of awareness among Jordanian physicians.

Interventions that improve adherence to antihypertensive medications in coronary heart disease patients: a systematic review

A systematic review is conducted to identify effective interventions that improved adherence to antihypertensive drugs among patients with coronary heart diseases (CHDs). Primary studies designed to measure interventions to improve adherence on antihypertensive drugs in patients with CHD were included. Three online databases, COCHRANE, EMBASE and MEDLINE, were searched for primary studies published in English from 2005 to 2019. Studies were screened independently for eligibility. Cochrane risk-of-bias tool and the Newcastle-Ottawa Scale were used for quality assessment of randomised controlled trials (RCTs) and non-randomised studies, respectively. Of the 2000 entries identified, seven articles, including one cross-sectional study and six RCTs, met the inclusion criteria and were reviewed. One of the articles evaluated two interventions, so eight interventions were evaluated in total. Quality of the included studies was generally high, with the cross-sectional study rated as having good quality under Newcastle-Ottawa Scale, while four and two RCTs were rated as having low and some risk of bias under Cochrane risk-of-bias tool, respectively. Six of the intervention programmes were considered effective. An intervention was considered effective if it is associated with a significant (p≤0.05) and non-trivial (Cohen's d≥0.2) improvement in compliance-related outcomes such as in terms of the Morisky 8-item Medication Adherence Scale. Medication education, disease education, health education, constant reminders and medications dispensed using blister packs were identified to be effective in improving patients' compliance to medications. The importance of the continuity of interventions was also established. It is recommended that health service institutions should provide continuous education programmes, daily reminders and regular follow-ups for their patients who have CHD. It is recommended that further research ought to be carried out by using only one intervention in each trial with a standardised outcome measure, or using factorial designs, so that further cost-effectiveness evaluation of each intervention can be carried out independently, leading to the formulation of a comprehensive, optimised intervention programme for patients with CHD taking antihypertensives.

Anti-inflammatory Therapy for Coronary Atherosclerotic Heart Disease: Unanswered Questions Behind Existing Successes

Coronary atherosclerotic heart disease is a serious threat to human health. The results of the Canakinumab Anti-Inflammatory Thrombosis Outcome Study published in 2017 put an end to the perennial debate about the anti-inflammatory treatment of coronary atherosclerotic heart disease. In addition to interleukin 1β monoclonal antibody, interleukin 6 receptor antagonists and colchicine have also shown exciting results in clinical trials within the last 3 years. However, behind these successes, questions remain that need to be addressed. In this review, we summarize the successes and existing doubts of interleukin 1β antibodies, interleukin 6 receptor antagonists, and colchicine in the anti-inflammatory treatment of coronary atherosclerotic heart disease.

Statin therapy is associated with better ambulatory blood pressure control: a propensity score analysis

OBJECTIVE

Statin therapy was associated with lower blood pressure (BP) in some but not all studies. We evaluated the association between statin therapy and ambulatory BP in a large hypertensive population using 'propensity score matching'.

METHODS

Retrospective observational study on 1827 consecutive essential hypertensive patients evaluated with 24-h ambulatory BP monitoring. Antihypertensive treatment intensity (ATI) was calculated to compare different drug associations. We used a propensity score matching to compare two equally-sized cohorts of patients with similar characteristics according to statin therapy. Matching was performed on log-transformed propensity score in a 1 : 1 fashion with a caliper of 0.1, in order to account for the different baseline characteristics between statin and no-statin group.

RESULTS

Mean age: 58.1 ± 13.8 years; male sex: 55%. Patients on statin therapy: 402 (22%). These patients showed lower 24-h BP (-2.8/-7.1 mmHg), daytime (-3.3/-7.6 mmHg) and night-time BP (-2.5/-6.0 mmHg, all P < 0.001). They also showed better ambulatory BP control, even after adjustment for confounding factors. The analyses on the groups derived from the 'propensity score matching' (369 patients in each group) confirmed these results (OR 1.8 for 24-h BP control; OR = 1.6 for daytime BP control; OR = 1.7 for night-time BP control, all P < 0.001).

CONCLUSION

Statin therapy is associated with better ambulatory BP control in essential hypertensive patients. This result is not affected by the intensity of the antihypertensive treatment or by the several cofactors analyzed.

Compound heterozygous MTHFR (C677T and A1298C) variants and anterior STEMI: cause or bystander?

We present the case of a 40-year-old female patient with ST-segment elevation myocardial infarction successfully treated with a primary percutaneous coronary intervention. Thrombophilia testing revealed compound heterozygous MTHFR (C677T and A1298C) variants. We searched the literature for myocardial infarction in the setting of MTHFR polymorphisms and the possible pathophysiologic mechanisms. In young patients presenting with a thrombotic event, screening for thrombophilia could be beneficial for identification of etiology.

In vitro investigation of protective mechanisms of triptolide against coronary heart disease by regulating miR-24-3p-BCL2L11 axis and PPARs-PGC1α pathway

Coronary heart disease (CHD) is a fatal disease associated with coronary atherosclerosis. Although triptolide (TTL) has been reported to protect against CHD, the mechanism has not yet been determined. This study intended to explore its molecular regulation mechanism in CHD. It is shown in this study that TTL contributed to the proliferation and migration of in vitro cell models of CHD (endothelial cells) and the inhibition of apoptosis, and had an improvement effect on apoptosis factors and endoplasmic reticulum stress (ERS). From its mechanisms, TTL evidently downregulates miR-24-3p which is elevated in CHD, and evidently upregulates BCL2-like 11 (BCL2L11) which is suppressed in CHD, as well as affects the activation of peroxisome proliferator-activated receptors (PPARs)-Peroxisome proliferator activated receptor-γ co-activator-1α (PGC-1α) pathway of nuclear receptor transcription factors. In addition, miR-24-3p-BCL2L11-PPARs-PGC1α axis regulates protective effects of TTL against CHD.

The Efficacy and Safety of Compound Danshen Dripping Pill Combined with Percutaneous Coronary Intervention for Coronary Heart Disease

Objective

Compound Danshen dripping pill (CDDP) is a well-known Chinese patent medicine, which is commonly used for the treatment of coronary heart disease (CHD) in China. This study is aimed at systematically assessing the clinical efficacy of CDDP for CHD patients.

Methods

Eight databases were retrieved for eligible research studies from the founding date to April 20, 2020. Risk ratio (RR) was used to assess major adverse cardiac events (MACE) and adverse reactions, and mean difference (MD) was adopted to evaluate the hemorheology and blood lipid indexes, vascular endothelial function, cardiac function, and inflammation.

Result

Twenty randomized controlled trials involving 2574 participants with CHD were included. The results indicated that, compared with percutaneous coronary intervention (PCI) alone, the combination of CDDP with PCI treatment remarkably reduced MACE (RR = 0.53, 95% confidence interval (CI) (0.44, 0.65), P < 0.00001). Moreover, hemorheology and blood lipid parameters and inflammatory mediators of CHD patients were also dramatically mitigated after the combined therapy (P < 0.01). In addition, vascular endothelial function and cardiac function were prominently improved by this combination (P < 0.001). However, there was no significant difference in adverse reactions between the two groups (P > 0.05).

Conclusion

Evidence from the meta-analysis demonstrated that CDDP combined with PCI treatment prominently reduced the incidence of MACE, improved cardiovascular functions, and inhibited inflammation in CHD patients. Therefore, CDDP combined with PCI treatment could be an effective and safe therapeutic method for CHD patients.

Coronary heart disease and atrial fibrillation: a vicious cycle

The population suffering from coronary heart disease (CHD) complicated by atrial fibrillation (AF) is rising rapidly. A strong correlation between the two diseases has been reported, and the many common risk factors they share may play prominent roles in their development. In addition, CHD can directly promote the progression of AF by affecting reentry formation, focal ectopic activity, and neural remodeling. At the same time, AF also affects CHD through three aspects: 1) atherosclerosis, 2) the mismatch of blood supply and oxygen consumption, and 3) thrombosis. In conclusion, CHD and AF can aggravate each other and seem to form a vicious cycle. For patients with CHD complicated by AF, principal studies and guidelines have focused on antithrombotic treatment and rhythm control, which are paramount for these patients. Of note, our review sheds light on the strategies to break the cycle of the two diseases, which may be fundamental to treat these patients and optimize the benefit.

LDL-C: lower is better for longer-even at low risk

BACKGROUND

Low-density lipoprotein cholesterol (LDL-C) causes atherosclerotic disease, as demonstrated in experimental and epidemiological cohorts, randomised controlled trials, and Mendelian randomisation studies.

MAIN TEXT

There is considerable inconsistency between existing guidelines as to how to effectively manage patients at low overall risk of cardiovascular disease (CVD) who have persistently elevated levels of LDL-C. We propose a step-by-step practical approach for the management of cardiovascular risks in individuals with low (< 1%) 10-year risk of CVD, and elevated (> 140 mg/dL, 3.6 mmol/L) LDL-C. The strategy proposed is based on the level of adherence to lifestyle interventions (LSI), and in case of non-adherence, stepwise practical management, including lipid-lowering therapy, is recommended to achieve a target LDL-C levels (< 115 mg/dL, 3.0 mmol/L).

CONCLUSIONS

Further studies are necessary to answer the questions on the long-term efficacy, safety, and cost-effectiveness of the suggested approach. This is critical, considering the ever-increasing numbers of such low-risk patients seen in clinical practice.

Waist circumference does not improve established cardiovascular disease risk prediction modeling

Despite considerable evidence demonstrating that waist circumference (WC) is independently associated with cardiovascular disease (CVD) and/or all-cause mortality, whether the addition of WC improves risk prediction models is unclear. The objective was to evaluate the improvement in risk prediction with the addition of WC, alone or in combination with BMI, to the Framingham Risk Score (FRS) and a population specific model. 34,377 men and 9,477 women aged 20 to 79 years who completed a baseline examination at the Cooper Clinic (Dallas, TX) during 1977–2003 and enrolled in the Aerobics Center Longitudinal Study (ACLS). WC was measured at the level of the umbilicus and expressed as a continuous variable. Deaths among participants were identified using the National Center for Health Statistics National Death Index. A total of 728 fatal cardiovascular disease (CVD) events occurred over a mean follow-up period of 13.1 ± 7.5 years. WC was significantly higher in CVD decedents (P = .002). The FRS C-statistic for fatal CVD in men was 0.836 (0.816–0.855) and 0.883 (0.851–0.915) in women. The addition of WC did not improve the C-statistic in men (0.831 (0.809–0.853)) or women (0.883 (0.850–0.916)). Similar findings were observed for non-fatal CVD and all-cause mortality, and when WC was added to a population specific model. Upon adding WC, the net-reclassification index was 0.024 with an integrated discrimination improvement of -0.0004. The addition of WC, alone or in combination with BMI, did not substantively improve risk prediction for CVD or all-cause mortality compared to the Framingham Risk Score or a population specific model.

Pathways leading to prevention of fatal and non-fatal cardiovascular disease: An interaction model on 15 years population-based cohort study

BACKGROUND

A comprehensive study on the interaction of cardiovascular disease (CVD) risk factors is critical to prevent cardiovascular events. The main focus of this study is thus to understand direct and indirect relationships between different CVD risk factors.

METHODS

A longitudinal data on adults aged ≥35 years, who were free of CVD at baseline, were used in this study. The endpoints were CVD events, whereas their measurements were demographic, lifestyle components, socio-economics, anthropometric measures, laboratory findings, quality of life status, and psychological factors. A Bayesian structural equation modelling was used to determine the relationships among 21 relevant factors associated with total CVD, stroke, acute coronary syndrome (ACS), and fatal CVDs.

RESULTS

In this study, a total of 3161 individuals with complete information were involved in the study. A total of 407 CVD events, with an average age of 54.77(10.66) years, occurred during follow-up. The causal associations between six latent variables were identified in the causal network for fatal and non-fatal CVDs. Lipid profile, with the coefficient of 0.26 (0.01), influenced the occurrence of CVD events as the most critical factor, while it was indirectly mediated through risky behaviours and comorbidities. Lipid profile at baseline was influenced by a wide range of other protective factors, such as quality of life and healthy lifestyle components.

CONCLUSIONS

Analysing a causal network of risk factors revealed the flow of information in direct and indirect paths. It also determined predictors and demonstrated the utility of integrating multi-factor data in a complex framework to identify novel preventable pathways to reduce the risk of CVDs.

Population-Attributable Risk for Cardiovascular Disease Associated With Hypertension in Black Adults

Importance

The prevalence of hypertension and the risk for hypertension-related cardiovascular disease (CVD) are high among black adults. The population-attributable risk (PAR) accounts for both prevalence and excess risk of disease associated with a risk factor.

Objective

To examine the PAR for CVD associated with hypertension among black adults.

Design, Setting, and Participants

This prospective cohort study used data on 12 497 black participants older than 21 years without CVD at baseline who were enrolled in the Jackson Heart Study (JHS) from September 26, 2000, through March 31, 2004, and cardiovascular events were adjudicated through December 31, 2015. The Reasons for Geographic and Racial Differences in Stroke (REGARDS) study participants were enrolled from July 1, 2003, through September 12, 2007, and cardiovascular events were adjudicated through March 31, 2016. Data analysis was performed from March 26, 2018, through July 10, 2019.

Exposures

Normal blood pressure and hypertension were defined using the 2017 American College of Cardiology/American Heart Association blood pressure guideline thresholds.

Main Outcomes and Measures

The PAR for CVD associated with hypertension, calculated using multivariable-adjusted hazard ratios (HRs) for CVD, coronary heart disease, heart failure, and stroke associated with hypertension vs normal blood pressure. Prevalence of hypertension among non-Hispanic black US adults 21 years and older without CVD was calculated using data from the National Health and Nutrition Examination Survey, 2011-2014.

Results

Of 12 497 participants, 1935 had normal blood pressure (638 [33.0%] male; mean [SD] age, 53.5 [12.4] years), 929 had elevated blood pressure (382 [41.1%] male; mean [SD] age, 58.6 [11.8] years), and 9633 had hypertension (3492 [36.3%] male; mean [SD] age, 62.0 [10.3] years). For a maximum 14.3 years of follow-up, 1235 JHS and REGARDS study participants (9.9%) experienced a CVD event. The multivariable-adjusted HR associated with hypertension was 1.91 (95% CI, 1.48-2.46) for CVD, 2.41 (95% CI, 1.59-3.66) for coronary heart disease, 1.52 (95% CI, 1.01-2.30) for heart failure, and 2.20 (95% CI, 1.44-3.36) for stroke. The prevalence of hypertension was 53.2% among non-Hispanic black individuals. The PAR associated with hypertension was 32.5% (95% CI, 20.5%-43.6%) for CVD, 42.7% (95% CI, 24.0%-58.4%) for coronary heart disease, 21.6% (95% CI, 0.6%-40.8%) for heart failure, and 38.9% (95% CI, 19.4%-55.6%) for stroke. The PAR was higher among those younger than 60 years (54.6% [95% CI, 37.2%-68.7%]) compared with those 60 years or older (32.0% [95% CI, 11.9%-48.1%]). No differences were present in subgroup analyses.

Conclusions and Relevance

These findings suggest that a substantial proportion of CVD cases among black individuals are associated with hypertension. Interventions to maintain normal blood pressure throughout the life course may reduce the incidence of CVD in this population.

Apolipoprotein B Particles and Cardiovascular Disease: A Narrative Review

Importance

The conventional model of atherosclerosis presumes that the mass of cholesterol within very low-density lipoprotein particles, low-density lipoprotein particles, chylomicron, and lipoprotein (a) particles in plasma is the principal determinant of the mass of cholesterol that will be deposited within the arterial wall and will drive atherogenesis. However, each of these particles contains one molecule of apolipoprotein B (apoB) and there is now substantial evidence that apoB more accurately measures the atherogenic risk owing to the apoB lipoproteins than does low-density lipoprotein cholesterol or non-high-density lipoprotein cholesterol.

Observations

Cholesterol can only enter the arterial wall within apoB particles. However, the mass of cholesterol per apoB particle is variable. Therefore, the mass of cholesterol that will be deposited within the arterial wall is determined by the number of apoB particles that are trapped within the arterial wall. The number of apoB particles that enter the arterial wall is determined primarily by the number of apoB particles within the arterial lumen. However, once within the arterial wall, smaller cholesterol-depleted apoB particles have a greater tendency to be trapped than larger cholesterol-enriched apoB particles because they bind more avidly to the glycosaminoglycans within the subintimal space of the arterial wall. Thus, a cholesterol-enriched particle would deposit more cholesterol than a cholesterol-depleted apoB particle whereas more, smaller apoB particles that enter the arterial wall will be trapped than larger apoB particles. The net result is, with the exceptions of the abnormal chylomicron remnants in type III hyperlipoproteinemia and lipoprotein (a), all apoB particles are equally atherogenic.

Conclusions and Relevance

Apolipoprotein B unifies, amplifies, and simplifies the information from the conventional lipid markers as to the atherogenic risk attributable to the apoB lipoproteins.

CYP17A1 deficient XY mice display susceptibility to atherosclerosis, altered lipidomic profile and atypical sex development

CYP17A1 is a cytochrome P450 enzyme with 17-alpha-hydroxylase and C17,20-lyase activities. CYP17A1 genetic variants are associated with coronary artery disease, myocardial infarction and visceral and subcutaneous fat distribution; however, the underlying pathological mechanisms remain unknown. We aimed to investigate the function of CYP17A1 and its impact on atherosclerosis in mice. At 4–6 months, CYP17A1-deficient mice were viable, with a KO:Het:WT ratio approximating the expected Mendelian ratio of 1:2:1. All Cyp17a1 knockout (KO) mice were phenotypically female; however, 58% were Y chromosome-positive, resembling the phenotype of human CYP17A1 deficiency, leading to 46,XY differences/disorders of sex development (DSD). Both male and female homozygous KO mice were infertile, due to abnormal genital organs. Plasma steroid analyses revealed a complete lack of testosterone in XY-KO mice and marked accumulation of progesterone in XX-KO mice. Elevated corticosterone levels were observed in both XY and XX KO mice. In addition, Cyp17a1 heterozygous mice were also backcrossed onto an Apoe KO atherogenic background and fed a western-type diet (WTD) to study the effects of CYP17A1 on atherosclerosis. Cyp17a1 x Apoe double KO XY mice developed more atherosclerotic lesions than Apoe KO male controls, regardless of diet (standard or WTD). Increased atherosclerosis in CYP17A1 XY KO mice lacking testosterone was associated with altered lipid profiles. In mice, CYP17A1 deficiency interferes with sex differentiation. Our data also demonstrate its key role in lipidomic profile, and as a risk factor in the pathogenesis of atherosclerosis.

Development of a nomogram that predicts the risk for coronary atherosclerotic heart disease

Studies seldom combine biological, behavioral and psychological factors to estimate coronary atherosclerotic heart disease (CHD) risk. Here, we evaluated the associations between these factors and CHD to develop a predictive nomogram to identify those at high risk of CHD. This case-control study included 4392 participants (1578 CHD cases and 2814 controls) in southeast China. Thirty-three biological, behavioral and psychological variables were evaluated. Following multivariate logistic regression analysis, which revealed eight risk factors associated with CHD, a predictive nomogram was developed based on a final model that included the three non-modifiable (sex, age and family history of CHD) and five modifiable (hypertension, hyperlipidemia, diabetes, recent experience of a major traumatic event, and anxiety) variables. The higher total nomogram score, the greater the CHD risk. Final model accuracy (as estimated from the area under the receiver operating characteristic curve) was 0.726 (95% confidence interval: 0.709-0.747). Validation analysis confirmed the high accuracy of the nomogram. High risk of CHD was associated with several biological, behavioral and psychological factors. We have thus developed an intuitive nomogram that could facilitate development of preliminary prevention strategies for CHD.

Waist circumference as a vital sign in clinical practice: a Consensus Statement from the IAS and ICCR Working Group on Visceral Obesity

Despite decades of unequivocal evidence that waist circumference provides both independent and additive information to BMI for predicting morbidity and risk of death, this measurement is not routinely obtained in clinical practice. This Consensus Statement proposes that measurements of waist circumference afford practitioners with an important opportunity to improve the management and health of patients. We argue that BMI alone is not sufficient to properly assess or manage the cardiometabolic risk associated with increased adiposity in adults and provide a thorough review of the evidence that will empower health practitioners and professional societies to routinely include waist circumference in the evaluation and management of patients with overweight or obesity. We recommend that decreases in waist circumference are a critically important treatment target for reducing adverse health risks for both men and women. Moreover, we describe evidence that clinically relevant reductions in waist circumference can be achieved by routine, moderate-intensity exercise and/or dietary interventions. We identify gaps in the knowledge, including the refinement of waist circumference threshold values for a given BMI category, to optimize obesity risk stratification across age, sex and ethnicity. We recommend that health professionals are trained to properly perform this simple measurement and consider it as an important 'vital sign' in clinical practice.

European Society of Cardiology: Cardiovascular Disease Statistics 2019

AIMS

The 2019 report from the European Society of Cardiology (ESC) Atlas provides a contemporary analysis of cardiovascular disease (CVD) statistics across 56 member countries, with particular emphasis on international inequalities in disease burden and healthcare delivery together with estimates of progress towards meeting 2025 World Health Organization (WHO) non-communicable disease targets.

METHODS AND RESULTS

In this report, contemporary CVD statistics are presented for member countries of the ESC. The statistics are drawn from the ESC Atlas which is a repository of CVD data from a variety of sources including the WHO, the Institute for Health Metrics and Evaluation, and the World Bank. The Atlas also includes novel ESC sponsored data on human and capital infrastructure and cardiovascular healthcare delivery obtained by annual survey of the national societies of ESC member countries. Across ESC member countries, the prevalence of obesity (body mass index ≥30 kg/m2) and diabetes has increased two- to three-fold during the last 30 years making the WHO 2025 target to halt rises in these risk factors unlikely to be achieved. More encouraging have been variable declines in hypertension, smoking, and alcohol consumption but on current trends only the reduction in smoking from 28% to 21% during the last 20 years appears sufficient for the WHO target to be achieved. The median age-standardized prevalence of major risk factors was higher in middle-income compared with high-income ESC member countries for hypertension {23.8% [interquartile range (IQR) 22.5-23.1%] vs. 15.7% (IQR 14.5-21.1%)}, diabetes [7.7% (IQR 7.1-10.1%) vs. 5.6% (IQR 4.8-7.0%)], and among males smoking [43.8% (IQR 37.4-48.0%) vs. 26.0% (IQR 20.9-31.7%)] although among females smoking was less common in middle-income countries [8.7% (IQR 3.0-10.8) vs. 16.7% (IQR 13.9-19.7%)]. There were associated inequalities in disease burden with disability-adjusted life years per 100 000 people due to CVD over three times as high in middle-income [7160 (IQR 5655-8115)] compared with high-income [2235 (IQR 1896-3602)] countries. Cardiovascular disease mortality was also higher in middle-income countries where it accounted for a greater proportion of potential years of life lost compared with high-income countries in both females (43% vs. 28%) and males (39% vs. 28%). Despite the inequalities in disease burden across ESC member countries, survey data from the National Cardiac Societies of the ESC showed that middle-income member countries remain severely under-resourced compared with high-income countries in terms of cardiological person-power and technological infrastructure. Under-resourcing in middle-income countries is associated with a severe procedural deficit compared with high-income countries in terms of coronary intervention, device implantation and cardiac surgical procedures.

CONCLUSION

A seemingly inexorable rise in the prevalence of obesity and diabetes currently provides the greatest challenge to achieving further reductions in CVD burden across ESC member countries. Additional challenges are provided by inequalities in disease burden that now require intensification of policy initiatives in order to reduce population risk and prioritize cardiovascular healthcare delivery, particularly in the middle-income countries of the ESC where need is greatest.

Long-Term Effectiveness of Liraglutide for Weight Management and Glycemic Control in Type 2 Diabetes

Background: Liraglutide is the first glucagon-like peptide-1 receptor agonist (GLP-1 RA) based on the human GLP-1 sequence, with potential weight loss benefits, approved for the treatment of type 2 diabetes (T2D) mellitus. Herein, we aimed to assess the 5-year effectiveness of Liraglutide in the management of weight and glycometabolic control in a Southern Italian cohort of overweight/obese T2D patients, who were naïve to GLP-1 RAs. Patients and Methods: Forty overweight or obese patients treated with Liraglutide at doses up to 1.8 mg/day, in combination with one or more oral antidiabetic agents, were retrospectively assessed at baseline, during, and after 60 months of continuous therapy. Results: After 5 years of Liraglutide treatment, body weight decreased from 92.1 ± 20.5 kg to 87.3 ± 20.0 Kg (p < 0.001), with a mean reduction of 5.0 ± 7.0 Kg and a body mass index (BMI) decrement of −2.0 ± 3.1 Kg/m². On Spearman’s univariate analysis, change in body weight was correlated with female gender and baseline BMI. Hemoglobin A1c (HbA1c) decreased from 7.9 ± 0.9% at baseline to 7.0 ± 0.7% at the end of the study period (p < 0.001), followed by a significant reduction in fasting plasma glucose. No significant differences emerged in other biochemical parameters, despite a trend toward improvement in lipid profile. Notwithstanding encouraging effects on several markers of cardiovascular disease (CVD), increments in the 5- and 10-year risk for the first atherosclerotic cardiovascular event were documented, as four incident cases of myocardial infarction. Conclusions: Prolonging treatment with Liraglutide can lead to durable benefits in relation to weight and glycemic control, with a greater impact on women. These results extend and corroborate previous observations, suggesting that gender per se may modulate the response to Liraglutide. Despite favorable effects on some established CVD risks factors, the long-term role of Liraglutide in primary prevention of CVD in patients with T2D remains controversial.