The Burden of Cardiovascular Diseases Among US States, 1990-2016

Periodontitis related to cardiovascular events and mortality: a long-time longitudinal study

OBJECTIVE

The present study assessed if individuals ≥ 60 years of age with periodontitis are more likely to develop stroke or ischemic heart diseases, or at a higher risk of death for 17 years.

MATERIAL AND METHODS

At baseline individuals ≥ 60 received a dental examination including a panoramic radiograph. Periodontitis was defined as having ≥ 30% sites with ≥ 5-mm distance from the cementoenamel junction to the marginal bone level. Medical records were annually reviewed from 2001 to 2018. Findings from the medical records identifying an ICD-10 code of stroke and ischemic heart diseases or death were registered.

RESULTS

Associations between periodontitis and incidence of ischemic heart disease were found in this 17-year follow-up study in all individuals 60-93 years (HR: 1.5, CI: 1.1-2.1, p = 0.017), in women (HR: 2.1, CI: 1.3-3.4, p = 0.002), and in individuals 78-96 years (HR: 1.7, CI: 1.0-2.6, p = 0.033). Periodontitis was associated with mortality in all individuals (HR: 1.4, CI: 1.2-1.8, p = 0.002), specifically in men (HR: 1.5, CI: 1.1-1.9, p = 0.006) or in ages 60-72 years (HR: 2.2, CI: 1.5-3.2, p = 0.000). Periodontitis was more prevalent among men (OR: 1.8, CI: 1.3-2.4, p = 0.000).

CONCLUSIONS

Individuals with periodontitis have an increased risk for future events of ischemic heart diseases and death.

CLINICAL RELEVANCE

Improving periodontal health in older individuals may reduce overall mortality and ischemic heart diseases. Both dental and medical professionals should be aware of the associations and ultimately cooperate.

Epidemiology and the Magnitude of Coronary Artery Disease and Acute Coronary Syndrome: A Narrative Review

BACKGROUND

Coronary Artery Disease (CAD) is the foremost single cause of mortality and loss of Disability Adjusted Life Years (DALYs) globally. A large percentage of this burden is found in low and middle income countries. This accounts for nearly 7 million deaths and 129 million DALYs annually and is a huge global economic burden.

OBJECTIVE

To review epidemiological data of coronary artery disease and acute coronary syndrome in low, middle and high income countries.

METHODS

Keyword searches of Medline, ISI, IBSS and Google Scholar databases. Manual search of other relevant journals and reference lists of primary articles.

RESULTS

Review of the results of studies reveals the absolute global and regional trends of the CAD and the importance and contribution of CAD for global health. Data demonstrates which region or countries have the highest and lowest age-standardized DALY rates and what factors might explain these patterns. Results also show differences among the determinants of CAD, government policies, clinical practice and public health measures across the various regions of world.

CONCLUSION

CAD mortality and prevalence vary among countries. Estimation of the true prevalence of CAD in the population is complex. A significant number of countries have not provided data, the estimation of the exact figures for epidemiological data is a barrier. The incidence of CAD continues to fall in developed countries over the last few decades and this may be due to both effective treatment of the acute phase and improved primary and secondary preventive measures. Developing countries show considerable variability in the incidence of CAD. The globalization of the Western diet and increased sedentary lifestyle will have a dramatic influence on the progressive increase in the incidence of CAD in these countries.

The slowdown in the reduction rate of premature mortality from cardiovascular diseases puts the Americas at risk of achieving SDG 3.4: A population trend analysis of 37 countries from 1990 to 2017

Cardiovascular diseases (CVD) are leading causes of mortality and morbidity in the Americas, resulting in substantial negative economic and social impacts. This study describes the trends and inequalities of CVD burden in the Americas to guide programmatic interventions and health system responses. We examined the CVD burden trends by age, sex, and countries between 1990 and 2017 and quantified social inequalities in CVD burden across countries. In 2017, CVD accounted for 2 million deaths in the Americas, 29% of total deaths. Age-standardized DALY rates caused by CVD declined by -1.9% (95% uncertainty interval, -2.0 to -1.7) annually from 1990 to 2017. This trend varied with a striking decreasing trend over the interval 1994-2003 (annual percent change (APC) -2.4% [-2.5 to 2.2]) and 2003-2007 (APC -2.8% [-3.4 to -2.2]). This was followed by a slowdown in the rate of decline over 2007-2013 (APC -1.83% [-2.1 to -1.6]) and a stagnation during the most recent period 2013-2017 (APC -0.1% [-0.5 to 0.3]). The social inequality in CVD burden along the socio-demographic gradient across countries decreased 2.75-fold. The CVD burden and related social inequality have both substantially decreased in the Americas since 1990, driven by the reduction in premature mortality. This trend occurred in parallel with the improvement in the socioeconomic development and health care of the region. The deceleration and stagnation in the rate of improvement of CVD burden and persistent social inequality pose major challenges to reduce the CVD burden and the achievement of the United Nations' Sustainable Development Goals Target 3.4.

Different Patterns in Ranking of Risk Factors for the Onset Age of Acute Myocardial Infarction between Urban and Rural Areas in Eastern Taiwan

This cross-sectional study aimed to investigate the difference in ranking of risk factors of onset age of acute myocardial infarction (AMI) between urban and rural areas in Eastern Taiwan. Data from 2013 initial onset of AMI patients living in the urban areas (n = 1060) and rural areas (n = 953) from January 2000 to December 2015, including onset age, and conventional risk factors including sex, smoking, diabetes, hypertension, dyslipidemia, and body mass index (BMI). The results of multiple linear regressions analysis showed smoking, obesity, and dyslipidemia were early-onset reversible risk factors of AMI in both areas. The ranking of impacts of them on the age from high to low was obesity (β = −6.7), smoking (β = −6.1), and dyslipidemia (β = −4.8) in the urban areas, while it was smoking (β = −8.5), obesity (β= −7.8), and dyslipidemia (β = −5.1) in the rural areas. Furthermore, the average onset ages for the patients who smoke, are obese, and have dyslipidemia simultaneously was significantly earlier than for patients with none of these comorbidities in both urban (13.6 years) and rural (14.9 years) areas. The findings of this study suggest that the different prevention strategies for AMI should be implemented in urban and rural areas.

Efficacy and safety of Naoxintong capsule for treating chronic stable angina: study protocol for a randomized controlled trial

Background

Cardiovascular disease is the leading cause of mortality and morbidity worldwide, Chronic stable angina (CSA) is the main symptom of myocardial ischemia, causes increased risk of major cardiovascular events such as sudden cardiac death and myocardial infarction. Naoxintong (NXT) capsule is a classical traditional Chinese medication used to treat CSA, however, few evidence to support the wide utility of NXT capsule for the treatment of CSA. We design this study to evaluate the efficacy and safety of NXT capsule versus placebo in patients with CSA.

Methods/design

This is a multicenter, randomized, double-blind, placebo-controlled clinical trial. A total of 260 eligible participants will be enrolled. The participants will be randomized assigned in an equal ratio to groups receiving either NXT or placebo for 12 weeks. After a 2-week run-in period, they will receive either NXT or placebo (3 pills, 3 times daily) for 12 weeks. The primary outcome is therapeutic efficacy. Secondary outcome measures include the quantitative score of TCM syndromes, severity grading of angina pectoris, the number of angina pectoris per week, nitroglycerin dosage, score of Seattle angina scale, serum homocysteine, and incidence of cardiovascular events. Safety outcomes and adverse events will be monitored throughout the trial.

Discussion

We designed this study in accordance with principles and regulations issued by the China Food and Drug Administration (CFDA). The results will provide clinical evidence of the efficacy and safety of NXT Capsule in the treatment of CSA.

Trial registration

Chinese Clinical Trial Registry ChiCTR2100044563. Registered on 24 March 2020.

National Trends of Tobacco, Alcohol, and Drug Use in Patients Admitted With Acute Myocardial Infarction

BACKGROUND

Acute myocardial infarction (AMI) is a significant health and economic burden in the US. Tobacco, alcohol, and drug use are established risk factors. We sought to evaluate the national trend of use of each substance in patients admitted with AMI.

METHODS

We used the National Inpatient Sample between 2005 and 2017. We included adult patients hospitalized with AMI. International Classification of Diseases, Ninth and Tenth Revisions codes were used to define tobacco, alcohol, cocaine, opioid, cannabis and other drug use. Trends of each substance use were assessed using multivariable Poisson regression, and were expressed as annual percent change (APC) with their 95% confidence intervals (CIs).

RESULTS

A total of 10,796,844 hospitalizations with AMI were included. Among all substances used, tobacco was the most common (32.7%), followed by alcohol (3.2%). Between 2005 and 2017, the prevalence ratio of tobacco use increased from 21.5% to 44.5% with an APC +6.2% (95%CI 6.2%-6.2%). Tobacco users had more percutaneous coronary intervention (41%vs25%) and coronary artery bypass surgery (6.9%vs4.9%), p < 0.001. Further, there were positive trends in alcohol (APC +3.1%; 95%CI 3.0%-3.2%), opioid (APC +9.0%; 95%CI 8.7%-9.2%), cannabis (APC + 7.2; 95% CI 7%-7.4%), and combined all drug use (+7.1%; 95%CI 7%-7.2%). Meanwhile, there was a slight negative trend in cocaine use.

CONCLUSIONS

This analysis outlines the national trends of substance use in patients admitted with AMI and reveals an increasing prevalence of tobacco use, alcohol and drug use. More effective cessation measures are necessary to reduce the risk for AMI and its burden on the healthcare system and economy.

Geographical Differences in Cardiovascular Comorbidities and Outcomes of COVID-19 Hospitalized Patients in the USA

Introduction

Cardiovascular comorbidities may predispose to adverse outcomes in hospitalized patients with coronavirus disease 2019 (COVID-19). However, across the USA, the burden of cardiovascular comorbidities varies significantly. Whether clinical outcomes of hospitalized patients with COVID-19 differ between regions has not yet been studied systematically. Here, we report differences in underlying cardiovascular comorbidities and clinical outcomes of patients hospitalized with COVID-19 in Texas and in New York state.

Methods

We established a multicenter retrospective registry including patients hospitalized with COVID-19 between March 15 and July 12, 2020. Demographic and clinical data were manually retrieved from electronic medical records. We focused on the following outcomes: mortality, need for pharmacologic circulatory support, need for mechanical ventilation, and need for hemodialysis. Univariate and multivariate logistic regression analyses were performed.

Results

Patients in the Texas cohort (n = 296) were younger (57 vs. 63 years, p value <0.001), they had a higher BMI (30.3 kg/m² vs. 28.5 kg/m², p = 0.015), and they had higher rates of diabetes mellitus (41 vs. 30%; p = 0.014). In contrast, patients in the New York state cohort (n = 218) had higher rates of coronary artery disease (19 vs. 10%, p = 0.005) and atrial fibrillation (11 vs. 5%, p = 0.012). Pharmacologic circulatory support, mechanical ventilation, and hemodialysis were more frequent in the Texas cohort (21 vs. 13%, p = 0.020; 30 vs. 12%, p < 0.001; and 11 vs. 5%, p = 0.009, respectively). In-hospital mortality was similar between the 2 cohorts (16 vs. 18%, p = 0.469). After adjusting for differences in underlying comorbidities, only the use of mechanical ventilation remained significantly higher in the participating Texas hospitals (odds ratios [95% CI]: 3.88 [1.23, 12.24]). Median time to pharmacologic circulatory support was 8 days (interquartile range: 2, 13.8) in the Texas cohort compared to 1 day (0, 3) in the New York state cohort, while median time to in-hospital mortality was 16 days (10, 25.5) and 7 days (4, 14), respectively (both p < 0.001). In-hospital mortality was higher in the late versus the early study phase in the New York state cohort (24 vs. 14%, p = 0.050), while it was similar between the 2 phases in the Texas cohort (16 vs. 15%, p = 0.741).

Conclusions

Geographical differences, including practice pattern variations and the impact of disease burden on provision of health care, are important for the evaluation of COVID-19 outcomes. Unadjusted data may cause bias affecting future regulatory policies and proper allocation of resources.

Geographic Variation in Trends and Disparities in Heart Failure Mortality in the United States, 1999 to 2017

Background Cardiovascular disease mortality related to heart failure (HF) is rising in the United States. It is unknown whether trends in HF mortality are consistent across geographic areas and are associated with state-level variation in cardiovascular health (CVH). The goal of the present study was to assess regional and state-level trends in cardiovascular disease mortality related to HF and their association with variation in state-level CVH. Methods and Results Age-adjusted mortality rates (AAMR) per 100 000 attributable to HF were ascertained using the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research from 1999 to 2017. CVH at the state-level was quantified using the Behavioral Risk Factor Surveillance System. Linear regression was used to assess temporal trends in HF AAMR were examined by census region and state and to examine the association between state-level CVH and HF AAMR. AAMR attributable to HF declined from 1999 to 2011 and increased between 2011 and 2017 across all census regions. Annual increases after 2011 were greatest in the Midwest (β=1.14 [95% CI, 0.75, 1.53]) and South (β=0.96 [0.66, 1.26]). States in the South and Midwest consistently had the highest HF AAMR in all time periods, with Mississippi having the highest AAMR (109.6 [104.5, 114.6] in 2017). Within race‒sex groups, consistent geographic patterns were observed. The variability in HF AAMR was associated with state-level CVH (P<0.001). Conclusions Wide geographic variation exists in HF mortality, with the highest rates and greatest recent increases observed in the South and Midwest. Higher levels of poor CVH in these states suggest the potential for interventions to promote CVH and reduce the burden of HF.

Relationships among visual acuity, risk of acute myocardial infarction, and stroke: a nationwide cohort study in south korea

Purpose: Visual impairment (VI) is highly prevalent in the elderly and is associated with functional decline. Previous research demonstrated an association between VI and cardiovascular events, but investigations have yet to be conducted in general population samples. We evaluated the relationship between visual acuity (VA) and development of cardiovascular diseases (CVD) in a nationwide Korean population.Methods: This is a nationwide retrospective cohort study. We used the National Health Information Database of the National Health Insurance Service of Korea to identify subjects who participated in the National Health Insurance Service health screening program in 2012. We monitored 5,941,761 subjects for the development of cardiovascular diseases for a period of 5 years.Results: After adjustments for age, sex, and other covariates, with subjects having a visual acuity better than 20/20 as the reference group, the adjusted hazard ratios (HRs) and 95% confidential intervals (CI) for acute myocardial infarction and stroke were visual acuity between 20/20 and 20/60, 1.073 (95% CI 1.053, 1.094) and 1.151 (95% CI 1.132, 1.171), respectively; for visual acuity between 20/60 and 20/200, 1.236 (95% CI 1.197, 1.277), and 1.336 (95% CI 1.302, 1.371), respectively; and for visual acuity worse than 20/200, 1.325 (95% CI 1.285, 1.366) and 1.383 (95% CI 1.349, 1.418), respectively.Conclusion: Subjects with lower VA had higher risks of acute myocardial infarction and stroke. These results suggest that low VA is an independent risk factor for CVD.

The effect of cholecystectomy on the risk of acute myocardial infarction in patients with gallbladder stones

Objectives: To investigate the effect of cholecystectomy on the subsequent risk of acute myocardial infarction (AMI) in patients with gallbladder stones (GBS).Methods: We used the Taiwan National Health Insurance Research Database (NHIRD) for hospitalization to conduct a retrospective nationwide population-based cohort study. The study cohort consisted of a total of 122,421 patients aged ≥20 years with cholecystectomy for GBS between 2000 and 2010. The control cohort consisted of the GBS patients without cholecystectomy and they were randomly selected by propensity score matching with the study cohort at a 1:1 ratio according to age, sex, occupation category, urbanization level, comorbidities, and year of the index date for cholecystectomy. We measured the incidence of AMI for both cohorts.Results: The cumulative incidence of AMI was lower in GB patients with cholecystectomy than that in those without cholecystectomy (2.26 vs 3.28 per 1000 person-years, adjusted hazard ratio [aHR] = 0.65, 95% confidence interval [CI] = 0.61-0.69). Compared to those without cholecystectomy, the risk of developing AMI after cholecystectomy was 0.69 (95% CI = 0.63-0.76) for the first year, 0.69 (95% CI = 0.63-0.77) for 2-5 years, and 0.59 (95% CI = 0.53-0.66) for ≥5 years, respectively.Conclusions: Our findings indicate cholecystectomy ameliorates the risk of AMI in patients with GBS, and the protective effect tends to increase with incremental duration of follow-up. However, it needs more studies to ascertain the protective mechanisms of cholecystectomy against AMI.

Rheumatic Fever and Rheumatic Heart Disease in the United States

During the 1920s, acute rheumatic fever (ARF) was the leading cause of mortality in children in the United States. By the 1980s, many felt ARF had all but disappeared from the US. However, although ARF and rheumatic heart disease (RHD) rates remain low in the US today, disease burden is unequal and tracks along other disparities of cardiovascular health. It is estimated that 1% to 3% of patients with untreated group A streptococcus (GAS) infection, most typically GAS pharyngitis, will develop ARF, and of these, up to 60% of cases will result in chronic RHD. This article reviews the epidemiology, pathogenesis, diagnosis, and management of ARF/RHD to increase awareness of ARF/RHD for clinicians based in the US. [Pediatr Ann. 2021;50(3):e98-e104.].

Pediatric Lipid Disorders

Current scientific evidence has proven that atherosclerosis is a process that begins in childhood and tracks into adulthood, likely culminating in adverse cardiovascular events such as coronary artery disease, peripheral artery disease, and stroke. In addition, the obesity epidemic and increasing awareness of genetic lipid disorders has made the understanding and management of lipid disorders necessary for pediatricians. Childhood offers a unique opportunity for preventing, modifying, or eliminating risk factors and, in doing so, reversing or slowing the process of atherosclerosis. In general, management involves targeted lifestyle interventions such as strict dietary changes and increases in physical activity. In some circumstances, pharmacotherapy, even in childhood, is warranted. [Pediatr Ann. 2021;50(3):e105-e112.].

Impact of Global Budget Payments on Cardiovascular Care in Maryland: An Interrupted Time Series Analysis

Background Global budget payments (GBP) are considered effective in containing health care expenditures; however, information on their impact on quality of cardiovascular care is limited. We aimed to evaluate the effects of GBP on utilization, outcomes, and costs for 3 major cardiovascular conditions. Methods We analyzed claims data of hospital admissions in Maryland from fiscal year 2013 to 2018. Using segmented regression, we evaluated temporal trends in hospitalizations, length of stay, percutaneous coronary intervention and coronary artery bypass grafting volumes, case mix-adjusted 30-day readmission rates, risk-standardized mortality rates, and hospitalization charges in patients with principal diagnosis of heart failure, acute ischemic stroke, and acute myocardial infarction (AMI) in relation to GBP implementation. Trends in global cardiovascular procedure charges/volumes were also studied. Results Hospitalization rates for congestive heart failure and AMI remained unaffected by GBP, while the gradient of ischemic stroke admissions decreased (P_trend <0.0001). Length of stay slightly increased for patients with congestive heart failure (P_trend=0.03). Inpatient coronary artery bypass grafting surgeries decreased (P_trend <0.0001). We observed a significant decrease in casemix-adjusted 30-day readmission rate in the AMI cohort beyond the prepolicy trend (P_trend=0.0069). There were no significant changes in mortality for any of the 3 conditions. Hospitalization charges increased for ischemic stroke (P_trend <0.0001), remained constant for congestive heart failure (P_trend=0.1), and decreased for AMI (P_trend=0.0005). We observed a significant increase in electrocardiography rate charges (P_trend <0.0001), coincidentally with a reduction in volumes (P_trend=0.0003). Conclusions Introducing GBP in Maryland had no perceivable adverse effects on inpatient outcomes and quality indicators for 3 major cardiovascular conditions. Savings were observed in the AMI cohort, possibly due to reduced unnecessary readmissions, efficiency improvements, or shifts to outpatient care. Reduced cardiovascular procedure volumes were counterbalanced by a proportional rise in charges. State-level adoption of GBP with pay-for-performance incentives may be effective for cost containment without adversely impacting quality of cardiovascular care.

Electrocardiographic Imaging: A Comparison of Iterative Solvers

Cardiac disease is a leading cause of morbidity and mortality in developed countries. Currently, non-invasive techniques that can identify patients at risk and provide accurate diagnosis and ablation guidance therapy are under development. One of these is electrocardiographic imaging (ECGI). In ECGI, the first step is to formulate a forward problem that relates the unknown potential sources on the cardiac surface to the measured body surface potentials. Then, the unknown potential sources on the cardiac surface are reconstructed through the solution of an inverse problem. Unfortunately, ECGI still lacks accuracy due to the underlying inverse problem being ill-posed, and this consequently imposes limitations on the understanding and treatment of many cardiac diseases. Therefore, it is necessary to improve the solution of the inverse problem. In this work, we transfer and adapt four inverse problem methods to the ECGI setting: algebraic reconstruction technique (ART), random ART, ART Split Bregman (ART-SB) and range restricted generalized minimal residual (RRGMRES) method. We test all these methods with data from the Experimental Data and Geometric Analysis Repository (EDGAR) and compare their solution with the recorded epicardial potentials provided by EDGAR and a generalized minimal residual (GMRES) iterative method computed solution. Activation maps are also computed and compared. The results show that ART achieved the most stable solutions and, for some datasets, returned the best reconstruction. Differences between the solutions derived from ART and random ART are almost negligible, and the accuracy of their solutions is followed by RRGMRES, ART-SB and finally the GMRES (which returned the worst reconstructions). The RRGMRES method provided the best reconstruction for some datasets but appeared to be less stable than ART when comparing different datasets. In conclusion, we show that the proposed methods (ART, random ART, and RRGMRES) improve the GMRES solution, which has been suggested as inverse problem solution for ECGI.

The Burden of Skin and Subcutaneous Diseases in the United States From 1990 to 2017

Importance

Skin and subcutaneous diseases affect the health of millions of individuals in the US. Data are needed that highlight the geographic trends and variations of skin disease burden across the country to guide health care decision-making.

Objective

To characterize trends and variations in the burden of skin and subcutaneous tissue diseases across the US from 1990 to 2017.

Design, Setting, and Participants

For this cohort study, data were obtained from the Global Burden of Disease (GBD), a study with an online database that incorporates current and previous epidemiological studies of disease burden, and from GBD 2017, which includes more than 90 000 data sources such as systematic reviews, surveys, population-based disease registries, hospital inpatient and outpatient data, cohort studies, and autopsy data. The GBD separated skin conditions into 15 subcategories according to incidence, prevalence, adequacy of data, and standardized disease definitions. GBD 2017 also estimated the burden from melanoma of the skin and keratinocyte carcinoma. Data analysis for the present study was conducted from September 9, 2019, to March 31, 2020.

Main Outcomes and Measures

Primary study outcomes included age-standardized disability-adjusted life-years (DALYs), incidence, and prevalence. The data were stratified by US states with the highest and lowest age-standardized DALY rate per 100 000 people, incidence, and prevalence of each skin condition. The percentage change in DALY rates in each state was calculated from 1990 to 2017.

Results

Overall, age-standardized DALY rates for skin and subcutaneous diseases increased from 1990 (821.6; 95% uncertainty interval [UI], 570.3-1124.9) to 2017 (884.2; 95% UI, 614.0-1207.9) in all 50 states and the District of Columbia. The degree of increase varied according to geographic location, with the largest percentage change of 0.12% (95% UI, 0.09%-0.15%) in New York and the smallest percentage change of 0.04% (95% UI, 0.02%-0.07%) in Colorado, 0.04% (95% UI, 0.01%-0.06%) in Nevada, 0.04% (95% UI, 0.02%-0.07%) in New Mexico, and 0.04% (95% UI, 0.02%-0.07%) in Utah. The age-standardized DALY rate, incidence, and prevalence of specific skin conditions differed among the states. New York had the highest age-standardized DALY rate for skin and subcutaneous disease in 2017 (1097.0 [95% UI, 764.9-1496.1]), whereas Wyoming had the lowest age-standardized DALY rate (672.9 [95% UI, 465.6-922.3]). In all 50 states and the District of Columbia, women had higher age-standardized DALY rates for overall skin and subcutaneous diseases than men (women: 971.20 [95% UI, 676.76-1334.59] vs men: 799.23 [95% UI, 559.62-1091.50]). However, men had higher DALY rates than women for malignant melanoma (men: 80.82 [95% UI, 51.68-123.18] vs women: 42.74 [95% UI, 34.05-70.66]) and keratinocyte carcinomas (men: 37.56 [95% UI, 29.35-49.52] vs women: 14.42 [95% UI, 10.01-20.66]).

Conclusions and Relevance

Data from the GBD suggest that the burden of skin and subcutaneous disease was large and that DALY rate trends varied across the US; the age-standardized DALY rate for keratinocyte carcinoma appeared greater in men. These findings can be used by states to target interventions and meet the needs of their population.

Textile Triboelectric Nanogenerators for Wearable Pulse Wave Monitoring

Arterial pulse waves are regarded as vital diagnostic tools in the assessment of cardiovascular disease (CVD). Because of their high sensitivity, rapid response time, wearability, and low cost, textile triboelectric nanogenerators (TENGs) are emerging as a compelling biotechnology for wearable pulse wave monitoring. We discuss sensing mechanisms for pulse-to-electricity conversion, analytical models for calculating cardiovascular parameters, and application scenarios for textile TENGs. We provide a prospective on the challenges that limit the wider application of this technology and suggest some future research directions. In the future, textile TENGs are expected to make an impact in the fields of wearable pulse wave monitoring and CVD diagnosis.

Accuracy of the Resting Energy Expenditure Estimation Equations for Healthy Women

Background: There exist several prediction equations for the estimation of resting energy expenditure (REE). However, none of these equations have been validated in the Chilean female population yet. The aims of this study are (1) to determine the accuracy of existing equations for prediction of REE and (2) to develop new equations in a sample of healthy Chilean women. Methods: A cross-sectional descriptive study was carried out on 620 Chilean women. The sample showed an age range between 18 and 73 years, a body mass index average of 28.5 ± 5.2 kg/m², and a prevalence of overweight and obesity of 41% and 33.2%, respectively. REE was measured by indirect calorimetry (REE_IC), which was used as the gold standard to determine the accuracy of twelve available REE prediction equations and to calculate alternative formulas for estimation of REE. Paired t-tests and Bland–Altman plots were used to know the accuracy of the estimation equations with REE_IC. At the same time, multiple linear regressions were performed to propose possible alternative equations. The analyses were carried out by age groups and according to nutritional status. Results: All the equations showed a tendency to overestimate REE, regardless of age or nutritional status. Overall, the Ireton-Jones equation achieved the highest mean percentage difference from REE_IC at 67.1 ± 31%. The alternative new equations, containing variables of body composition, reached a higher percentage of classification within ±10% of REE_IC. Conclusions: The available equations do not adequately estimate REE in this sample of Chilean women. Although they must be validated, the new formulas proposed show better adaptation to this Chilean sample.

Epidemiology of Ischemic Heart Disease and Diabetes in South Asia: An Overview of the Twin Epidemic

BACKGROUND & OBJECTIVES

Ischemic heart disease (IHD) is one of the most important causes of death and disability in the world and diabetes is an important risk factor. This review was performed to describe the mortality and morbidity burden from this twin epidemic in South Asian countries.

METHODS

Country-level data on the epidemiology of IHD and diabetes were obtained from the Global Burden of Disease (GBD) study. Sub-national data were available only for India. We also retrieved epidemiological studies from published reviews on IHD and diabetes in India. These were supplemented with MEDLINE search.

RESULTS

GBD study and regional epidemiological studies have reported that there are significant regional variations in IHD mortality and disease burden within South Asian countries. IHD burden has increased significantly from 2000 to 2017. Prospective Urban Rural Epidemiology study has reported that diabetes is an important IHD risk factor in the South Asian region. GBD Study and International Diabetes Federation have reported increasing diabetes-related mortality and disease burden in South Asian countries, especially India. There are regional variations in diabetes-related mortality, disease burden, and prevalence in South Asia. At the macrolevel, rapid food and nutrition transition along with increasing physical inactivity is responsible for this twin epidemic.

CONCLUSION

Increasing trends in IHD and diabetes-related mortality and disease burden with regional variations are observed in South Asian countries.

Association of Maternal Hypothyroidism With Cardiovascular Diseases in the Offspring

BACKGROUND

No previous study has examined the effect of maternal hypothyroidism on a broad spectrum of cardiovascular disease (CVD) endpoints in the offspring.

METHODS

A nationwide population-based cohort study based on the linkage of several Danish nationwide registries was conducted to explore whether maternal hypothyroidism is associated with offspring's CVD. Altogether 1,041,448 singletons born between the 1st of January 1978 and the 31st of December 1998 were investigated from the age of 8 years to the 31st of December 2016. Exposure was maternal diagnosis of hypothyroidism across lifespan and the outcome of interest was a CVD diagnosis in the offspring. Cox regression models were performed to estimate the hazard ratios (HRs) of CVD.

RESULTS

Offspring born to mothers with hypothyroidism had an increased risk of CVD (hazard ratios (HR)=1.23, 95% confidence interval (CI): 1.12-1.35), and of several subcategories of CVD including hypertension, arrhythmia, and acute myocardial infarction in offspring. The magnitude of association was the most pronounced in an exposure occur during pregnancy (HR=1.71, 95% CI: 1.10-2.67), which is consistent across all the subgroup analysis, including sibling analysis.

CONCLUSIONS

Maternal hypothyroidism is associated with an increased risk of CVD in offspring. Thyroid hormone insufficiency during pregnancy may predominantly contribute to the observed associations; however, the effects of a shared genetic background and a time-stable familial environment/lifestyle factors cannot be excluded.

Pleiotropic Effects of Secretin: A Potential Drug Candidate in the Treatment of Obesity?

Secretin is the first hormone that has been discovered, inaugurating the era and the field of endocrinology. Despite the initial focus, the interest in its actions faded away over the decades. However, there is mounting evidence regarding the pleiotropic beneficial effects of secretin on whole-body homeostasis. In this review, we discuss the evidence from preclinical and clinical studies based on which secretin may have a role in the treatment of obesity.

Association of Medicaid Expansion With Rates of Utilization of Cardiovascular Therapies Among Medicaid Beneficiaries Between 2011 and 2018

BACKGROUND

The Affordable Care Act expanded Medicaid eligibility allowing low-income individuals greater access to health care. However, the uptake of state Medicaid expansion has been variable. It remains unclear how the Medicaid expansion was associated with the temporal trends in use of evidence-based cardiovascular drugs.

METHODS

We used the publicly available Medicaid Drug Utilization and Current Population Survey to extract filled prescription rates per 1000 Medicaid beneficiaries of statins, antihypertensives, P2Y12 inhibitors, and direct oral anticoagulants. We defined expander states as those who expanded Medicaid on or before January 1, 2014, and nonexpander states as those who had not expanded by December 31, 2018. Difference-in-differences (DID) analyses were performed to compare the association of the Medicaid expansion with per-capita cardiovascular drug prescription rates in expander versus nonexpander states.

RESULTS

Between 2011 and 2018, the total number of prescriptions among all Medicaid beneficiaries increased, with gains of 89.7% in statins (11.0 to 20.8 million), 76% in antihypertensives (35.3 to 62.2 million), and 37% in P2Y12 inhibitors (1.7 to 2.3 million). Medicaid expansion was associated with significantly greater increases in quarterly prescriptions (per 1000 Medicaid beneficiaries) of statins (DID estimate [95% CI]: 22.5 [16.5-28.6], P<0.001), antihypertensives (DID estimate [95% CI]: 63.2 [47.3-79.1], P<0.001), and P2Y12 inhibitors (DID estimate [95% CI]: 1.7 [1.2-2.2], P<0.001). Between 2013 and 2018, >75% of the expander states had increases in prescription rates of both statins and antihypertensives. In contrast, 44% of nonexpander states saw declines in statins and antihypertensives. The Medicaid expansion was not associated with higher direct oral anticoagulants prescription rates (DID estimate [95% CI] 0.9 [-0.3 to 2.1], P=0.142).

CONCLUSIONS

The 2014 Medicaid expansion was associated with a significant increase in per-capita utilization of cardiovascular prescription drugs among Medicaid beneficiaries. These gains in utilization may contribute to long-term cardiovascular benefits to lower-income and previously underinsured populations.

Statin Use for Atherosclerotic Cardiovascular Disease Prevention Among Sexual Minority Adults

Background

Sexual minority, or lesbian, gay, and bisexual (LGB), individuals are at increased risk for cardiovascular disease attributable to elevated rates of health risk factors. However, although there is clear evidence that statin use can prevent cardiovscular disease in certain adult populations, no studies have examined how statins are being used among the LGB population. This study aimed to examine the prevalence and predictors of statin use among LGB and non‐LGB individuals using Facebook‐delivered online surveys.

Methods and Results

We conducted a cross‐sectional online survey about statin use in adults ≥40 years of age between September and December 2019 using Facebook advertising (n=1531). We calculated the prevalence of statin use by age, sexual orientation, and statin benefit populations. We used multivariable logistic regression to examine whether statin use differed by sexual orientation, adjusting for covariates. We observed a significantly lower rate of statin use in the LGB versus non‐LGB respondents (20.8% versus 43.8%; P<0.001) in the primary prevention population. However, the prevalence of statin use was not statistically different in the LGB versus non‐LGB respondents in the secondary prevention population. Adjusting for the covariates, the LGB participants were less likely to use statins than the non‐LGB respondents in the primary prevention population (odds ratio, 0.37; 95% CI, 0.19–0.70).

Conclusions

Our results are the first to emphasize the urgent need for tailored, evidence‐based cardiovascular disease prevention programs that aim to promote statin use, and thus healthy aging, in the LGB population.

Depression and cardiovascular disease events among patients with type 2 diabetes: A systematic review and meta-analysis with bias analysis

AIMS

To provide updated systematic and quantitative summary of the association between depression and the risk of CVD events among individuals with type 2 diabetes. We also aimed to examine the sensitivity of the association to uncontrolled confounding.

METHODS

Data sources included Medline, Embase, and PsycInfo through September 2019. Two independent reviewers selected cohort studies that evaluated the association between depression and fatal or non-fatal CVD events among individuals with type 2 diabetes. Bias analysis was performed using the bias formula approach.

RESULTS

Of 2527 citations screened, 17 eligible studies with a total of 1,033,131 participants were identified. Based on random-effects meta-analysis, depression was associated with higher risks of non-fatal CVD events (relative risk 1.35, 95% confidence interval [CI] 1.20 to 1.53) and fatal CVD event (relative risk 1.47, 95% CI 1.21 to 1.77). Bias analysis indicated that unmeasured confounders alone may not explain the observed association between depression and CVD events among individuals with type 2 diabetes.

CONCLUSIONS

Depression was associated with a higher risk of non-fatal and fatal CVD events among individuals with type 2 diabetes. Our findings provide updated and robust evidence about the association between depression and CVD events among individuals with type 2 diabetes.

County-level phenomapping to identify disparities in cardiovascular outcomes: An unsupervised clustering analysis: Short title: Unsupervised clustering of counties and risk of cardiovascular mortality

INTRODUCTION

Significant heterogeneity in cardiovascular disease (CVD) risk and healthcare resource allocation has been demonstrated in the United States, but optimal methods to capture heterogeneity in county-level characteristics that contribute to CVD mortality differences are unclear. We evaluated the feasibility of unsupervised machine learning (ML)-based phenomapping in identifying subgroups of county-level social and demographic risk factors with differential CVD outcomes.

METHODS

We performed a cross-sectional study using county-level data from 2008 to 2018 from the Centers for Disease Control (CDC) WONDER platform and the 2020 Robert Wood Johnson County Health Rankings program. Unsupervised clustering was performed on 46 facets of population characteristics spanning the demographic, health behaviors, socioeconomic, and healthcare access domains. Spatial autocorrelation was assessed using the Moran's I test, and temporal trends in age-adjusted CVD outcomes were evaluated using linear mixed effect models and least square means.

RESULTS

Among 2676 counties, 4 county-level phenogroups were identified (Moran's I p-value <0.001). Phenogroup 1 (N ​= ​924; 24.5%) counties were largely white, suburban households with high income and access to healthcare. Phenogroup 2 counties (N ​= ​451; 16.9%) included predominantly Hispanic residents and below-average prevalence of CVD risk factors. Phenogroup 3 (N ​= ​951; 35.5%) counties included rural, white residents with the lowest levels of access to healthcare. Phenogroup 4 (350; 13.1%) comprised counties with predominantly Black residents, substantial cardiovascular comorbidities, and physical and socioeconomic burdens. Least square means in age-adjusted cardiovascular mortality over time increased in a stepwise fashion from 223 in phenogroup 1 to 317 per 100,000 residents in phenogroup 4.

CONCLUSIONS

Unsupervised ML-based clustering on county-level population characteristics can identify unique phenogroups with differential risk of CVD mortality. Phenogroup identification may aid in developing a uniform set of preventive initiatives for clustered counties to address regional differences in CVD mortality.

Pharmacotherapy for Hospitalized Patients with COVID-19: Treatment Patterns by Disease Severity

BACKGROUND

Treatment decisions for Coronavirus Disease 2019 (COVID-19) depend on disease severity, but the prescribing pattern by severity and drivers of therapeutic choices remain unclear.

OBJECTIVES

The objectives of the study were to evaluate pharmacological treatment patterns by COVID-19 severity and identify the determinants of prescribing for COVID-19.

METHODS

Using electronic health record data from a large Massachusetts-based healthcare system, we identified all patients aged ≥ 18 years hospitalized with laboratory-confirmed COVID-19 from 1 March to 24 May, 2020. We defined five levels of COVID-19 severity at hospital admission: (1) hospitalized but not requiring supplemental oxygen; (2-4) hospitalized and requiring oxygen ≤ 2, 3-4, and ≥ 5 L per minute, respectively; and (5) intubated or admitted to an intensive care unit. We assessed the medications used to treat COVID-19 or as supportive care during hospitalization.

RESULTS

Among 2821 patients hospitalized for COVID-19, we found inpatient mortality increased by severity from 5% for level 1 to 23% for level 5. As compared to patients with severity level 1, those with severity level 5 were 3.53 times (95% confidence interval 2.73-4.57) more likely to receive a medication used to treat COVID-19. Other predictors of treatment were fever, low oxygen saturation, presence of co-morbidities, and elevated inflammatory biomarkers. The use of most COVID-19 relevant medications has dropped substantially while the use of remdesivir and therapeutic anticoagulants has increased over the study period.

CONCLUSIONS

Careful consideration of disease severity and other determinants of COVID-19 drug use is necessary for appropriate conduct and interpretation of non-randomized studies evaluating outcomes of COVID-19 treatments.

Excess 30-Day Heart Failure Readmissions and Mortality in Black Patients Increases With Neighborhood Deprivation

BACKGROUND

Longstanding racial disparities in heart failure (HF) outcomes exist in the United States, in part, due to social determinants of health. We examined whether neighborhood environment modifies the disparity in 30-day HF readmissions and mortality between Black and White patients in the Southeastern United States.

METHODS

We created a geocoded retrospective cohort of patients hospitalized for acute HF within Emory Healthcare from 2010 to 2018. Quartiles of the Social Deprivation Index characterized neighborhood deprivation at the census tract level. We estimated the relative risk of 30-day readmission and 30-day mortality following an index hospitalization for acute HF. Excess readmissions and mortality were estimated as the absolute risk difference between Black and White patients within each Social Deprivation Index quartile, adjusted for geographic clustering, demographic, clinical, and hospital characteristics.

RESULTS

The cohort included 30 630 patients, mean age 66 years, 48% female, 53% Black. Compared with White patients, Black patients were more likely to reside in deprived census tracts and have higher comorbidity scores. From 2010 to 2018, 29.4% of Black and 23.0% of White patients experienced either a 30-day HF readmission or 30-day death (P<0.001). Excess in composite 30-day HF readmissions and mortality for Black patients ranged from 3.9% (95% CI, 1.5%-6.3%; P=0.0002) to 6.8% (95% CI, 4.1%-9.5%; P<0.0001) across Social Deprivation Index quartiles. Accounting for traditional risk factors did not eliminate the Black excess in combined 30-day HF readmissions or mortality in any of the neighborhood quartiles.

CONCLUSIONS

Excess 30-day HF readmissions and mortality are present among Black patients in every neighborhood strata and increase with progressive neighborhood socioeconomic deprivation.

A dynamic remodeling bio-mimic extracellular matrix to reduce thrombotic and inflammatory complications of vascular implants

Thrombotic and inflammatory complications induced by vascular implants remain a challenge to treat cardiovascular disease due to the lack of self-adaption and functional integrity of implants. Inspired by the dynamic remodeling of the extracellular matrix (ECM), we constructed a bio-mimic ECM with a dual-layer nano-architecture on the implant surface to render the surface adaptive to inflammatory stimuli and remodelable possessing long-term anti-inflammatory and anti-thrombotic capability. The inner layer consists of PCL-PEG-PCL [triblock copolymer of polyethylene glycol and poly(ε-caprolactone)]/Au-heparin electrospun fibers encapsulated with indomethacin while the outer layer is composed of polyvinyl alcohol (PVA) and ROS-responsive poly(2-(4-((2,6-dimethoxy-4-methylphenoxy)methyl)phenyl)-4,4,5,5-tetramethyl-1,3,2-dioxaborolane) (PBA) fibers. In response to acute inflammation after vascular injury, the outer layer reduces ROS rapidly by PBA degradation for inflammation suppression. The degraded outer layer facilitates inner layer reconstruction with enhanced hemocompatibility through the H-bond between PVA and PCL-PEG-PCL. Furthermore, chronic inflammation is effectively depressed with the sustained release of indomethacin from the inner layer. The substantial enhancement of the functional integrity of implants and reduction of thrombotic and inflammatory complications with the self-adaptive ECM are demonstrated both in vitro and in vivo. Our work paves a new way to develop long-term anti-thrombotic and anti-inflammatory implants with self-adaption and self-regulation properties.

Lipoprotein(a) and High Sensitivity C-Reactive Protein among Patients with HIV in Ghana: The Study on Cardiovascular Risk Profile of HIV-Infected Patients on HAART (SCRIPT)

Background:

Lipoprotein(a) [Lp(a)] and high-sensitivity C-reactive protein (hs-CRP) levels are associated with cardiovascular disease (CVD) in the general population, even after adjusting for conventional CVD risk factors. However, data are limited regarding the distribution of Lp(a) and hs-CRP among patients with HIV in Ghana. We explored levels of Lp(a), hs-CRP and other cardiovascular risk factors among people who were HIV positive (HIV+) on ART (HIV+ART+), HIV+ART–, and HIV–ART– in a Ghanaian population.

Methods:

We conducted a cross sectional study, recruited individuals who were HIV+ART+ and HIV+ART– from the largest HIV clinic in central Ghana between August 2018 and December 2019. HIV negative controls were recruited from communities and adjoining suburbs of Kumasi. Lipoprotein(a) was measured using Immunoturbidimetric assay and high sensitive-CRP concentrations were determined using particle-enhanced turbidimetric assay. We compared levels of Lp(a), hs-CRP, and conventional CVD risk factors among these groups and used multivariable stepwise logistic regression models to explore associations between them.

Results:

Among HIV+ART+ (n = 156), HIV+ART– (n = 131), and HIV–ART– (n = 147), mean(SD) ages were 48 (9.1) years, 41 (11.1) years and 45 (11.9) years, p = <0.001, proportion of females were 71.2%, 67.9% and 73.5% respectively. Median(IQR) concentrations of hs-CRP in mg/L were 1.7 (0.8,4.5), 2.03 (0.5,8.58) and 1.0 (0.45,2.74) across respective groups and the proportion of elevated Lp(a) concentrations (Lp[a] > 30mg/dL) were 70%, 48% and 62% among HIV+ART+,HIV+ART– and HIV–ART– participants respectively. Diabetes mellitus, dyslipidemia, waist-to-hip ratio and metabolic syndrome were associated with higher hs-CRP levels. Compared to HIV–ART–, HIV+ patients had higher odds of having hs-CRP > 3mg/L while HIV+ART+ patients had higher odds of elevated Lp(a) than HIV+ART– after multivariable adjustment.

Conclusion:

PLWHA in Ghana are associated with higher odds of elevated hs-CRP, regardless of ART use. HIV+ART+ is significantly associated with higher odds of elevated Lp(a) levels compared to HIV+ART–; even after multivariable adjustments. Reasons for this and potential clinical implications merit further study.

The COVID-19 pandemic: a global health crisis

The novel coronavirus SARS-CoV-2 was identified as the causative agent for a series of atypical respiratory diseases in the Hubei Province of Wuhan, China in December of 2019. The disease SARS-CoV-2, termed COVID-19, was officially declared a pandemic by the World Health Organization on March 11, 2020. SARS-CoV-2 contains a single-stranded, positive-sense RNA genome surrounded by an extracellular membrane containing a series of spike glycoproteins resembling a crown. COVID-19 infection results in diverse symptoms and morbidity depending on individual genetics, ethnicity, age, and geographic location. In severe cases, COVID-19 pathophysiology includes destruction of lung epithelial cells, thrombosis, hypercoagulation, and vascular leak leading to sepsis. These events lead to acute respiratory distress syndrome (ARDS) and subsequent pulmonary fibrosis in patients. COVID-19 risk factors include cardiovascular disease, hypertension, and diabetes, which are highly prevalent in the United States. This population has upregulation of the angiotensin converting enzyme-2 (ACE2) receptor, which is exploited by COVID-19 as the route of entry and infection. Viral envelope proteins bind to and degrade ACE2 receptors, thus preventing normal ACE2 function. COVID-19 infection causes imbalances in ACE2 and induces an inflammatory immune response, known as a cytokine storm, both of which amplify comorbidities within the host. Herein, we discuss the genetics, pathogenesis, and possible therapeutics of COVID-19 infection along with secondary complications associated with disease progression, including ARDS and pulmonary fibrosis. Understanding the mechanisms of COVID-19 infection will allow the development of vaccines or other novel therapeutic approaches to prevent transmission or reduce the severity of infection.

Managing Asthma and Obesity Related Symptoms (MATADORS): An mHealth Intervention to Facilitate Symptom Self-Management among Youth

Youth with multi-morbidity (one or more chronic diseases) are at increased risk of further morbidity and early mortality as they enter their adult years. Recent increases in both asthma and obesity among youth have led to high health care utilization, increased health related complications, and expanded risks of subsequent cardiovascular disease burden. Common symptoms seen with asthma and obesity include fatigue, pain, depression, and anxiety. These symptoms can result in decreased physical activity, social isolation, and poor quality of life, which also may contribute to increased morbidity and mortality over time. Youth ages 10–17 are in a transitionary period where their overall health and disease management shifts from one of parental oversight to one where the youth gradually experience increased autonomy over their health and care management. Managing Asthma and Obesity Related Symptoms (MATADORS), is a mHealth technology-enhanced nurse-guided intervention that incorporates a novel mobile health application and motivational enhancement principles within a behavioral activation framework. Providing high-risk youth with strategies to enhance symptom self-management may result in decreased symptom prevalence, improved quality of life, and long-term reduction of cardiovascular morbidity and mortality as they move into adulthood. Moreover, developing low-cost, scalable tools with end-user input may facilitate promote early intervention and improved access to care, and reduce overall disease burden and healthcare costs.

The course of multiple sclerosis rewritten: a Norwegian population-based study on disease demographics and progression

OBJECTIVES

Over the past few decades, there has been an improvement in the rate of disability progression in multiple sclerosis (MS) patients, and most studies relate this evolvement to the introduction of disease-modifying therapies. However, several other factors have changed over this period, including access to MRI and newer diagnostic criteria. The aim of this study is to investigate changes in the natural course of MS over time in a near-complete and geographically well-defined population from the south-east of Norway.

METHODS

We examined disease progression and demographics over two decades and assessed the effect of disease-modifying therapies using linear mixed-effect models.

RESULTS

In a cohort of 2097 patients, we found a significant improvement in disability as measured by the Expanded Disability Status Scale (EDSS) stratified by age, and the improvement remained significant after adjusting for time on disease-modifying medications, gender and progressive MS at onset. The time from disease onset to EDSS 6 in the total cohort was 29.8 years (95% CI 28.5-31.1) and was significantly longer in patients diagnosed after 2006 compared to patients diagnosed before. There are significant differences between patient demographics, as well as time to EDSS 6, in the near-complete, geographically well-defined population compared to an additional cohort from the capital Oslo and its suburbs.

CONCLUSION

The natural course of MS is improving, but the improvement seen in disease progression has multifaceted explanations. Our study underlines the importance of completeness of data, relevant timeframes and demographics when comparing different MS populations. Studies on incomplete populations should be interpreted with caution.

Discriminatory Capacity of Anthropometric Indices for Cardiovascular Disease in Adults: A Systematic Review and Meta-Analysis

INTRODUCTION

Obesity is one of the main risk factors for cardiovascular disease (CVD) and cardiometabolic disease (CMD). Many studies have developed cutoff points of anthropometric indices for predicting these diseases. The aim of this systematic review was to differentiate the screening potential of body mass index (BMI), waist circumference (WC), and waist-to-hip ratio (WHR) for adult CVD risk.

METHODS

We used relevant key words to search electronic databases to identify studies published up to 2019 that used receiver operating characteristic (ROC) curves for assessing the cut-off points of anthropometric indices. We used a random-effects model to pool study results and assessed between-study heterogeneity by using the I² statistic and Cochran's Q test.

RESULTS

This meta-analysis included 38 cross-sectional and 2 cohort studies with 105 to 137,256 participants aged 18 or older. The pooled area under the ROC curve (AUC) value for BMI was 0.66 (95% CI, 0.63-0.69) in both men and women. The pooled AUC values for WC were 0.69 (95% CI, 0.67-0.70) in men and 0.69 (95% CI, 0.64-0.74) in women, and the pooled AUC values for WHR were 0.69 (95% CI, 0.66-0.73) in men and 0.71 (95% CI, 0.68-0.73) in women.

CONCLUSION

Our findings indicated a slight difference between AUC values of these anthropometric indices. However, indices of abdominal obesity, especially WHR, can better predict CVD occurrence.

The American Heart Association's Call to Action for Reducing the Global Burden of Rheumatic Heart Disease: A Policy Statement From the American Heart Association

Rheumatic heart disease (RHD) affects ≈40 million people and claims nearly 300 000 lives each year. The historic passing of a World Health Assembly resolution on RHD in 2018 now mandates a coordinated global response. The American Heart Association is committed to serving as a global champion and leader in RHD care and prevention. Here, we pledge support in 5 key areas: (1) professional healthcare worker education and training, (2) technical support for the implementation of evidence-based strategies for rheumatic fever/RHD prevention, (3) access to essential medications and technologies, (4) research, and (5) advocacy to increase global awareness, resources, and capacity for RHD control. In bolstering the efforts of the American Heart Association to combat RHD, we hope to inspire others to collaborate, communicate, and contribute.

Prevalence and associated factors of chronic non-communicable diseases among cross-country truck drivers in Ethiopia

BACKGROUND

Non-communicable diseases (NCDs) are diseases that are not transmitted from one person to another. Currently, NCDs are the primary causes of morbidity and mortality globally. Truck driving is an occupation that prone drivers to risk factors for NCDs than other occupations. Eventhough risk of developing NCDs among these population is high, studies that showed the prevalence and associated factors of chronic NCDs among truck drivers in Ethiopia are not available. Therefore, this study aimed to assess the prevalence and associated factors of chronic NCDs among truck drivers in Ethiopia.

METHODS

A cross-sectional study was conducted among 422 cross-country truck drivers at the Modjo dry port in Ethiopia. The interviwer-administered questionnaire technique was used to collect the data. The body mass index of the study participants was measured using DHM-15A standardized scale (BMI Height and Weight body fat scale).

RESULTS

Of the 400 truck drivers interviewed, the prevalence of chronic non-communicable diseases was 28.5, 95% CI (24.1-32.9%). Eighty (20%) had hypertension followed by 32(8%), and 22 (5.5%) had diabetes mellitus and asthma, respectively. The study also found that being married (AOR = 3.14, 95%CI [1.78-5.86]) and Separated/Divorced/Widower (AOR = 2.31, 95% CI [1.12-3.55]), having 3 or more family sizes (AOR = 1.46, 95% CI [1.33-4.42]), BMI ≥ 25 (AOR = 4.66, 95% CI [2.85-7.62]), smoking cigarettes [AOR = 1.71, 95% CI [1.03-2.81]), driving 10 or more years (AOR = 3.48, 95% CI [1.89-5.24]) and driving 9 or more hours daily (AOR = 3.76, 95% CI [1.96-6.54]) were statistically associated with chronic non-communicable diseases.

CONCLUSION

The prevalence of chronic NCDs among truck drivers was significant (28.5%), and we can conclude that chronic NCDs are of public health importance among truck drivers in Ethiopia. This may create a substantial load on the healthcare system as an end result of increased demand and contact with healthcare services. Therefore, a rigorous effort is needed to develop strategies for the prevention and management of NCDs.

Life After Myocardial Infarction: A Qualitative Study on Experiences of Kurdish Patients Affected by Iran-Iraq War

Background

Coronary artery disease (CAD) is a major cause of death globally. Myocardial infarction (MI) secondary to CAD affects patients’ quality of life and their lifestyle. The experience of war can affect people’s perception of phenomena. Given the scarcity of information in Kurdish patients with MI, the current study was designed to explore the lived experiences of individuals after MI in Kurdish patients affected by Iran–Iraq war.

Methods

This interpretive-phenomenological study was conducted on eleven patients with MI (9 men, 2 women) at Imam Ali Hospital, Center for Heart Diseases, in Kermanshah, Iran, considering MI as a phenomenon. Data was collected by a semi-structured interview and analyzed using the Van Mannen method. We employed the Lincoln and Guba criteria to examine the credibility, confirmability, dependability, and transferability of data. MAXQDA software was used for data management. We followed the COREQ checklist to ensure the rigor of our study

Results

Four themes and ten sub-themes were emerged as (1) “changes in the quality of life” including (a) negative physical outcomes, (b) mental effects, (c) social support, (d) adopting healthy behaviors, (e) increase or decrease in self-efficiency, (f) previous experience, and (g) developing future behaviors; (2) “bodily perceptions and medical care” including (a) medical care: saving or terminating life?, (b) a new message from the heart; (3) “returning to spirituality against death” including (a) spirituality as a guiding principle, (b) accepting death as an eventual destiny; and (4) denial.

Conclusion

The results suggest that MI could change the quality of physical and mental health of the person, anywhere from deterioration to full recovery. Furthermore, the influence of spirituality and previous experience of war to overcome the complications of MI has been discussed, leading to either acceptance or denial of MI, and the consequences.

The role of traditional risk factors in explaining the social disparities in cardiovascular death: The national health and Nutrition Examination Survey III (NHANES III)

Objective

─ To assess the role of traditional risk factors in explaining the association between cumulative social risk exposure and disparities in CVD death among US adults.

Methods

─ The study included 15,906 participants from the Third National Health and Nutrition Examination Survey III who were CVD-free at enrollment. Baseline social risk factors (minority race, poverty-income ratio<1, education<12 grade, and living single) were used to create a cumulative social risk score (0 to ≥3). CVD death served as the primary outcome. We assessed the contribution of each major CVD risk factor to the link between cumulative social risk exposure and CVD death.

Results

─ During a median follow-up of 14 years, 1309 CVD deaths occurred. Participants with elevated cumulative social risk score were at increased risk of CVD death, with hazard ratio 1.19(95%CI 1.01–1.41), 1.52(95%CI 1.28–1.79), and 1.46 (95%CI 1.23–1.74) in individuals with score 1, 2 and ​≥ ​3 respectively, compared with individuals with score of 0. Traditional CVD risk factors explained about one third of the disparities in CVD death in individuals with the elevated social risk exposure. Among the one third effect by combined CVD risk factors, current smoking contributed the largest proportion, accounting for approximately one half of the combined risk factors effect, followed by obesity and diabetes.

Conclusions

─Among the traditional risk factors, control of smoking appears to be the greatest opportunity to attenuate the social disparities in CVD death. While these findings call for further studies to identify other pathways that explain the elevated CVD mortality in socially disadvantaged population.

Feature matching based ECG generative network for arrhythmia event augmentation

Recent developments in the field of deep learning has shown a rise in its use for clinical applications such as electrocardiogram (ECG) analysis and cardiac arrhythmia classification. Such systems are essential in the early detection and management of cardiovascular diseases. However, due to privacy concerns and also the lack of resources, there is a gap in the data available to run such powerful and data-intensive models. To address the lack of annotated, high-quality ECG data for heart disease research, ECG data generation from a small set of ECG to obtain huge annotated data is seen as an effective solution. Generative Feature Matching Network (GFMN) was shown to resolve few drawbacks of commonly used generative adversarial networks (GAN). Based on this, we developed a deep learning model to generate ECGs that resembles real ECG by feature matching with the existing data.Clinical relevance- This work addresses the lack of a large quantity of good quality, publicly available annotated ECG data required to build deep learning models for cardiac signal processing research. We can use the model presented in this paper to generate ECG signals of a target rhythm pattern and also subject-specific ECG morphology that could improve their cardiac health monitoring while maintaining privacy.

Estimating the influence of adolescent delinquent behavior on adult health using sibling fixed effects

Despite the well-established link between juvenile delinquency and socioeconomic attainment in adulthood, less is known about whether engagement in delinquent behavior during adolescence shapes adult health outcomes. This study examines the association between juvenile delinquency and adult physical and mental health, and whether this association is confounded by unobserved family heterogeneity. Moreover, this study explores the potential underlying mechanisms through which juvenile delinquency shapes adult physical and mental health. Using data from the National Longitudinal Study of Adolescent to Adult Health (Add Health) 1994-1995 (Wave 1) and 2007-2008 (Wave 4), we adopted a sibling fixed effect approach to account for genetic factors, family environment, and childhood social contexts such as school and neighborhood effects. The conventional OLS results show that engagement in delinquent behavior during adolescence strongly predicts higher levels of Framingham cardiovascular disease (CVD) risk score and depressive symptoms in adulthood. Once we account for family-specific heterogeneity, however, the point estimates of the associations of delinquency with CVD risk score and depressive symptoms are attenuated by 33% and 45%, respectively. Despite this attenuation, the association of juvenile delinquency with adult health is robust: a one standard-deviation increase in juvenile delinquency is associated with approximately 8 and 6 percent of one standard-deviation increases in CVD risk and depressive symptoms, respectively. Our mediation analyses suggest that a combination of several mediating pathways jointly explain the association between juvenile delinquency with adult health. The most consistent and significant mediating pathways connecting juvenile delinquency to both physical and mental health included disruption in student-teacher relationship, smoking, criminal justice contact, and educational attainment. Moreover, while binge drinking explained part of the association between delinquency and CVD risk score, student-friend relationship partially mediated the association with depression.

Prediction of incident myocardial infarction using machine learning applied to harmonized electronic health record data

Background

With cardiovascular disease increasing, substantial research has focused on the development of prediction tools. We compare deep learning and machine learning models to a baseline logistic regression using only ‘known’ risk factors in predicting incident myocardial infarction (MI) from harmonized EHR data.

Methods

Large-scale case-control study with outcome of 6-month incident MI, conducted using the top 800, from an initial 52 k procedures, diagnoses, and medications within the UCHealth system, harmonized to the Observational Medical Outcomes Partnership common data model, performed on 2.27 million patients. We compared several over- and under- sampling techniques to address the imbalance in the dataset. We compared regularized logistics regression, random forest, boosted gradient machines, and shallow and deep neural networks. A baseline model for comparison was a logistic regression using a limited set of ‘known’ risk factors for MI. Hyper-parameters were identified using 10-fold cross-validation.

Results

Twenty thousand Five hundred and ninety-one patients were diagnosed with MI compared with 2.25 million who did not. A deep neural network with random undersampling provided superior classification compared with other methods. However, the benefit of the deep neural network was only moderate, showing an F1 Score of 0.092 and AUC of 0.835, compared to a logistic regression model using only ‘known’ risk factors. Calibration for all models was poor despite adequate discrimination, due to overfitting from low frequency of the event of interest.

Conclusions

Our study suggests that DNN may not offer substantial benefit when trained on harmonized data, compared to traditional methods using established risk factors for MI.

Role of B cells and the aging brain in stroke recovery and treatment

As mitigation of brain aging continues to be a key public health priority, a wholistic and comprehensive consideration of the aging body has identified immunosenescence as a potential contributor to age-related brain injury and disease. Importantly, the nervous and immune systems engage in bidirectional communication and can exert profound influence on each other. Emerging evidence supports numerous impacts of innate, inflammatory immune responses and adaptive T cell-mediated immunity in neurological function and diseased or injured brain states, such as stroke. Indeed, a growing body of evidence supports key impacts of brain-resident immune cell activation and peripheral immune infiltration in both the post-stroke acute injury phase and the long-term recovery period. As such, modulation of the immune system is an attractive strategy for novel therapeutic interventions for a devastating age-related brain injury for which there are few readily available neuroprotective treatments or neurorestorative approaches. However, the role of B cells in the context of brain function, and specifically in response to stroke, has not been thoroughly elucidated and remains controversial, leaving our understanding of neuroimmune interactions incomplete. Importantly, emerging evidence suggests that B cells are not pathogenic contributors to stroke injury, and in fact may facilitate functional recovery, supporting their potential value as novel therapeutic targets. By summarizing the current knowledge of the role of B cells in stroke pathology and recovery and interpreting their role in the context of their interactions with other immune cells as well as the immunosenescence cascades that alter their function in aged populations, this review supports an increased understanding of the complex interplay between the nervous and immune systems in the context of brain aging, injury, and disease.

The effect of egg and its derivatives on vascular function: A systematic review of interventional studies

BACKGROUND & AIMS

Cardiovascular diseases (CVDs) are considered as a major cause of health loss for all regions of the world. Atherosclerosis is one of the most important underlying causes of CVDs. Vascular dysfunction is the primary marker of atherosclerosis. Various studies have investigated the effect of egg intake on CVDs. This study aimed to determine the effect of egg and its derivatives consumption on vascular function.

METHODS

Using a comprehensive search strategy, the searching was conducted on PubMed, Scopus and Google Scholar search engines resources (from inception up to Feb 2020). Intended exposure and outcome were egg or its derivatives intake, and vascular function measuring methods, respectively.

RESULTS

A total of 35 papers were found through search databases. Finally, seven trials were included, which were published between 2005 and 2018. Results showed that acute and chronic consumption of whole eggs did not have a significant adverse effect on flow-mediated dilatation (FMD). Also, lutein-enriched egg yolk and egg ovalbumin-derived protein hydrolysate did not have significant positive effects on FMD and pulse wave velocity (PWV), respectively. However, one month egg-yolk-derived phospholipid (PL) preparation intervention increased FMD by 3.4% (p < 0.05), and replacing a portion of a glucose challenge with whole eggs or egg whites improved postprandial FMD (p < 0.05).

CONCLUSIONS

We concluded that consumption of whole egg, despite being rich in cholesterol, has no adverse effect on vascular function, and even some of egg derivatives may improve vascular function. Further research is needed to justify the potential effects of egg or its derivatives on vascular function.

Genetics of age-related clonal hematopoiesis and atherosclerotic cardiovascular disease

PURPOSE OF REVIEW

While advanced age is the major risk factor for the development of atherosclerotic cardiovascular disease (ASCVD), we have a poor understanding of how aging promotes the progression of this disease. Recent evidence suggests that the age-dependent accumulation of somatic mutations in hematopoietic cells may represent a new causal risk factor for ASCVD.

RECENT FINDINGS

A hallmark of aging is the accumulation of somatic DNA mutations in all tissues of the body. Accordingly, evidence shows that hematopoietic stem/progenitor cells accumulate somatic mutations as a function of age in nonsymptomatic individuals. When these mutations occur in driver genes that provide a selective advantage to the hematopoietic stem/progenitor cells, they undergo a clonal expansion and progressively give rise to blood leukocytes that harbor these mutations. This phenomenon, referred to as clonal hematopoiesis, has been associated with the increased risk of mortality, hematologic malignancy, ASCVD, and related diseases. Notably, many individuals exhibiting clonal hematopoiesis carry single 'driver' mutations in preleukemic genes including DNA methyltransferase 3a, ten-eleven translocation 2, additional sex combs like 1, and Janus kinase 2. Experimental studies show that these mutations in some of these genes can alter the inflammatory properties of the leukocyte and contribute to the pathogenesis of ASCVD.

SUMMARY

We review recent epidemiological and experimental findings on the association between age-related clonal hematopoiesis and ASCVD by focusing on prevalent driver gene mutations.

Therapeutic advances in cardiac targeted drug delivery: from theory to practice

The most commonly used administration methods in clinics and life are oral administration, intravenous injection, and other systemic administration methods. Targeted administration must be an essential long-term development direction due to the limited availability and a high incidence of systemic side effects. Cardiovascular diseases (CVD) are the leading cause of death all over the world. Targeted drug delivery (TDD) methods with the heart as the target organ have developed rapidly and are diversified. This article reviews the research progress of various TDD methods around the world with a heart as the target organ. It is mainly divided into two parts: the targeting vector represented by nanoparticles and various TDD methods such as intracoronary injection, ventricular wall injection, pericardial injection, and implantable medical device therapy and put forward some suggestions on the development of targeting. Different TDD methods described in this paper have not been widely used in clinical practice, and some have not even completed preclinical studies. Targeted drug delivery still requires long-term efforts by many researchers to realize the true meaning of the heart. HIGHLIGHTS Targeted administration can achieve a better therapeutic effect and effectively reduce the occurrence of adverse reactions. Parenteral administration or medical device implantation can be used for targeted drug delivery. Combined with new dosage forms or new technologies, better-targeted therapy can be achieved. Clinical trials have confirmed the safety and effectiveness of several administration methods.

Cardioprotective Potential of Exogenous Ubiquitin

Ischemic heart disease (IHD) accounts for the majority of heart disease-related deaths worldwide. Ubiquitin (UB), found in all eukaryotic cells, is a highly conserved low molecular weight (~8.5 kDa) protein. A well-known intracellular function of UB is to regulate protein turnover via the UB-proteasome system. UB is a normal constituent of plasma, and elevated levels of UB are observed in the serum of patients under a variety of pathological conditions. Recent studies provide evidence for cardioprotective potential of exogenous UB in the remodeling process of the heart in IHD, including effects on cardiac myocyte apoptosis, inflammatory response, and reorganization of the vasculature and extracellular matrix. This review summarizes functions of UB with an emphasis on the role of exogenous UB in myocardial remodeling in IHD.

Trends in cardiovascular diseases burden and vascular risk factors in Italy: The Global Burden of Disease study 1990-2017

AIMS

An exhaustive and updated estimation of cardiovascular disease burden and vascular risk factors is still lacking in European countries. This study aims to fill this gap assessing the global Italian cardiovascular disease burden and its changes from 1990 to 2017 and comparing the Italian situation with European countries.

METHODS

All accessible data sources from the 2017 Global Burden of Disease study were used to estimate the cardiovascular disease prevalence, mortality and disability-adjusted life years and cardiovascular disease attributable risk factors burden in Italy from 1990 to 2017. Furthermore, we compared the cardiovascular disease burden within the 28 European Union countries.

RESULTS

Since 1990, we observed a significant decrease of cardiovascular disease burden, particularly in the age-standardised prevalence (-12.7%), mortality rate (-53.8%), and disability-adjusted life years rate (-55.5%). Similar improvements were observed in the majority of European countries. However, we found an increase in all-ages prevalence of cardiovascular diseases from 5.75 m to 7.49 m Italian residents. Cardiovascular diseases still remain the first cause of death (34.8% of total mortality). More than 80% of the cardiovascular disease burden could be attributed to known modifiable risk factors such as high systolic blood pressure, dietary risks, high low density lipoprotein cholesterol, and impaired kidney function.

CONCLUSIONS

Our study shows a decline in cardiovascular mortality and disability-adjusted life years, which reflects the success in reducing disability, premature death and early incidence of cardiovascular diseases. However, the burden of cardiovascular diseases is still high. An approach that includes the cooperation and coordination of all stakeholders of the Italian National Health System is required to further reduce this burden.