European Society of Cardiology: Cardiovascular Disease Statistics 2017

Exosomes in Cardiovascular Diseases: Pathological Potential of Nano-Messenger

Cardiovascular diseases (CVDs) represent a major global health problem, due to their continued high incidences and mortality. The last few decades have witnessed new advances in clinical research which led to increased survival and recovery in CVD patients. Nevertheless, elusive and multifactorial pathophysiological mechanisms of CVD development perplexed researchers in identifying efficacious therapeutic interventions. Search for novel and effective strategies for diagnosis, prevention, and intervention for CVD has shifted research focus on extracellular vesicles (EVs) in recent years. By transporting molecular cargo from donor to recipient cells, EVs modulate gene expression and influence the phenotype of recipient cells, thus EVs prove to be an imperative component of intercellular signaling. Elucidation of the role of EVs in intercellular communications under physiological conditions implied the enormous potential of EVs in monitoring and treatment of CVD. The EVs secreted from the myriad of cells in the cardiovascular system such as cardiomyocytes, cardiac fibroblasts, cardiac progenitor cells, endothelial cells, inflammatory cells may facilitate the communication in physiological and pathological conditions. Understanding EVs-mediated cellular communication may delineate the mechanism of origin and progression of cardiovascular diseases. The current review summarizes exosome-mediated paracrine signaling leading to cardiovascular disease. The mechanistic role of exosomes in cardiovascular disease will provide novel avenues in designing diagnosis and therapeutic interventions.

Economic evaluation of complete revascularization versus stress echocardiography-guided revascularization in the STEACS with multivessel disease

INTRODUCTION AND OBJECTIVES

Economic studies may help decision making in the management of multivessel disease in the setting of myocardial infarction. We sought to perform an economic evaluation of CROSS-AMI (Complete Revascularization or Stress Echocardiography in Patients With Multivessel Disease and ST-Segment Elevation Acute Myocardial Infarction) randomized clinical trial.

METHODS

We performed a cost minimization analysis for the strategies (complete angiographic revascularization [ComR] and selective stress echocardiography-guided revascularization [SelR]) compared in the CROSS-AMI clinical trial (N=306), attributable the initial hospitalization and readmissions during the first year of follow-up, using current rates for health services provided by our health system.

RESULTS

The index hospitalization costs were higher in the ComR group than in SelR arm (19 657.9±6236.8 € vs 14 038.7±4958.5 €; P <.001). There were no differences in the costs of the first year of follow-up rehospitalizations between both groups for (ComR 2423.5±4568.0 vs SelR 2653.9±5709.1; P=.697). Total cost was 22 081.3±7505.6 for the ComR arm and 16 692.6±7669.9 for the SelR group (P <.001).

CONCLUSIONS

In the CROSS-AMI trial, the initial extra economic costs of the ComR versus SelR were not offset by significant savings during follow-up. SelR seems to be more efficient than ComR in patients with ST-segment elevation acute coronary syndrome and multivessel disease treated by emergent angioplasty. Study registred at ClinicalTrial.gov (Identifier: NCT01179126).

Protective effect of berberine against LPS-induced endothelial cell injury via the JNK signaling pathway and autophagic mechanisms

The role of autophagic mechanisms in the protective effect of berberine (BBR) on lipopolysaccharide (LPS)-induced injury in the endothelial cells human umbilical vein endothelial cells (HUVECs) and human pulmonary microvascular endothelial cells (HPMECs) was investigated. Cell viability, proliferation, and apoptosis were detected by the CCK-8 assay, the EdU kit, and flow cytometry, respectively, and autophagy-related protein expression, the number of autophagic vacuoles, and LC3 double-fluorescence were examined using western blot analysis, transmission electron microscopy, and confocal microscopy, respectively. LPS resulted in a decrease in the cell viability and proliferation of HUVECs and HPMECs and an increase in the number of apoptotic cells, while BBR treatment resulted in an increase in cell viability and proliferation, as well as a decrease in cell apoptosis. Furthermore, BBR could inhibit LPS-induced autophagy, as demonstrated by its inhibitory effects on the LC3-II/LC3-I ratio and Beclin-1 levels and its promotive effect on p62 expression. Addition of the autophagy inducer rapamycin (RAPA) aggravated LPS-induced injury, while treatment with the autophagy blocker 3-methyladenine (3-MA) attenuated the injury. Further, the protective effect of BBR was inhibited by rapamycin. JNK inhibition by SP600125 inhibited LPS-induced autophagy, and BBR could not alter the LPS-induced autophagy in HUVECs and HPMECs that were pretreated with SP600125. The present data indicate that BBR attenuated LPS-induced cell apoptosis by blocking JNK-mediated autophagy in HUVECs and HPMECs. Therefore, the JNK-mediated autophagy pathway could be a potential target for the prevention and treatment of cardiovascular disease.

Development of Nonlaboratory-Based Risk Prediction Models for Cardiovascular Diseases Using Conventional and Machine Learning Approaches

Criticism of the implementation of existing risk prediction models (RPMs) for cardiovascular diseases (CVDs) in new populations motivates researchers to develop regional models. The predominant usage of laboratory features in these RPMs is also causing reproducibility issues in low–middle-income countries (LMICs). Further, conventional logistic regression analysis (LRA) does not consider non-linear associations and interaction terms in developing these RPMs, which might oversimplify the phenomenon. This study aims to develop alternative machine learning (ML)-based RPMs that may perform better at predicting CVD status using nonlaboratory features in comparison to conventional RPMs. The data was based on a case–control study conducted at the Punjab Institute of Cardiology, Pakistan. Data from 460 subjects, aged between 30 and 76 years, with (1:1) gender-based matching, was collected. We tested various ML models to identify the best model/models considering LRA as a baseline RPM. An artificial neural network and a linear support vector machine outperformed the conventional RPM in the majority of performance matrices. The predictive accuracies of the best performed ML-based RPMs were between 80.86 and 81.09% and were found to be higher than 79.56% for the baseline RPM. The discriminating capabilities of the ML-based RPMs were also comparable to baseline RPMs. Further, ML-based RPMs identified substantially different orders of features as compared to baseline RPM. This study concludes that nonlaboratory feature-based RPMs can be a good choice for early risk assessment of CVDs in LMICs. ML-based RPMs can identify better order of features as compared to the conventional approach, which subsequently provided models with improved prognostic capabilities.

Patients with stable coronary artery disease and type 2 diabetes but without prior myocardial infarction or stroke and THEMIS-like patients: real-world prevalence and risk of major outcomes from the SNDS French nationwide claims database

AIM AND HYPOTHESES

The THEMIS randomized trial compared ticagrelor plus aspirin versus placebo plus aspirin for patients with stable coronary artery disease and type 2 diabetes mellitus (CAD-T2DM), and without prior myocardial infarction (MI) or stroke. The aim of the study was to quantify the size of the CAD-T2DM population without prior MI or stroke population in a real-world setting, and more specifically populations with similar THEMIS selection criteria (THEMIS-like and THEMIS-PCI-like populations), as well as their risk of major outcomes in current practice.

METHODS

A 2-year follow-up cohort study included all CAD-T2DM without MI/stroke prevalent patients on January 1st, 2014 in the SNDS French nationwide claims database. The THEMIS-like population concerned those ≥ 50 years of age with similar THEMIS inclusion and exclusion criteria. Prevalence was standardized to the European population. The cumulative incidence function was used to estimate the incidence of clinical outcomes (MI, ischemic stroke, and major bleeding according to the TIMI classification) with death as competing risk, and the Kaplan-Meier estimate for all-cause death and a composite outcome of MI, stroke and all-cause death.

RESULTS

From a population of about 50 million adults, the prevalence of CAD-T2DM without MI/stroke, THEMIS-like and THEMIS-PCI-like populations was respectively at 6.04, 1.50 and 0.27 per 1000 adults, with a mean age of 72.7, 72.3 and 70.9 years and less comorbidities and diabetic complications for the THEMIS-like and THEMIS-PCI-like population. The 2-year cumulative incidence was respectively 1.7%, 1.3% and 1.6% for MI, 1.7%, 1.5% and 1.4% for stroke, 4.8%, 3.1% and 2.9% for major bleeding, 13.6%, 9.7% and 6.8% for all-cause death, and 16.2%, 12.0% and 9.5% for the composite outcome.

CONCLUSION

THEMIS-like prevalence was estimated at 1.50 per 1,000 adults, representing about a quarter of CAD-T2DM without MI/stroke patients, and 0.27 per 1000 adults for the THEMIS-PCI-like populations. In current French practice, the median age of both these populations was about 5-6 years older than in the THEMIS trial, with a 2-year incidence of major outcomes between two or four time above the ones of the placebo arm of the THEMIS trial using very close definitions. Registration No. EUPAS27402 ( http://www.ENCEPP.eu ).

Imaging techniques for the assessment of adverse cardiac remodeling in metabolic syndrome

Metabolic syndrome (MetS) includes different metabolic conditions (i.e. abdominal obesity, impaired glucose tolerance, hypertriglyceridemia, decreased HDL cholesterol, and/or hypertension) that concour in the development of cardiovascular disease and diabetes. MetS individuals often show adverse cardiac remodeling and myocardial dysfunction even in the absence of overt coronary artery disease or valvular affliction. Diastolic impairment and hypertrophy are hallmarks of MetS-related cardiac remodeling and represent the leading cause of heart failure with preserved ejection fraction (HFpEF). Altered cardiomyocyte function, increased neurohormonal tone, interstitial fibrosis, coronary microvascular dysfunction, and a myriad of metabolic abnormalities have all been implicated in the development and progression of adverse cardiac remodeling related to MetS. However, despite the enormous amount of literature produced on this argument, HF remains a leading cause of morbidity and mortality in such population. The early detection of initial adverse cardiac remodeling would enable the optimal implementation of effective therapies aiming at preventing the progression of the disease to the symptomatic phase. Beyond conventional imaging techniques, such as echocardiography, cardiac tomography, and magnetic resonance, novel post-processing tools and techniques provide information on the biological processes that underlie metabolic heart disease. In this review, we summarize the pathophysiology of MetS-related cardiac remodeling and illustrate the relevance of state-of-the-art multimodality cardiac imaging to identify and quantify the degree of myocardial involvement, prognosticate long-term clinical outcome, and potentially guide therapeutic strategies.

Trends in the use of oral anticoagulants, antiplatelets and statins in four European countries: a population-based study

Purpose

To evaluate time trends in the prevalence of antithrombotic and statin use in four European countries.

Methods

Using population-based data from the United Kingdom, Denmark, Spain and Italy between 2010 and 2018, we calculated standardized annual prevalence proportions of antithrombotics and statin use, and changes in prevalence proportions (2018 vs. 2010).

Results

Prevalence proportion of statins increased from 24.8% to 24.6% (UK), 21.0% to 22.3% (Region of Southern Denmark [RSD]), 12.9% to 14.3% (Udine, Italy), and 20.3% to 23.2% (Spain). Prevalence proportions of antithrombotics declined in all four countries: 18.7% to 15.9% (UK; − 2.8% points), 18.9% to 18.1% (RSD; − 0.8% points), 17.7% to 16.6% (Udine; − 1.1% points) and 15.0% to 13.6% (Spain; − 1.4% points). These declines were driven by reductions in low-dose aspirin use: 15.3% to 8.9% (UK; − 6.4% points), 16.3% to 9.5% (RSD; − 6.8% points), 13.5% to 11.6% (Udine; − 1.9% points), and 10.2% to 8.8% (Spain; − 1.4% points). In the UK, low-dose aspirin use declined from 9.1% to 4.3% (− 4.8% points) for primary CVD prevention, and from 49.6% to 36.9% (− 12.7% points) for secondary prevention. Oral anticoagulant use gradually increased but did not fully account for the decrease in low-dose aspirin use.

Conclusions

Antithrombotic use in the UK, RSD, Udine and Spain declined between 2010 and 2018, driven by a reduction in use of low-dose aspirin that is not completely explained by a gradual increase in OAC use. Use of statins remained constant in the UK, and increased gradually in the RSD, Udine and Spain.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00228-021-03250-6.

Access to dental care and blood pressure profiles in adults with high socioeconomic status

Background

Reduced access to dental care may increase cardiovascular risk; however, socioeconomic factors are believed to confound the associations. We hypothesized that the relation persists despite economic wellness and high education, with reduced access to dental care affecting cardiovascular risk at least in part through its effect on blood pressure (BP), possibly mediated by systemic inflammation.

Methods

We first assessed the sociodemographic and clinical characteristics related to last dental visit timing (≤ or >6 months; self‐reported) using national representative cross‐sectional data. Then, the association of last dental visit timing with clinic BP was selectively investigated in highly educated, high income participants, further matched for residual demographic and clinical confounders using propensity score matching (PSM). The mediating effect of systemic inflammation was formally tested. Machine learning was implemented to investigate the added value of dental visits in predicting high BP over the variables included in the Framingham Hypertension Risk Score among individuals without an established diagnosis of hypertension.

Results

Of 27,725 participants included in the population analysis, 46% attended a dental visit ≤6 months. In the PSM cohort (n = 2350), last dental visit attendance >6 months was consistently associated with 2 mmHg higher systolic BP (P = 0.001) and with 23 to 35% higher odds of high/uncontrolled BP compared with attendance ≤6 months. Inflammation mildly mediated the association. Access to dental care improved the prediction of high BP by 2%.

Conclusions

Dental care use impacts on BP profiles independent of socioeconomic confounders, possibly through systemic inflammation. Regular dental visits may contribute to preventive medicine.

Transferring Cross-Corpus Knowledge: An Investigation on Data Augmentation for Heart Sound Classification

Human auscultation has been regarded as a cheap, convenient and efficient method for the diagnosis of cardiovascular diseases. Nevertheless, training professional auscultation skills needs tremendous efforts and is time-consuming. Computer audition (CA) that leverages the power of advanced machine learning and signal processing technologies has increasingly attracted contributions to the field of automatic heart sound classification. While previous studies have shown promising results in CA based heart sound classification with the 'shuffle split' method, machine learning for heart sound classification decreases in accuracy with a cross-corpus test dataset. We investigate this problem with a cross-corpus evaluation using the PhysioNet CinC Challenge 2016 Dataset and propose a new combination of data augmentation techniques that leads to a CNN robust for such cross-corpus evaluation. Compared with the baseline, which is given without augmentation, our data augmentation techniques combined improve by 20.0 % the sensitivity and by 7.9 % the specificity on average across 6 databases, which is a significant difference on 4 out of these (p < .05 by one-tailed z-test).

Effects of Danhong injection on cardiac function and blood lipid in patients with angina pectoris of coronary heart disease: A protocol for randomized, double-blind, placebo-controlled clinical trial

BACKGROUND

Angina pectoris of coronary heart disease is the leading cause of death worldwide. Danhong injection is a supplement for angina pectoris of coronary heart disease. A large number of studies have confirmed its efficacy and safety. However, there is no rigorous clinical study to evaluate the effects of Danhong injection on cardiac function and blood lipid in patients with angina pectoris of coronary heart disease.

METHODS

This is a prospective, randomized, double-blind, placebo-controlled trial to study the effects of Danhong injection on cardiac function and lipid profile in patients with angina pectoris of coronary heart disease. Participants will be randomly divided into treatment group and control group. The treatment group will be treated with Danhong injection and the control group will be treated with placebo under basic treatment according to recommended guideline, and followed up for 3 months after 14 consecutive days of treatment. Outcomes include: cardiac function (left ventricular end-diastolic diameter); left ventricular end-systolic diameter; left ventricular ejection fraction, blood lipid levels (total cholesterol; triacylglycerol; low density lipoprotein cholesterol; high density lipoprotein cholesterol), the number of angina attacks per week, total amount of nitroglycerin tablets, and adverse reactions.

DISCUSSION

This study will evaluate the efficacy of Danhong injection in improving cardiac function and blood lipid in patients with angina pectoris of coronary heart disease. The results of this study will provide reference for clinical use of Danhong injection to improve cardiac function and blood lipid in patients with angina pectoris of coronary heart disease.Trial registration: OSF Registration number: DOI 10.17605/OSF.IO/TPZJ5.

Effectiveness of hospital lipid-lowering protocol of intensive lipid-lowering therapy for patients with acute coronary syndrome

BACKGROUND AND AIMS

The achievement of a target low-density lipoprotein cholesterol (LDL-C) level in clinical settings is often insufficient. A hospital lipid-lowering protocol (HLP) could be effective for providing the optimal lipid-lowering therapy. Herein we determined the effectiveness of a HLP for acute coronary syndrome (ACS) patients.

METHODS

We retrospectively analyzed 1,497 patients who underwent successful percutaneous coronary intervention for ACS at our hospital (November 2011 to May 2020). In December 2018, we introduced a HLP that included the prescription of the maximum tolerated dose of statin, ezetimibe, and eicosapentaenoic acid. We compared the lipid profile and clinical outcomes at 12 months between before (Control group: 1,219 patients) and after the HLP's introduction (HLP group: 278 patients). The primary outcome was the achievement rate of LDL-C < 1.8 mmol/L (70 mg/dL). The key secondary outcomes were the change value and ratio of LDL-C plus the major adverse cardiac events (MACE), defined as a composite of cardiac death, myocardial infarction, target vessel revascularization, and stent thrombosis.

RESULTS

The achievement rate of LDL-C < 1.8 mmol/L was significantly higher in the HLP group than in the Control group (58% vs. 27%, p < 0.01). The HLP group's change ratio and LDL-C values were significantly lower than those of the Control group (-39.5 [-55.1, -13.2]% vs. -20.4 [-38.4, 0]%, p < 0.001; -41 [-69, -11] mg/dL vs. -21 [-38, 0] mg/dL, p < 0.001). MACE was similar between the groups (16.9 vs. 15.5%, p = 0.66).

CONCLUSION

Implementing a HLP for ACS patients improved the achievement of target LDL-C at 12 months.

Smoking and Obstructive Sleep Apnea: Is There An Association between These Cardiometabolic Risk Factors?-Gender Analysis

Background and Objectives: Studies have tried to establish a relationship between Obstructive Sleep Apnea syndrome (OSA) and smoking but data still remain controversial. We aimed: 1. To evaluate the relationship between smoking and OSA; 2. To explore potential differences according to gender, and 3. To analyze the prevalence of cardiovascular disease (CVD) co-morbidities according to gender and smoking status. Materials and Methods: This retrospective study included 3791 (70.6% males) adult patients who visited a Sleep Clinic. All participants underwent nocturnal polysomnography. Daytime somnolence and insomnia were assessed by using the Epworth Sleepiness Scale (ESS) and the Athens Insomnia Scale (AIS). Ever-smokers completed the Fagerstrom Test for Nicotine Dependence (FTND). Results: OSA was confirmed in 72.1% of participants with 62.2% suffering from moderate-to-severe disease. The number of cigarettes/day, Pack/Years, and FTND were significantly higher in patients with more severe OSA. The prevalence of current smokers was higher in those without OSA or with mild disease, whereas the prevalence of former smokers was higher in moderate and severe OSA. In univariate analysis, current smokers were found to be 1.2 times more likely to have OSA compared with never and former smokers combined and former smokers 1.49 times more likely compared with never smokers. In the multiple regression analysis, after adjusting for BMI, gender, age and number of alcoholic drinks per week, smoking was not found to be significantly associated with OSA. In gender stratified multivariate analyses, no significant associations were observed. CVD co-morbidities were more frequent in more severe OSA. Hypertension, coronary disease and diabetes were more prevalent in former smokers with AHI ≥ 15, compared with current smokers, especially in men. Conclusions: Even if an independent effect of smoking on OSA was not found, the number of cigarettes/day, Pack/Years, and FTND were higher in patients with more severe OSA with more prevalent CVD co-morbidities.

Physical activity, sedentary behavior and risk of coronary artery disease, myocardial infarction and ischemic stroke: a two-sample Mendelian randomization study

AIMS

Observational evidence suggests that physical activity (PA) is inversely and sedentarism positively related with cardiovascular disease risk. We performed a two-sample Mendelian randomization (MR) analysis to examine whether genetically predicted PA and sedentary behavior are related to coronary artery disease, myocardial infarction, and ischemic stroke.

METHODS AND RESULTS

We used single nucleotide polymorphisms (SNPs) associated with self-reported moderate to vigorous PA (n = 17), accelerometer based PA (n = 7) and accelerometer fraction of accelerations > 425 milli-gravities (n = 7) as well as sedentary behavior (n = 6) in the UK Biobank as instrumental variables in a two sample MR approach to assess whether these exposures are related to coronary artery disease and myocardial infarction in the CARDIoGRAMplusC4D genome-wide association study (GWAS) or ischemic stroke in the MEGASTROKE GWAS. The study population included 42,096 cases of coronary artery disease (99,121 controls), 27,509 cases of myocardial infarction (99,121 controls), and 34,217 cases of ischemic stroke (404,630 controls). We found no associations between genetically predicted self-reported moderate to vigorous PA, accelerometer-based PA or accelerometer fraction of accelerations > 425 milli-gravities as well as sedentary behavior with coronary artery disease, myocardial infarction, and ischemic stroke.

CONCLUSIONS

These results do not support a causal relationship between PA and sedentary behavior with risk of coronary artery disease, myocardial infarction, and ischemic stroke. Hence, previous observational studies may have been biased.

"Help in a Heartbeat?": A Systematic Evaluation of Mobile Health Applications (Apps) for Coronary Heart Disease

For patients with coronary heart disease (CHD) lifestyle changes and disease management are key aspects of treatment that could be facilitated by mobile health applications (MHA). However, the quality and functions of MHA for CHD are largely unknown, since reviews are missing. Therefore, this study assessed the general characteristics, quality, and functions of MHA for CHD. Hereby, the Google Play and Apple App stores were systematically searched using a web crawler. The general characteristics and quality of MHA were rated with the Mobile Application Rating Scale (MARS) by two independent raters. From 3078 identified MHA, 38 met the pre-defined criteria and were included in the assessment. Most MHA were affiliated with commercial companies (52.63%) and lacked an evidence-base. An overall average quality of MHA (M = 3.38, SD = 0.36) was found with deficiencies in information quality and engagement. The most common functions were provision of information and CHD risk score calculators. Further functions included reminders (e.g., for medication or exercises), feedback, and health management support. Most MHA (81.58%) had one or two functions and MHA with more features had mostly higher MARS ratings. In summary, this review demonstrated that a number of potentially helpful MHA for patients with CHD are commercially available. However, there is a lack of scientific evidence documenting their usability and clinical potential. Since it is difficult for patients and healthcare providers to find suitable and high-quality MHA, databases with professionally reviewed MHA are required.

Analysis of Metabolic Markers in Patients with Chronic Heart Failure before and after LVAD Implantation

Chronic heart failure (HF) is a clinical syndrome characterized by functional impairments of the myocardium. Metabolic and clinical changes develop with disease progression. In an advanced state, left ventricular assist devices (LVADs) are implanted for mechanical unloading. Our study aimed to assess the effects of LVAD implantation on the metabolic phenotypes and their potential to reverse the latter in patients with advanced HF. Plasma metabolites were analyzed by LC–MS/MS in 20 patients with ischemic cardiomyopathy (ICM), 20 patients with dilative cardiomyopathy (DCM), and 20 healthy controls. Samples were collected in HF patients before, 30 days after, and >100 days after LVAD implantation. Out of 188 measured metabolites, 63 were altered in HF. Only three metabolites returned to pre-LVAD concentrations 100 days after LVAD implantation. Pre-LVAD differences between DCM and ICM were mainly observed for amino acids and biogenic amines. This study shows a reversal of metabolite abnormalities in HF as a result of LVAD implantation. The etiology of the underlying disease plays an essential role in defining which specific metabolic parameter is altered in HF and reversed by LVAD implantation. Our findings provide a detailed insight into the disease pattern of ICM and DCM and the potential for reversibility of metabolic abnormalities in HF.

Sirtuin 5 promotes arterial thrombosis by blunting the fibrinolytic system

AIMS

Arterial thrombosis as a result of plaque rupture or erosion is a key event in acute cardiovascular events. Sirtuin 5 (SIRT5) belongs to the lifespan-regulating sirtuin superfamily and has been implicated in acute ischaemic stroke and cardiac hypertrophy. This project aims at investigating the role of SIRT5 in arterial thrombus formation.

METHODS AND RESULTS

Sirt5 transgenic (Sirt5Tg/0) and knock-out (Sirt5-/-) mice underwent photochemically induced carotid endothelial injury to trigger arterial thrombosis. Primary human aortic endothelial cells (HAECs) were treated with SIRT5 silencing-RNA (si-SIRT5) as well as peripheral blood mononuclear cells from acute coronary syndrome (ACS) patients and non-ACS controls (case-control study, total n = 171) were used to increase the translational relevance of our data. Compared to wild-type controls, Sirt5Tg/0 mice displayed accelerated arterial thrombus formation following endothelial-specific damage. Conversely, in Sirt5-/- mice, arterial thrombosis was blunted. Platelet function was unaltered, as assessed by ex vivo collagen-induced aggregometry. Similarly, activation of the coagulation cascade as assessed by vascular and plasma tissue factor (TF) and TF pathway inhibitor expression was unaltered. Increased thrombus embolization episodes and circulating D-dimer levels suggested augmented activation of the fibrinolytic system in Sirt5-/- mice. Accordingly, Sirt5-/- mice showed reduced plasma and vascular expression of the fibrinolysis inhibitor plasminogen activator inhibitor (PAI)-1. In HAECs, SIRT5-silencing inhibited PAI-1 gene and protein expression in response to TNF-α. This effect was mediated by increased AMPK activation and reduced phosphorylation of the MAP kinase ERK 1/2, but not JNK and p38 as shown both in vivo and in vitro. Lastly, both PAI-1 and SIRT5 gene expressions are increased in ACS patients compared to non-ACS controls after adjustment for cardiovascular risk factors, while PAI-1 expression increased across tertiles of SIRT5.

CONCLUSION

SIRT5 promotes arterial thrombosis by modulating fibrinolysis through endothelial PAI-1 expression. Hence, SIRT5 may be an interesting therapeutic target in the context of atherothrombotic events.

Application of Modern Clinical Risk Scores in the Global Assessment of Risks Related to the Diagnosis and Treatment of Acute Coronary Syndromes in Everyday Medical Practice

This article presents an overview of contemporary risk assessment systems used in patients with myocardial infarction. The full range of risk scales, both recommended by the European Society of Cardiology and others published in recent years, is presented. Scales for assessing the risk of ischemia/death as well as for assessing the risk of bleeding are presented. A separate section is devoted to systems assessing the integrated risk associated with both ischemia and bleeding. In the first part of the work, each of the risk scales is described in detail, including the clinical trials/registers on the basis of which they were created, the statistical methods used to develop them, as well as the specification of their individual parameters. The next chapter presents the practical application of a given scale in the patient risk assessment process, the timing of its application on the timeline of myocardial infarction, as well as a critical assessment of its potential advantages and limitations. The last part of the work is devoted to the presentation of potential directions for the development of risk assessment systems in the future.

Sunlight powered degradation of pentoxifylline Cs0.5Li0.5FeO2 as a green reusable photocatalyst: Mechanism, kinetics and toxicity studies

The degradation of Pentoxifylline (PXF) was achieved successfully by green energy in a built-in solar photocatalytic system using hybrid LiCs ferrites (Li_0.5Cs_0.5FeO₂) as magnetically recoverable photocatalysts. Kinetics showed a first-order reaction rate with maximum PXF removal of 94.91% at mildly acidic pH; additionally, the ferromagnetic properties of catalyst allowed recovery and reuse multiple times, reducing costs and time in degradation processes. The degradation products were identified by HPLC-MS and allowed us to propose a thermodynamically feasible mechanism that was validated through DFT calculations. Additionally, toxicity studies have been performed in bacteria and yeast where high loadings of Cs showed to be harmful to Staphylococcus aureus (MIC≥ 4.0 mg/mL); Salmonella typhi (MIC≥ 8.0 mg/mL) and Candida albicans (MIC≥ 10.0 mg/mL). The presented setup shows effectiveness and robustness in a degradation process using alternative energy sources for the elimination of non-biodegradable pollutants.

The Changes in the p53 Protein across the Animal Kingdom Point to Its Involvement in Longevity

Recently, the quest for the mythical fountain of youth has produced extensive research programs that aim to extend the healthy lifespan of humans. Despite advances in our understanding of the aging process, the surprisingly extended lifespan and cancer resistance of some animal species remain unexplained. The p53 protein plays a crucial role in tumor suppression, tissue homeostasis, and aging. Long-lived, cancer-free African elephants have 20 copies of the TP53 gene, including 19 retrogenes (38 alleles), which are partially active, whereas humans possess only one copy of TP53 and have an estimated cancer mortality rate of 11–25%. The mechanism through which p53 contributes to the resolution of the Peto’s paradox in Animalia remains vague. Thus, in this work, we took advantage of the available datasets and inspected the p53 amino acid sequence of phylogenetically related organisms that show variations in their lifespans. We discovered new correlations between specific amino acid deviations in p53 and the lifespans across different animal species. We found that species with extended lifespans have certain characteristic amino acid substitutions in the p53 DNA-binding domain that alter its function, as depicted from the Phenotypic Annotation of p53 Mutations, using the PROVEAN tool or SWISS-MODEL workflow. In addition, the loop 2 region of the human p53 DNA-binding domain was identified as the longest region that was associated with longevity. The 3D model revealed variations in the loop 2 structure in long-lived species when compared with human p53. Our findings show a direct association between specific amino acid residues in p53 protein, changes in p53 functionality, and the extended animal lifespan, and further highlight the importance of p53 protein in aging.

Design of Smart Steering Wheel for Unobtrusive Health and Drowsiness Monitoring

This article describes the design of a smart steering wheel intended for use in unobtrusive health and drowsiness monitoring. The aging population, cardiovascular disease, personalized medicine, and driver fatigue were significant motivations for developing a monitoring platform in cars because people spent much time in cars. The purpose was to create a unique, comprehensive monitoring system for the driver. The crucial parameters in health or drowsiness monitoring, such as heart rate, heart rate variability, and blood oxygenation, are measured by an electrocardiograph and oximeter integrated into the steering wheel. In addition, an inertial unit was integrated into the steering wheel to record and analyze the movement patterns performed by the driver while driving. The developed steering wheel was tested under laboratory and real-life conditions. The measured signals were verified by commercial devices to confirm data correctness and accuracy. The resulting signals show the applicability of the developed platform in further detecting specific cardiovascular diseases (especially atrial fibrillation) and drowsiness.

Excessive daytime sleepiness, morning tiredness and major adverse cardiovascular events in patients with chronic coronary syndrome

BACKGROUND

Sleep-related breathing disorders (SRBDs), particularly obstructive sleep apnoea, are associated with increased cardiovascular (CV) risk. However, it is not known whether individual questions used for SRBD screening are associated with major adverse CV events (MACE) and death specifically in patients with chronic coronary syndrome (CCS).

METHODS

Symptoms associated with SRBD were assessed by a baseline questionnaire in 15,640 patients with CCS on optimal secondary preventive therapy in the STABILITY trial. The patients reported the frequency (never/rarely, sometimes, often and always) of: 1) loud snoring; 2) more than one awakening/night; 3) morning tiredness (MT); 4) excessive daytime sleepiness (EDS); or 5) gasping, choking or apnoea when asleep. In adjusted Cox regression models, associations between the frequency of SRBD symptoms and CV outcomes were assessed with never/rarely as reference.

RESULTS

During a median follow-up time of 3.7 years, 1,588 MACE events (541 CV deaths, 749 nonfatal myocardial infarctions [MI] and 298 nonfatal strokes) occurred. EDS was associated (hazard ratio [HR], 95% confidence interval [CI]) with increased risk of MACE (sometimes 1.14 [1.01-1.29], often 1.19 [1.01-1.40] and always 1.43 [1.15-1.78]), MI (always 1.61 [1.17-2.20]) and all-cause death (often 1.26 [1.05-1.52] and always 1.71 [1.35-2.15]). MT was associated with higher risk of MACE (often 1.23 [1.04-1.45] and always 1.46 [1.18-1.81]), MI (always 1.61 [1.22-2.14]) and all-cause death (always 1.54 [1.20-1.98]). The other SRBD-related questions were not consistently associated with worse outcomes.

CONCLUSIONS

In patients with CCS, gradually higher levels of EDS and MT were independently associated with increased risk of MACE, including mortality.

Poor long-term prognosis in patients admitted with strong suspicion of acute myocardial infarction but discharged with another diagnosis

BACKGROUND

Characteristics and prognosis of patients admitted with strong suspicion of myocardial infarction (MI) but discharged without an MI diagnosis are not well-described.

OBJECTIVES

To compare background characteristics and cardiovascular outcomes in patients discharged with or without MI diagnosis.

METHODS

The DETermination of the role of Oxygen in suspected Acute Myocardial Infarction (DETO2X-AMI) trial compared 6629 patients with strong suspicion of MI randomized to oxygen or ambient air. The main composite end-point of this subgroup analysis was the incidence of all-cause death, rehospitalization with MI, heart failure (HF) or stroke during a follow-up of 2.1 years (median; range: 1-3.7 years) irrespective of randomized treatment.

RESULTS

1619 (24%) received a non-MI discharge diagnosis, and 5010 patients (76%) were diagnosed with MI. Groups were similar in age, but non-MI patients were more commonly female and had more comorbidities. At thirty days, the incidence of the composite end-point was 2.8% (45 of 1619) in non-MI patients, compared to 5.0% (250 of 5010) in MI patients with lower incidences in all individual end-points. However, for the long-term follow-up, the incidence of the composite end-point increased in the non-MI patients to 17.7% (286 of 1619) as compared to 16.0% (804 of 5010) in MI patients, mainly driven by a higher incidence of all-cause death, stroke and HF.

CONCLUSIONS

Patients admitted with a strong suspicion of MI but discharged with another diagnosis had more favourable outcomes in the short-term perspective, but from one year onwards, cardiovascular outcomes and death deteriorated to a worse long-term prognosis.

100% Fruit juice intake and cardiovascular risk: a systematic review and meta-analysis of prospective and randomised controlled studies

PURPOSE

The relationship between 100% fruit juice (100%FJ) consumption and cardiovascular risk is object of debate: indeed, recently published investigations provided new but discrepant evidence on this important question and International dietary guidelines are not in agreement on recommendations about fruit juice consumption. Therefore, we performed a meta-analysis of the prospective studies and the randomised controlled trials (RCTs) that explored the relationship between 100%FJ intake, cardiovascular risk profile and risk of cardiovascular events.

METHODS

We performed a systematic search of publications up to August 2019. Summary relative risks and exploration of linearity of the association were estimated for prospective studies and summary mean differences (MDs) calculated for RCTs.

RESULTS

A total of 21 prospective studies and 35 RCTs met the inclusion criteria. Dose-response analysis detected a significant inverse association between low-moderate 100%FJ consumption and risk of stroke (up to 200 ml/day) or total CV events (up to 170 ml/day) compared with no consumption, with a non-linear relationship (p for non-linearity < 0.05). No significant association was found for coronary heart disease and diabetes risk. In RCTs, a favorable and significant effect of 100%FJ intake was detected on blood pressure (systolic, MD: - 3.14 mmHg; diastolic, MD: - 1.68 mmHg), arterial compliance (carotid-femoral pulse wave velocity, - 0.38 m/s) and endothelial function (flow-mediated dilation, 2.10%). Neutral effects were found on body weight, blood lipids and glucose metabolism.

CONCLUSIONS

The results of these analyses indicate that 100%FJ consumption is not associated with higher CV risk. A non-linear inverse dose-response relationship occurs between 100%FJ consumption and CV disease, in particular for risk of stroke, probably mediated by the decrease in blood pressure.

TRIAL REGISTRATION

PROSPERO registration number (CRD42019135577).

Endostatin attenuates heart failure via inhibiting reactive oxygen species in myocardial infarction rats

The purpose of the present study was to evaluate whether endostatin overexpression could improve cardiac function, hemodynamics, and fibrosis in heart failure (HF) via inhibiting reactive oxygen species (ROS). The HF models were established by inducing ischemia myocardial infarction (MI) through ligation of the left anterior descending (LAD) artery in Sprague-Dawley (SD) rats. Endostatin level in serum was increased in MI rats. The decrease in cardiac function and hemodynamics in MI rats were enhanced by endostatin overexpression. Endostatin overexpression inhibited the increase in collagen I, collagen III, α-smooth muscle actin (α-SMA), connective tissue growth factor (CTGF), matrix metalloproteinase (MMP)-2 and MMP9 in the hearts of MI rats. MI-induced cardiac hypertrophy was reduced by endostatin overexpression. The increased levels of malondialdehyde (MDA), superoxide anions, the promoted NAD(P)H oxidase (Nox) activity, and the reduced superoxide dismutase (SOD) activity in MI rats were reversed by endostatin overexpression. Nox4 overexpression inhibited the cardiac protective effects of endostatin. These results demonstrated that endostatin improved cardiac dysfunction and hemodynamics, and attenuated cardiac fibrosis and hypertrophy via inhibiting oxidative stress in MI-induced HF rats.

Electrocardiographic abnormalities, preclinical carotid atherosclerosis andcardiovascular risk, in an apparently healthy real-world population: data from the project "No Stroke, No Infarction" of the rotary international - District 2110 "Sicily & Malta"

BACKGROUND

Cardiovascular diseases (CVDs) represent important causes of morbidity and mortality. Our study aimed to evaluate cardiovascular risk using the EUROSCORE, ECG and carotid ultrasound for prevention purpose in a 50-70 years population and companions asymptomatic and without CVD.

METHODS

History of CVD, risk factors (RFs), ECG and carotid ultrasound were evaluated. Intima-media thickness (IMT) was defined as wall thickness > 0.9 mm, while focal thickening ≥ 1.5 mm protruding into the lumen as asymptomatic carotid plaque (ACP).

RESULTS

Totally, 1860 subjects were screened. 393 (21.1%) had no RFs, 780 (42%) hypertension, 571 (30.7%) hypercholesterolemia, 557 (29.9%) diabetes, 474 (25.5%) smoking, 648 (34.8%) overweight, 300 (16.1%) obesity and 184 (9.9%) metabolic syndrome. Carotid atherosclerosis was detected in 903 (48.5%) subjects, 821 (44.1%) had IMT and 547 (29.4%) ACP, and was significantly related to diabetes, hypertension and hypercholesterolemia. Atrial fibrillation was found in 29 subjects (1.6%) and Brugada pattern in one. Using EUROSCORE, 220 subjects resulted at low (11.8%), 1338 at moderate (71.9%), 292 at high (15.7%) and 10 at very-high risk (0.5%). Adding ACP, the percentages were: low 159 (8,54%), moderate 1020 (54,83%), high 663 (35,64%) and very-high risk 18 (0,96%).

CONCLUSIONS

A total of 302 (16.2%) subjects were at least at high risk for CV events according to the EUROSCORE, increasing to 681 (36,61% - p < 0.001) adding ACP. The combination of EUROSCORE with ECG may help to stratify CV risk in primary prevention. Carotid ultrasound furtherly increases the power of stratification of asymptomatic patients suitable for pharmacological treatment.

ALKBH1-demethylated DNA N6-methyladenine modification triggers vascular calcification via osteogenic reprogramming in chronic kidney disease

Vascular calcification (VC) predicts cardiovascular morbidity and mortality in chronic kidney disease (CKD). To date, the underlying mechanisms remain unclear. We detected leukocyte DNA N6-methyladenine (6mA) levels in patients with CKD with or without aortic arch calcification. We used arteries from CKD mice infected with vascular smooth muscle cell-targeted (VSMC-targeted) adeno-associated virus encoding alkB homolog 1 (Alkbh1) gene or Alkbh1 shRNA to evaluate features of calcification. We identified that leukocyte 6mA levels were significantly reduced as the severity of VC increased in patients with CKD. Decreased 6mA demethylation resulted from the upregulation of ALKBH1. Here, ALKBH1 overexpression aggravated whereas its depletion blunted VC progression and osteogenic reprogramming in vivo and in vitro. Mechanistically, ALKBH1-demethylated DNA 6mA modification could facilitate the binding of octamer-binding transcription factor 4 (Oct4) to bone morphogenetic protein 2 (BMP2) promoter and activate BMP2 transcription. This resulted in osteogenic reprogramming of VSMCs and subsequent VC progression. Either BMP2 or Oct4 depletion alleviated the procalcifying effects of ALKBH1. This suggests that targeting ALKBH1 might be a therapeutic method to reduce the burden of VC in CKD.

Investigating the Pharmacological Mechanisms of SheXiang XinTongNing Against Coronary Heart Disease Based on Network Pharmacology and Experimental Evaluation

SheXiang XinTongNing (XTN), which is composed of six traditional Chinese herbs, is a commercially available Chinese patent medicine that has been widely used as the treatment of coronary heart disease (CHD). Its mechanisms against coronary heart disease, however, remain largely unknown. This study aimed to investigate the pharmacological mechanisms of XTN against CHD via network pharmacology and experimental evaluation. In this study, GO enrichment and KEGG pathway enrichment were firstly performed for acquiring the potentially active constituents of XTN, the candidate targets related to coronary heart disease, the drug-components-targets network as well as the protein-protein interaction network and further predicting the mechanisms of XTN against coronary heart disease. Subsequently, a series of in vitro experiments, specifically MTT assay, flow cytometry and Real-time quantitative polymerase chain reaction analysis, and a succession of in vivo experiments, including Tunel staining and immunohistochemical staining were conducted for further verification. Results showed that Bcl-2, IGF1, CASP3 were the key candidate targets which significantly associated with multiple pathways, namely PI3K-Akt signaling pathway and MAPK signaling pathway. It indicated that the potential mechanism of XTN against CHD may be predominantly associated with cell apoptosis. The in vitro experimental results showed that XTN treatment remarkably decreased the apoptotic rate and Bax/Bcl-2 ratio of H9c2 cells. Histological results confirmed that XTN not only effectively alleviated oxidative damage caused by myocardial ischemia but inhibited cell apoptosis. Given the above, through the combined utilization of virtual screening and experimental verification, the findings suggest that XTN makes a significant contribution in protecting the heart from oxidative stress via regulating apoptosis pathways, which lays the foundations and offers an innovative idea for future research.

Health disparities in Russia at the regional and global scales

BACKGROUND

The capacity for health comparisons, including the accurate comparison of indicators, is necessary for a comprehensive evaluation of well-being in places where people live. An important issue is the assessment of within-country heterogeneity for geographically extensive countries. The aim of this study was to assess the spatial and temporal changes in health status in Russia and to compare these regional changes with global trends.

METHODS

The index, which considers the infant mortality rate and the male and female life expectancy at birth, was used for this purpose. Homogeneous territorial groups were identified using principal component analysis and multivariate ranking procedures. Trend analysis of individual indicators included in the index was also performed to assess the changes over the past 20 years (1990-2017).

RESULTS

The study indicated a trend towards convergence in health indicators worldwide, which is largely due to changes in infant mortality. It also revealed that the trend of increasing life expectancy in many regions of Russia is not statistically significant. Significant interregional heterogeneity of health status in Russia was identified according to the application of typological ranking. The regions were characterized by similar index values until the mid-1990s.

CONCLUSIONS

The strong spatial inequality in health of population was found in Russia. While many regions of Russia were comparable to the countries in the high-income group in terms of GDP, the progress in health was less pronounced. Perhaps this can be explained by intraregional inequality, expressed by significant fluctuations in income levels.

TRIAL REGISTRATION

Not applicable.

The association between advanced practice nursing roles and outcomes in adults following cardiac surgery: A systematic review of randomized controlled trials

BACKGROUND

Empirical findings have shown significant and non-significant effects of advanced practice nursing roles within postoperative cardiac settings. The inconsistencies of the current literature preclude the identification of a significant effect of advanced practice nursing roles on patient and organizational outcomes.

OBJECTIVE

1) identify patient and organizational outcomes of advanced practice nursing roles in postoperative cardiac surgery and 2) synthesize the evidence of current roles of advanced practice nurses in postoperative cardiac surgery to provide the best quality of care for patients.

METHOD

A systematic review of randomized controlled trials was conducted in six electronic databases, including Medline, CINHAL, Embase, Cochrane Database, Joanna Briggs Database and Web of Science, and the grey literature. Randomized controlled trials published after 1999 were included if they examined advanced practice nursing roles and recruited patients who underwent cardiac surgery. The study selection was performed by two independent reviewers, and consensus was achieved with a third reviewer. Data extraction was conducted by one reviewer and revised by a second reviewer. The methodological quality of the included studies was assessed with the Evidence Project risk of bias tool by two independent reviewers and revised by a third reviewer. A narrative synthesis of the available evidence was completed. No meta-analysis technique was attempted because of the high heterogeneity of the included studies.

RESULTS

Among 4,448 retrieved papers, ten randomized controlled trials and three secondary analyses were included in this review. The methodological quality of the included studies was moderate. All studies included a comparison group and the majority of the studies collected data using a blinded researcher. However, all studies were based on small sample sizes and failed to randomly recruit participants. Five studies implemented nurse practitioner roles and five studies implemented clinical nurse specialist roles. The advanced practice nursing care included health condition management, lifestyle promotion and coping strategies with patients. A total of 22 outcomes were identified, including 13 patient outcomes (e.g., depressive symptoms) and nine organizational outcomes (e.g., rehospitalization after discharge). Each outcome was examined in one to five studies. All of the included outcomes were associated with inconsistent findings.

CONCLUSION

The findings from existing literature remain inconsistent. The high risk of bias and the small sample sizes could potentially explain the non-significant findings. Avenues for future research should focus on the development of methodologically high-quality studies with larger sample sizes to enhance our understanding of the effectiveness of advanced practice nursing roles.

Social inequities in cardiovascular risk factors in women and men by autonomous regions in Spain

OBJECTIVE

To describe social inequities in cardiovascular risk factors in women and men by autonomous regions in Spain.

METHOD

We used data from 20,406 individuals aged 18 or older from the 2017 Spanish National Health Survey. We measured socioeconomic position using occupational social class and used data on self-reported cardiovascular risk factors: high cholesterol, diabetes, hypertension, obesity, and smoking. We estimated the relative risk of inequality using Poisson regression models. Analyses were stratified by men and women and by region (autonomous communities).

RESULTS

Overall, the relative risk of inequality was 1.02, 1.13, 1.06, 1.17 and 1.09 for high cholesterol, diabetes, hypertension, obesity, and current smoking, respectively. Ocuupational social class inequities in diabetes, hypertension, and obesity was stronger for women. Results showed a large regional heterogeneity in these inequities; some regions (e.g. Asturias and Balearic Islands) presented wider social inequities in cardiovascular risk factors than others (e.g. Galicia, Navarra or Murcia).

CONCLUSION

In Spain, we found marked social inequities in the prevalence of cardiovascular risk factors, with wide regional and women/men heterogeneity in these inequities. Education, social, economic and health policies at the regional level could reduce health inequities in cardiovascular risk factors and, thus, prevent cardiovascular disease.

Subclinical left atrial dysfunction profiles for prediction of cardiac outcome in the general population

OBJECTIVE

Echocardiographic definitions of subclinical left atrial dysfunction based on epidemiological data remain scarce. In this population study, we derived outcome-driven thresholds for echocardiographic left atrial function parameters discriminating between normal and abnormal values.

METHODS

In 1306 individuals (mean age, 50.7 years; 51.6% women), we echocardiographically assessed left atrial function and LV global longitudinal strain. We derived cut-off values for left atrial emptying fraction (LAEF), left atrial function index (LAFI) and left atrial reservoir strain (LARS) to define left atrial dysfunction using receiver-operating curve threshold analysis. Main outcome was the incidence of cardiac events and atrial fibrillation (AFib) on average 8.5 years later.

RESULTS

For prediction of new-onset AFib, left atrial cut-offs yielding the best balance between sensitivity and specificity (highest Youden index) were: LAEF less than 55%, LAFI less than 40.5 and LARS less than 23%. Applying these cut-offs, abnormal LAEF, LAFI and LARS were, respectively, present in 27, 37.1 and 18.1% of the cohort. Abnormal LARS (<23%) was independently associated with higher risk for cardiac events and new-onset AFib (P ≤ 0.012). Participants with both abnormal LAEF and LARS presented a significantly higher risk to develop cardiac events (hazard ratio: 2.10; P = 0.014) and AFib (hazard ratio: 6.45; P = 0.0036) than normal counterparts. The concomitant presence of an impaired LARS and LV global longitudinal strain improved prognostic accuracy beyond a clinical risk model for cardiac events and the CHARGE-AF Risk Score for AFib.

CONCLUSION

Left atrial dysfunction based on outcome-driven thresholds predicted cardiac events and AFib independent of conventional risk factors. Screening for subclinical left atrial and LV systolic dysfunction may enhance cardiac disease prediction in the community.

Automated cardiac segmentation of cross-modal medical images using unsupervised multi-domain adaptation and spatial neural attention structure

Accurate cardiac segmentation of multimodal images, e.g., magnetic resonance (MR), computed tomography (CT) images, plays a pivot role in auxiliary diagnoses, treatments and postoperative assessments of cardiovascular diseases. However, training a well-behaved segmentation model for the cross-modal cardiac image analysis is challenging, due to their diverse appearances/distributions from different devices and acquisition conditions. For instance, a well-trained segmentation model based on the source domain of MR images is often failed in the segmentation of CT images. In this work, a cross-modal images-oriented cardiac segmentation scheme is proposed using a symmetric full convolutional neural network (SFCNN) with the unsupervised multi-domain adaptation (UMDA) and a spatial neural attention (SNA) structure, termed UMDA-SNA-SFCNN, having the merits of without the requirement of any annotation on the test domain. Specifically, UMDA-SNA-SFCNN incorporates SNA to the classic adversarial domain adaptation network to highlight the relevant regions, while restraining the irrelevant areas in the cross-modal images, so as to suppress the negative transfer in the process of unsupervised domain adaptation. In addition, the multi-layer feature discriminators and a predictive segmentation-mask discriminator are established to connect the multi-layer features and segmentation mask of the backbone network, SFCNN, to realize the fine-grained alignment of unsupervised cross-modal feature domains. Extensive confirmative and comparative experiments on the benchmark Multi-Modality Whole Heart Challenge dataset show that the proposed model is superior to the state-of-the-art cross-modal segmentation methods.

Nephrosclerosis impacts time trajectory of renal function and outcomes in elderly individuals with chronic kidney disease

Despite hypertension ranks among the leading causes of chronic kidney disease (CKD), the impact of chronic hypertensive nephropathy, the so-called 'nephrosclerosis' (NS), on CKD progression is often unpredictable, particularly in elderly population. We have conducted a prospective, observational study to define renal function patterns and outcomes in elderly CKD individuals with or without NS. Three hundred four individuals with an already established CKD were categorized according to the etiology of CKD. NS was defined as the presence of CKD associated with long-term essential hypertension, hypertensive retinopathy, left ventricular hypertrophy and minimal proteinuria. Time trajectories in estimated glomerular filtration rate (eGFR) (CKD-Epi) were computed over a 4-year follow-up. In addition, we analyzed the occurrence of a composite outcome of doubling of serum creatinine levels, eGFR reduction ≥25% and/or the need of chronic renal replacement therapy. CKD was secondary to nephrosclerosis (CKD-NS) in 220 (72.3%). In the whole cohort, the average estimated annual GFR slope was 1.8 mL/min/1.73 m² eGFR decline was slower in CKD-NS as compared with others (1.4 vs 3.4 mL/min/1.73 m²; p<0.001). The composite renal outcome during follow-up occurred less frequently among elderly with CKD-NS (16/204 vs 14/70; p=0.01, crude HR 0.43, 95% CI 0.22 to 0.85) and was associated at logistic analyses with the etiology of CKD, background cardiovascular disease, total and low density lipoproteins (LDL) cholesterol, and glycemia levels (p value was ranging from 0.01 to 0.05). Despite being highly prevalent in the elderly, NS is associated with a more favorable renal disease course as compared with other conditions.

Unwillingness to participate in health checks for cardiometabolic diseases: A survey among primary health care patients in five European countries

BACKGROUND AND AIMS

Since cardiometabolic diseases (CMD) are a frequent cause of death worldwide, preventive strategies are needed. Recruiting adults for a health check could facilitate the identification of individuals at risk for CMD. For successful results, participation is crucial. We aimed to identify factors related to unwillingness to participate in CMD health checks.

METHODS

We performed a cross-sectional study in the Czech Republic, Denmark, Greece, the Netherlands, and Sweden. A questionnaire was distributed among persons without known CMD consulting general practice between January and July 2017 within the framework of the SPIMEU study.

RESULTS

In total, 1354 persons responded. Nine percent was unwilling to participate in a CMD health check. Male gender, smoking, higher self-rated health, never been invited before, and not willing to pay were related to unwillingness to participate. The most mentioned reason for unwillingness to participate was "I think that I am healthy" (57%). Among the respondents who were willing to participate, 94% preferred an invitation by the general practitioner and 66% was willing to pay.

CONCLUSION

A minority of the respondents was unwilling to participate in a CMD health check with consistent results within the five countries. This provides a promising starting point to increase participation in CMD health checks in primary care.

A double-blind, randomized, placebo-controlled trial on the effect of Ashwagandha (Withania somnifera dunal.) root extract in improving cardiorespiratory endurance and recovery in healthy athletic adults

ETHNOPHARMACOLOGICAL RELEVANCE

Ashwagandha is a reputed herb in traditional Ayurveda, used for various ailments and improving general well-being. Improved cardiorespiratory endurance can aid in attaining better physiological, metabolic, and functional abilities in humans. According to Ayurveda, Ashwagandha has such potential to improve human health.

AIM OF THE STUDY

This study aimed to evaluate the efficacy and safety of Ashwagandha root extract in enhancing cardiorespiratory endurance in healthy athletic adults.

MATERIALS AND METHODS

Fifty healthy athletic adults were selected randomly and equally allocated to Ashwagandha and placebo groups. The Ashwagandha group received 300 mg of Ashwagandha root extract capsules, twice daily, for 8-weeks. Cardiorespiratory endurance was assessed by measuring the maximum aerobic capacity (VO2 max). Estimation of stress management was done through Total Quality Recovery Scores (TQR), Recovery-Stress Questionnaire for Athletes (RESTQ), and Daily Analysis of Life Demands for Athletes (DALDA) questionnaires along with the antioxidant level measurement.

RESULTS

At the end of the study, a statistically significant improvement in VO2 max outcome was observed in the Ashwagandha group when compared to the placebo group (P = 0.0074). The subjects in the Ashwagandha group also displayed a statistically significant increase at the end of the study when compared to the baseline (P < 0.0001). Significantly improved TQR scores were observed in the Ashwagandha group members compared to their placebo counterparts (P < 0.0001). DALDA questionnaire analysis in the Ashwagandha group was found statistically significant (P < 0.0001) compared to the placebo group. RESTQ assessment also yielded better outcomes, especially for fatigue recovery (P < 0.0001), lack of energy (P < 0.0001), and fitness analysis (P < 0.0001). The enhanced antioxidant level was significant (P < 0.0001) in the Ashwagandha group.

CONCLUSION

The present findings suggest that Ashwagandha root extract can successfully enhance cardiorespiratory endurance and improve the quality of life in healthy athletic adults. No adverse events were reported by any of the subjects in this study.

Comparison of cine and real-time cardiac MRI in rhesus macaques

Cardiac MRI in rhesus macaques, a species of major relevance for preclinical studies on biological therapies, requires artificial ventilation to realize breath holding. To overcome this limitation of standard cine MRI, the feasibility of Real-Time (RT) cardiac MRI has been tested in a cohort of ten adult rhesus macaques using a clinical MR-system. In spite of lower tissue contrast and sharpness of RT-MRI, cardiac functions were similarly well assessed by RT-MRI compared to cine MRI (similar intra-subject repeatability). However, systematic underestimation of the end-diastolic volume (31 ± 9%), end-systolic volume (20 ± 11%), stroke volume (40 ± 12%) and ejection fraction (13 ± 9%) hamper the comparability of RT-MRI results with those of other cardiac MRI methods. Yet, the underestimations were very consistent (< 5% variability) for repetitive measurements, making RT-MRI an appropriate alternative to cine MRI for longitudinal studies. In addition, RT-MRI enabled the analysis of cardio-respiratory coupling. All functional parameters showed lower values during expiration compared to inspiration, most likely due to the pressure-controlled artificial ventilation. In conclusion, despite systematic underestimation of the functional parameters, RT-MRI allowed the assessment of left ventricular function in macaques with significantly less experimental effort, measurement time, risk and burden for the animals compared to cine MRI.

Health research and knowledge translation for achieving the sustainable development goals: tackling the hurdles

We are far from reaching the sustainable development goals (SDGs) for health despite a wealth of novel insights in disease mechanisms and possible solutions. Why have we failed in knowledge translation and implementation? Starting from the case of cardiovascular diseases as one of the most prevalent non-communicable diseases, we examine barriers and hurdles, and perspectives for future health research. Health has multiple links with other SDGs. To accelerate the progress towards a healthy society, health research needs to take a broader view and become more cross-disciplinary and cross-sectoral. As one example, behavioural studies will underpin better prevention and treatment adherence. The next generation workforce in health and research needs an adapted education and training to implement more effective health approaches. As well, only effective dialogue and communication between researchers, practitioners, society and policymakers can lead to translation of evidence into policies, addressing the complexity of socioeconomic factors and commercial interests. Within Europe, health research needs a comprehensive vision and strategy that connects to achieving better health, as one of the interconnected SDGs.

In-Cell Nanoelectronics: Opening the Door to Intracellular Electrophysiology

Establishing a reliable electrophysiological recording platform is crucial for cardiology and neuroscience research. Noninvasive and label-free planar multitransistors and multielectrode arrays are conducive to perform the large-scale cellular electrical activity recordings, but the signal attenuation limits these extracellular devices to record subthreshold activities. In recent decade, in-cell nanoelectronics have been rapidly developed to open the door to intracellular electrophysiology. With the unique three-dimensional nanotopography and advanced penetration strategies, high-throughput and high-fidelity action potential like signal recordings is expected to be realized. This review summarizes in-cell nanoelectronics from versatile nano-biointerfaces, penetration strategies, active/passive nanodevices, systematically analyses the applications in electrogenic cells and especially evaluates the influence of nanodevices on the high-quality intracellular electrophysiological signals. Further, the opportunities, challenges and broad prospects of in-cell nanoelectronics are prospected, expecting to promote the development of in-cell electrophysiological platforms to meet the demand of theoretical investigation and clinical application.

Molecular imaging-guided repair after acute myocardial infarction by targeting the chemokine receptor CXCR4

AIMS

Balance between inflammatory and reparative leucocytes allows optimal healing after myocardial infarction (MI). Interindividual heterogeneity evokes variable functional outcome complicating targeted therapy. We aimed to characterize infarct chemokine CXC-motif receptor 4 (CXCR4) expression using positron emission tomography (PET) and establish its relationship to cardiac outcome. We tested whether image-guided early CXCR4 directed therapy attenuates chronic dysfunction.

METHODS AND RESULTS

Mice (n = 180) underwent coronary ligation or sham surgery and serial PET imaging over 7 days. Infarct CXCR4 content was elevated over 3 days after MI compared with sham (%ID/g, Day 1:1.1 ± 0.2; Day 3:0.9 ± 0.2 vs. 0.6 ± 0.1, P < 0.001), confirmed by flow cytometry and histopathology. Mice that died of left ventricle (LV) rupture exhibited persistent inflammation at 3 days compared with survivors (1.2 ± 0.3 vs. 0.9 ± 0.2% ID/g, P < 0.001). Cardiac magnetic resonance measured cardiac function. Higher CXCR4 signal at 1 and 3 days independently predicted worse functional outcome at 6 weeks (rpartial = -0.4, P = 0.04). Mice were treated with CXCR4 blocker AMD3100 following the imaging timecourse. On-peak CXCR4 blockade at 3 days lowered LV rupture incidence vs. untreated MI (8% vs. 25%), and improved contractile function at 6 weeks (+24%, P = 0.01). Off-peak CXCR4 blockade at 7 days did not improve outcome. Flow cytometry analysis revealed lower LV neutrophil and Ly6Chigh monocyte content after on-peak treatment. Patients (n = 50) early after MI underwent CXCR4 PET imaging and functional assessment. Infarct CXCR4 expression in acute MI patients correlated with contractile function at time of PET and on follow-up.

CONCLUSION

Positron emission tomography imaging identifies early CXCR4 up-regulation which predicts acute rupture and chronic contractile dysfunction. Imaging-guided CXCR4 inhibition accelerates inflammatory resolution and improves outcome. This supports a molecular imaging-based theranostic approach to guide therapy after MI.

Imaging residual inflammatory cardiovascular risk

Targeting residual cardiovascular risk in primary and secondary prevention, would allow deployment of novel therapeutic agents, facilitating precision medicine. For example, lowering vascular inflammation is a promising strategy to reduce the residual inflammatory cardiovascular risk in patients already receiving optimal medical therapy, but prescribing novel anti-inflammatory treatments will be problematic due to the lack of specific companion diagnostic tests, to guide their targeted use in clinical practice. Currently available tests for the detection of coronary inflammation are either non-specific for the cardiovascular system (e.g. plasma biomarkers) or expensive and not readily available (e.g. hybrid positron emission tomography imaging). Recent technological advancements in coronary computed tomography angiography (CCTA) allow non-invasive detection of high-risk plaque features (positive remodelling, spotty calcification, low attenuation plaque, and napkin-ring sign) and help identify the vulnerable patient, but they provide only indirectly information about coronary inflammation. Perivascular fat attenuation index (FAI), a novel method for assessing coronary inflammation by analysing routine CCTA, captures changes in the perivascular adipose tissue composition driven by inflammatory signals coming from the inflamed coronary artery, by analysing the three-dimensional gradients of perivascular attenuation, followed by adjustments for technical, anatomical, and biological factors. By detecting vascular inflammation, perivascular FAI enhances cardiovascular risk discrimination which could aid more cost-effective deployment of novel therapeutic agents. In this article, we present the existing non-invasive modalities for the detection of coronary inflammation and provide a practical guide for their use in clinical practice.

Patient, hospital and country-level risk factors of all-cause mortality among patients with chronic heart failure: Prospective international cohort study

Background

Although many studies have described patient-level risk factors for outcomes in heart failure (HF), health care structural determinants remain largely unexplored. This research reports patient-, hospital- and country-level characteristics associated with 1-year all-cause mortality among patients with chronic HF, and investigates geographic and hospital variation in mortality.

Methods and findings

We included 9,277 patients with chronic HF enrolled between May 2011 and November 2017 in the prospective cohort study European Society of Cardiology Heart Failure Long Term registry across 142 hospitals, located in 22 countries. Mean age of the selected outpatients was 65 years (sd 13.2) and 28% were female. The all-cause 1-year mortality rate per 100 person-years was 7.1 (95% confidence interval (CI) 6.6–7.7), and varied between countries (median 6.8, IQR 5.6–11.2) and hospitals (median 7.8, IQR 5.2–12.4). Mortality was associated with age (incidence rate ratio 1.03, 95% CI 1.02–1.04), diabetes mellitus (1.37, 1.15–1.63), peripheral artery disease (1.56, 1.27–1.92), New York Heart Association class III/IV (1.91, 1.60–2.30), treatment with angiotensin-converting enzyme inhibitor and angiotensin receptor antagonists (0.71, 0.57–0.87) and HF clinic (0.64, 0.46–0.89). No other hospital-level characteristics, and no country-level healthcare characteristics were associated with 1-year mortality, with case-mix standardised variance between countries being very low (1.83e-06) and higher for hospitals (0.372).

Conclusions

All-cause mortality at 1 year among outpatients with chronic HF varies between countries and hospitals, and is associated with patient characteristics and the availability of hospital HF clinics. After full adjustment for clinical, hospital and country variables, between-country variance was negligible while between-hospital variance was evident.

Age and Gender Specific Lung Cancer Incidence and Mortality in Hungary: Trends from 2011 Through 2016

Objective: No assessment was conducted describing the age and gender specific epidemiology of lung cancer (LC) prior to 2018 in Hungary, thus the objective of this study was to appraise the detailed epidemiology of lung cancer (ICD-10 C34) in Hungary based on a retrospective analysis of the National Health Insurance Fund database.

Methods: This longitudinal study included patients aged ≥20 years with LC diagnosis (ICD-10 C34) between January 1, 2011 and December 31, 2016. Patients with different cancer-related codes 6 months before or 12 months after LC diagnosis or having any cancer treatment other than lung cancer protocols were excluded.

Results: Lung cancer incidence and mortality increased with age, peaking in the 70–79 age group (375.0/100,000 person-years) among males, while at 60–69 age group for females (148.1/100,000 person-years). The male-to-female incidence rate ratio reached 2.46–3.01 (p < 0.0001) among the 70–79 age group. We found 2–11% decrease in male incidence rate at most age groups, while a significant 1–3% increase was observed in older females (>60) annually during the study period.

Conclusion: This nationwide epidemiology study demonstrated that LC incidence and mortality in Hungary decreased in younger male and female population, however we found significant increase of incidence in older female population, similar to international trends. Incidence rates peaked in younger age-groups compared to Western countries, most likely due to higher smoking prevalence in these cohorts, while lower age LC incidence could be attributed to higher competing cardiovascular risk resulting in earlier mortality in smoking population.

Validation of the Dutch-Flemish translated ABCD questionnaire to measure cardiovascular diseases knowledge and risk perception among adults

Valid and reliable measurement of an individual's knowledge and risk perception is pivotal to monitor and evaluate the effectiveness of interventions aimed at preventing cardiovascular diseases (CVDs). The recently developed Attitudes and Beliefs about Cardiovascular Disease (ABCD) knowledge and risk questionnaire is shown to be valid in England. In this study, we evaluated the psychometric properties of the modified and Dutch (Flemish)-translated ABCD questionnaire using both the classical test and item response theory (IRT) analysis. We conducted a community-based survey among 525 adults in Antwerp city, Belgium. We assessed the item- and scale-level psychometric properties and validity indices of the questionnaire. Parameters of IRT, item scalability, monotonicity, item difficulty and discrimination, and item fit statistics were evaluated. Furthermore, exploratory and confirmatory factorial validity, and internal consistency measures were explored. Descriptive statistics showed that both the knowledge and risk scale items have sufficient variation to differentiate individuals' level of knowledge and risk perception. The overall homogeneity of the knowledge and risk subscales was within the acceptable range (> 0.3). The exploratory and confirmatory factor analyses of the risk scale supported a three-factor solution corresponding to risk perception (F1), perceived benefits and intention to change physical activity (F2), and perceived benefit and intention to change healthy dietary habit (F3). The two parametric logistic (2-PL) and rating scale models showed that the item infit and outfit values for knowledge and risk subscales were within the acceptable range (0.6 to 1.4) for most of the items. In conclusion, this study investigated the Dutch (Flemish) version of the ABCD questionnaire has good psychometric properties to assess CVD related knowledge and risk perception in the adult population. Based on the factor loadings and other psychometric properties, we suggested a shorter version, which has comparable psychometric properties.

AMPA-Type Glutamate Receptors Associated With Vascular Smooth Muscle Cell Subpopulations in Atherosclerosis and Vascular Injury

Objectives and Aims: Vascular smooth muscle cells (VSMCs) are key constituents of both normal arteries and atherosclerotic plaques. They have an ability to adapt to changes in the local environment by undergoing phenotypic modulation. An improved understanding of the mechanisms that regulate VSMC phenotypic changes may provide insights that suggest new therapeutic targets in treatment of cardiovascular disease (CVD). The amino-acid glutamate has been associated with CVD risk and VSMCs metabolism in experimental models, and glutamate receptors regulate VSMC biology and promote pulmonary vascular remodeling. However, glutamate-signaling in human atherosclerosis has not been explored. Methods and Results: We identified glutamate receptors and glutamate metabolism-related enzymes in VSMCs from human atherosclerotic lesions, as determined by single cell RNA sequencing and microarray analysis. Expression of the receptor subunits glutamate receptor, ionotropic, α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic (AMPA)-type subunit 1 (GRIA1) and 2 (GRIA2) was restricted to cells of mesenchymal origin, primarily VSMCs, as confirmed by immunostaining. In a rat model of arterial injury and repair, changes of GRIA1 and GRIA2 mRNA level were most pronounced at time points associated with VSMC proliferation, migration, and phenotypic modulation. In vitro, human carotid artery SMCs expressed GRIA1, and selective AMPA-type receptor blocking inhibited expression of typical contractile markers and promoted pathways associated with VSMC phenotypic modulation. In our biobank of human carotid endarterectomies, low expression of AMPA-type receptor subunits was associated with higher content of inflammatory cells and a higher frequency of adverse clinical events such as stroke. Conclusion: AMPA-type glutamate receptors are expressed in VSMCs and are associated with phenotypic modulation. Patients suffering from adverse clinical events showed significantly lower mRNA level of GRIA1 and GRIA2 in their atherosclerotic lesions compared to asymptomatic patients. These results warrant further mapping of neurotransmitter signaling in the pathogenesis of human atherosclerosis.

Harnessing artificial intelligence in cardiac rehabilitation, a systematic review

Aim: This systematic review aims to evaluate the current body of research surrounding the efficacy of artificial intelligence (AI) in cardiac rehabilitation. Presently, AI can be incorporated into personal devices such as smart watches and smartphones, in diagnostic and home monitoring devices, as well as in certain inpatient care settings. Materials & methods: The PRISMA guidelines were followed in this review. Inclusion and exclusion criteria were set using the Population, Intervention, Comparison and Outcomes (PICO) tool. Results: Eight studies meeting the inclusion criteria were found. Conclusion: Incorporation of AI into healthcare, cardiac rehabilitation delivery, and monitoring holds great potential for early detection of cardiac events, allowing for home-based monitoring, and improved clinician decision making.