Cardiovascular Disease Prevention: Training Opportunities, the Challenges, and Future Directions

Cardiometabolic medicine: a review of the current proposed approaches to revamped training in the United States

Cardiovascular disease (CVD) remains the leading cause of mortality in the United States, and the population of patients with cardiometabolic conditions, including obesity, metabolic syndrome and diabetes mellitus, continues to grow. There is a need for physicians with specific training in cardiometabolic medicine to provide a ‘medical home’ for patients with cardiometabolic disease, rather than the fractured care that currently exists in the United States. Cardiometabolic specialists will head multidisciplinary clinics, develop practice guidelines, and lead through research. Proposals for US training in cardiometabolic medicine include: maintain the current training model, a dedicated 2–3 year fellowship following internal medicine residency, a 1-year fellowship following either internal medicine residency or fellowship in cardiology or endocrinology, and certification available to any interested clinician. This review discusses the pros and cons of these approaches. The authors believe that a dedicated cardiometabolic training fellowship has significant advantages over the other options.

Cardiovascular disease prevention career pathways: The status quo and future directions

Cardiovascular disease prevention is a complicated field requiring similar resource allocation and training as any other subspecialty in cardiology. To highlight the increasing need for primordial, primary and secondary cardiovascular disease prevention at a population level, it is necessary to have a clear vision for not only adequate training in the field but also sample career trajectories that today’s fellows-intraining (FIT) and early career (EC) physicians can use as a reference. However due to less centralized training, reduced exposure to the discipline and no clear institutional champions, direct access to “role model” careers in cardiovascular disease prevention may be lacking for today’s generation of trainees. These trends may change with more formalized recognition and more visibility of career trajectories in the field. In the current short report, we propose career pathways in cardiovascular disease prevention that can serve as a board resource roadmap for today’s FIT/EC physicians to design their careers in cardiovascular disease prevention. We explore three types of preventive cardiologists prototypes including; “the researcher”, “the clinician” and “the academic” preventive cardiologist models. These models are based on experiences gained in separate preventive cardiology training fellowships in addition to general cardiology training. Further, with advances in the scientific technologies, we highlight the future trajectory in the field. Preventive cardiology, although currently not the most desired path for FIT/EC physicians to pursue today, has the potential to be seen as the lucrative and essential training field in the future.

NOD2 induces VCAM-1 and ET-1 gene expression via NF-κB in human umbilical vein endothelial cells with muramyl dipeptide stimulation

OBJECTIVES

Endothelial dysfunction is involved in various aspects of vascular biology and different stages of cardiovascular diseases (CVDs). Nucleotide-binding oligomerization domain-containing protein (NOD) 2, a pivotal innate immune receptor for muramyl dipeptide (MDP), has been reported to be a central regulator in CVDs. Previously, we reported that NOD2 played a leading role in MDP-triggered oxidative stress in endothelial cells (ECs). However, whether NOD2 participates in the regulatory mechanism of vascular cell adhesion molecule‑1 (VCAM-1) and endothelin‑1 (ET-1) expression was not elucidated.

METHODS

Human umbilical vein endothelial cells (HUVECs) were stimulated with MDP for 12 h. mRNA expression of VCAM‑1 and ET‑1 was detected using real time polymerase chain reaction (PCR). Scrambled control small interfering RNA (siRNA) and NOD2 siRNA were transfected into HUVECs using Lipofectamine 2000 reagent (Invitrogen, Waltham, MA, USA). Furthermore, pyrrolidine dithiocarbamate was adopted to investigate the effect of nuclear factor κB (NF-κB) on NOD2-mediated VCAM‑1 and ET‑1 gene expression in MDP-treated HUVECs.

RESULTS

Data showed that MDP significantly increased VCAM‑1 and ET‑1 mRNA expression, which was dependent on NOD2. In addition, NF-κB inhibition suppressed NOD2-mediated gene expression of VCAM‑1 and ET‑1.

CONCLUSION

Collectively, we confirmed NOD2 aggravated VCAM‑1 and ET‑1 gene expression through NF-κB in HUVECs treated with MDP.

Salidroside-Mediated Autophagic Targeting of Active Src and Caveolin-1 Suppresses Low-Density Lipoprotein Transcytosis across Endothelial Cells

Subendothelial retention of apolipoprotein B100-containing lipoprotein, such as low-density lipoprotein (LDL), is the initial step of atherogenesis. Activation of autophagy exhibits beneficial effects for the treatment of atherosclerosis. In our previous study, we demonstrated that hyperglycemia suppressed autophagic degradation of caveolin-1, which in turn resulted in acceleration of caveolae-mediated LDL transcytosis across endothelial cells and lipid retention. Therefore, targeting the crossed pathway in autophagy activation and LDL transcytosis interruption may be a promising antiatherosclerotic strategy. In metabolic diseases, including atherosclerosis, salidroside, a phenylpropanoid glycoside compound (3,5-dimethoxyphenyl) methyl-β-glucopyranoside), is the most important compound responsible for the therapeutic activities of Rhodiola. However, whether salidroside suppresses LDL transcytosis to alleviate atherosclerosis has not yet been elucidated. In the present study, we demonstrated that salidroside significantly decreased LDL transcytosis across endothelial cells. Salidroside-induced effects were dramatically blocked by AMPK (adenosine monophosphate-activated protein kinase) inhibitor (compound c, AMPKα siRNA) and by overexpression of exogenous tyrosine-phosphorylated caveolin-1 using transfected cells with phosphomimicking caveolin-1 on tyrosine 14 mutant plasmids (Y14D). Furthermore, we observed that salidroside promoted autophagosome formation via activating AMPK. Meanwhile, the interaction between caveolin-1 and LC3B-II, as well as the interaction between active Src (indicated by the phosphorylation of Src on tyrosine 416) and LC3B-II, was significantly increased, upon stimulation with salidroside. In addition, both bafilomycin A₁ (a lysosome inhibitor) and an AMPK inhibitor (compound c) markedly prevented salidroside-induced autophagic degradation of p-Src and caveolin-1. Moreover, the phosphorylation of caveolin-1 on tyrosine 14 was disrupted due to the downregulation of p-Src and caveolin-1, thereby directly decreasing LDL transcytosis by attenuating the number of caveolae on the cell membrane and by preventing caveolae-mediated LDL endocytosis released from the cell membrane. In ApoE^−/− mice, salidroside significantly delayed the formation of atherosclerotic lesions. Meanwhile, a significant increase in LC3B, accompanied by attenuated accumulation of the autophagy substrate SQSTM1, was observed in aortic endothelium of ApoE^−/− mice. Taken together, our findings demonstrated that salidroside protected against atherosclerosis by inhibiting LDL transcytosis through enhancing the autophagic degradation of active Src and caveolin-1.

Cardiometabolic-Based Chronic Disease, Addressing Knowledge and Clinical Practice Gaps: JACC State-of-the-Art Review

In the second part of this JACC State-of-the-Art Review, an early and sustainable preventive care plan is described for cardiometabolic-based chronic disease. This plan can improve cardiometabolic health by targeting early mechanistic events to decrease the risk for certain cardiovascular diseases (e.g., coronary heart disease, heart failure, and atrial fibrillation). Included are various prevention modalities, intensive lifestyle interventions, pharmacotherapy and cardiovascular outcome trial evidence, and bariatric/metabolic procedures. A tactical approach of implementing published clinical practice guidelines/algorithms for early behavioral, adiposity, and dysglycemia targeting is emphasized, as well as relevant educational and research implications.

[Clinical and economic consequences in patients initiating therapy with clopidogrel brand-name vs. generic: A real-life retrospective study]

OBJECTIVE

To evaluate the adherence to treatment, resource use, and costs in subjects initiating treatment with brand-name versus generic clopidogrel for acute coronary syndrome (ACS) and peripheral arterial disease (PAD).

PATIENTS AND METHODS

Observational, retrospective study based on the medical records of patients aged ≥18 years who initiated treatment with clopidogrel (brand-name vs. generic) between 4 April 2015 and 31 March 2017. Four study groups were compared, and the follow-up was one year. The main measurements were: comorbidity, treatment adherence, medication possession ratio (MPR), resource use, and costs. The results were analysed using multivariate analysis. The level of statistical significance was P<.05.

RESULTS

Four groups were compared: a) ACS: brand-name clopidogrel (N=1,067) vs. generic (N=3,504), and b) PAD: brand-name clopidogrel (N=425) vs. generic (N=994). In the ACS comparison (mean age: 69.7 years, 61.4% male), adherence (65.3% vs. 61.0%, P<.001), adjusted hazard ratio 0.85 and MPR (89.8% vs. 86.7%, P=.045) were more superior with brand-name clopidogrel than with the generic and with a lower mean cost per unit (€2,890 vs. €3,865, P=.001). In the PAD comparison, similar results were observed: persistence (64.7% vs. 58.9%, P=.039); adjusted hazard-ratio 0.86 and MPR (88.6% vs. 81.7%; P=.013) were more superior with brand-name clopidogrel than for the generic, with a lower mean cost per unit (€2,880 vs. €3,532, P=.044).

CONCLUSIONS

There was better treatment adherence in patients initiating treatment with brand-name compared with generic clopidogrel for ACS and PAD, resulting in lower health costs for the Spanish National Health System.

Sini Decoction Intervention on Atherosclerosis via PPARγ-LXRα-ABCA1 Pathway in Rabbits

Aim

Sini decoction (SND) is a commonly used herbal formula showing lipid-lowering effects and is applied in traditional Chinese medicine (TCM) for the treatment of cardiovascular disease (CVD) and atherosclerosis (AS). However, the mechanisms behind its anti-atherosclerotic effects are still unknown, and will be investigated in this study.

Methods

AS was induced in rabbits by high fat diet (HFD) and treated with solvent (HFD group), atorvastatin (Ator group), or SND (SND group) for 12 weeks. Healthy rabbits (Chow group) were used as control. Serum and liver homogenates were collected, and lipid profiles as well as serum ApoA-I and ApoB were examined. Histopathological changes and lipid deposition in the proximal aorta and liver were detected by Oil red O staining. Western blot was used to detect the expression of ABCA1, ApoA-I, ApoB, PPARγ, and LXRα in liver, peritoneal macrophages, peripheral mononuclear cells (PMC), and adipose tissues.

Results

SND significantly attenuated the levels of total cholesterol (TC), triglyceride (TG), and low density lipoprotein cholesterol(LDL-C) in serum and liver. However, high density lipoprotein cholesterol (HDL-C) dramatically increased. SND treatment also decreased lipid deposition and improved the structure of the liver and aorta. Furthermore, SND enhanced the expression levels of ABCA1, PPARγ, and LXRα in liver, adipose tissues, PMC, and peritoneal macrophages. It also upregulated hepatic and serum ApoA-I expression and serum ApoA-I/ApoB ratio. CONCLUSIONS:SND treatment relieved AS, improved lipid profiles, and increased serum HDL-C level. The potential mechanism behind this might be the improvement of reverse cholesterol transport (RCT) involved with enhanced expression of ABCA1, ApoA-I, PPARγ, and LXRα.

Extracellular histones are the ligands for the uptake of exosomes and hydroxyapatite-nanoparticles by tumor cells via syndecan-4

The mechanisms by which exosomes (nano-vesicular messengers of cells) are taken up by recipient cells are poorly understood. We hypothesized that histones associated with these nanoparticles are the ligands which facilitate their interaction with cell surface syndecan-4 (SDC4) to mediate their uptake. We show that the incubation with fetuin-A (exosome-associated proteins) and histones mediates the uptake of exosomes that are normally not endocytosed. Similarly, hydroxyapatite-nanoparticles incubated with fetuin-A and histones (FNH) are internalized by tumor cells, while nanoparticles incubated with fetuin-A alone (FN) are not. The uptake of exosomes and FNH, both of which move to the perinuclear region of the cell, is attenuated in SDC4-knockdown cells. Data show that FNH can compete with exosomes for uptake and that both use SDC4 as uptake receptors.