Screening for early detection of cardiovascular disease in asymptomatic individuals

Tracking the Risk of Cardiovascular Disease after Almond and Oat Milk Intervene or Statin Medication with a Powerful Reflex SH-SAW POCT Platform

Cardiovascular disease (CVD) represents the leading cause of death worldwide. For individuals at elevated risk for cardiovascular disease, early detection and monitoring of lipid status is imperative. The majority of lipid measurements conducted in hospital settings employ optical detection, which necessitates the use of relatively large-sized detection machines. It is, therefore, necessary to develop point-of-care testing (POCT) for lipoprotein in order to monitor CVD. To enhance the management and surveillance of CVD, this study sought to develop a POCT approach for apolipoprotein B (ApoB) utilizing a shear horizontal surface acoustic wave (SH-SAW) platform to assess the risk of heart disease. The platform employs a reflective SH-SAW sensor to reduce the sensor size and enhance the phase-shifted signals. In this study, the platform was utilized to monitor the impact of a weekly almond and oat milk or statins intervention on alterations in CVD risk. The SH-SAW ApoB test exhibited a linear range of 0 to 212 mg/dL, and a coefficient correlation (R) of 0.9912. Following a four-week intervention period, both the almond and oat milk intervention (-23.3%, p < 0.05) and statin treatment (-53.1%, p < 0.01) were observed to significantly reduce ApoB levels. These findings suggest that the SH-SAW POCT device may prove a valuable tool for monitoring CVD risk, particularly during routine daily or weekly follow-up visits.

Association between health literacy and Framingham risk score

High health literacy (HL) plays a critical role in preventing or delaying the onset of cardiovascular diseases (CVDs) and can improve disease management and control. The present study aims to determine the association between HL and non-laboratory-based (office-based) Framingham 10-year risk score of CVD. This cross-sectional study was conducted on 648 people aged 30-65 in the health centers of Jahrom. The Health Literacy Instrument for Adults (HELIA) was used to assess HL. The non-laboratory-based Framingham risk score (FRS) was utilized to determine the 10-year risk of CVDs. Risk factors such as age, gender, diabetes, current smoking status, systolic blood pressure (SBP), hypertension (HTN) treatment, and body mass index (BMI) were applied in the non-laboratory-based model. The average age of the subjects was 44.7 ± 10.5 years, among which 49.2% were males. The prevalence of diabetes, HTN, and smoking equaled 8.5%, 15.7%, and 10%, respectively. In addition, the average BMI was 26.1 ± 3.6 kg/m2. Based on the non-laboratory-based Framingham 10-year risk score of CVD, 72.5%, 13.9%, and 13.6% of the subjects were in the low, moderate, and high risk groups, respectively. Based on the HL grouping, the levels of insufficient, borderline, sufficient, and excellent HL were 19.3%, 26.4%, 34.6%, and 19.7%, respectively. A significant association was observed between 10-year CVD risk and HL grouping. In addition, a negative correlation was reported at the individual level between HL and non-laboratory-based FRS among the whole population (r = - 0.39, p < 0.001), men (r = - 0.32, p < 0.001), and women (r = - 0.42, p < 0.001). A higher HL score is associated with a lower risk of CVD. In addition, the adjusted logistic regression analysis showed that there was a strong association between elevated CVD risk (≥ 10%) and HL (OR 6.1, 95% CI 2.9-12.6) among inadequate HL participants compared with excellent HL individuals. Thus, designing and implementing training programs to increase HL, especially among those who are at risk of CVDs, should be regarded as an important issue for the prevention of such diseases.

Review on Emerging Therapeutic Strategies for Managing Cardiovascular Disease

Cardiovascular disease (CVD) remains a foremost global health concern, necessitating ongoing exploration of innovative therapeutic strategies. This review surveys the latest developments in cardiovascular therapeutics, offering a comprehensive overview of emerging approaches poised to transform disease management. The examination begins by elucidating the current epidemiological landscape of CVD and the economic challenges it poses to healthcare systems. It proceeds to scrutinize the limitations of traditional therapies, emphasizing the need for progressive interventions. The core focus is on novel pharmacological interventions, including advancements in drug development, targeted therapies, and repurposing existing medications. The burgeoning field of gene therapy and its potential in addressing genetic predispositions to cardiovascular disorders are explored, alongside the integration of artificial intelligence and machine learning in risk assessment and treatment optimization. Non-pharmacological interventions take center stage, with an exploration of digital health technologies, wearable devices, and telemedicine as transformative tools in CVD management. Regenerative medicine and stem cell therapies, offering promises of tissue repair and functional recovery, are investigated for their potential impact on cardiac health. This review also delves into the interplay of lifestyle modifications, diet, exercise, and behavioral changes, emphasizing their pivotal role in cardiovascular health and disease prevention. As precision medicine gains prominence, this synthesis of emerging therapeutic modalities aims to guide clinicians and researchers in navigating the dynamic landscape of cardiovascular disease management, fostering a collective effort to alleviate the global burden of CVD and promote a healthier future.

Long-Term Cumulative Exposure to High γ-Glutamyl Transferase Levels and the Risk of Cardiovascular Disease: A Nationwide Population-Based Cohort Study

BACKGRUOUND

Elevated γ-glutamyl transferase (γ-GTP) levels are associated with metabolic syndrome. We investigated the association of cumulative exposure to high γ-GTP with the risk of cardiovascular disease (CVD) in a large-scale population.

METHODS

Using nationally representative data from the Korean National Health Insurance system, 1,640,127 people with 4 years of consecutive γ-GTP measurements from 2009 to 2012 were included and followed up until the end of 2019. For each year of the study period, participants were grouped by the number of exposures to the highest γ-GTP quartile (0-4), and the sum of quartiles (0-12) was defined as cumulative γ-GTP exposure. The hazard ratio for CVD was evaluated using the Cox proportional hazards model.

RESULTS

During the 6.4 years of follow-up, there were 15,980 cases (0.97%) of myocardial infarction (MI), 14,563 (0.89%) of stroke, 29,717 (1.81%) of CVD, and 25,916 (1.58%) of death. Persistent exposure to high γ-GTP levels was associated with higher risks of MI, stroke, CVD, and death than those without such exposure. The risks of MI, stroke, CVD, and mortality increased in a dose-dependent manner according to total cumulative γ-GTP (all P for trend <0.0001). Subjects younger than 65 years, with a body mass index <25 kg/m2, and without hypertension or fatty liver showed a stronger relationship between cumulative γ-GTP and the incidence of MI, CVD, and death.

CONCLUSION

Cumulative γ-GTP elevation is associated with CVD. γ-GTP could be more widely used as an early marker of CVD risk, especially in individuals without traditional CVD risk factors.

Variation in aorta attenuation in contrast-enhanced CT and its implications for calcification thresholds

Background

CT contrast media improves vessel visualization but can also confound calcification measurements. We evaluated variance in aorta attenuation from varied contrast-enhancement scans, and quantified expected plaque detection errors when thresholding for calcification.

Methods

We measured aorta attenuation (AoHU) in central vessel regions from 10K abdominal CT scans and report AoHU relationships to contrast phase (non-contrast, arterial, venous, delayed), demographic variables (age, sex, weight), body location, and scan slice thickness. We also report expected plaque segmentation false-negative errors (plaque pixels misidentified as non-plaque pixels) and false-positive errors (vessel pixels falsely identified as plaque), comparing a uniform thresholding approach and a dynamic approach based on local mean/SD aorta attenuation.

Results

Females had higher AoHU than males in contrast-enhanced scans by 65/22/20 HU for arterial/venous/delayed phases (p < 0.001) but not in non-contrast scans (p > 0.05). Weight was negatively correlated with AoHU by 2.3HU/10kg but other predictors explained only small portions of intra-cohort variance (R² < 0.1 in contrast-enhanced scans). Average AoHU differed by contrast phase, but considerable overlap was seen between distributions. Increasing uniform plaque thresholds from 130HU to 200HU/300HU/400HU produces respective false-negative plaque content losses of 35%/60%/75% from all scans with corresponding false-positive errors in arterial-phase scans of 95%/60%/15%. Dynamic segmentation at 3SD above mean AoHU reduces false-positive errors to 0.13% and false-negative errors to 8%, 25%, and 70% in delayed, venous, and arterial scans, respectively.

Conclusion

CT contrast produces heterogeneous aortic enhancements not readily determined by demographic or scan protocol factors. Uniform CT thresholds for calcified plaques incur high rates of pixel classification errors in contrast-enhanced scans which can be minimized using dynamic thresholds based on local aorta attenuation. Care should be taken to address these errors and sex-based biases in baseline attenuation when designing automatic calcification detection algorithms intended for broad use in contrast-enhanced CTs.

Electromechanical Wave Imaging With Machine Learning for Automated Isochrone Generation

Standard Electromechanical Wave Imaging isochrone generation relies on manual selection of zero-crossing (ZC) locations on incremental strain curves for a number of pixels in the segmented myocardium for each echocardiographic view and patient. When considering large populations, this becomes a time-consuming process, that can be limited by inter-observer variability and operator bias. In this study, we developed and optimized an automated ZC selection algorithm, towards a faster more robust isochrone generation approach. The algorithm either relies on heuristic-based baselines or machine learning classifiers. Manually generated isochrones, previously validated against 3D intracardiac mapping, were considered as ground truth during training and performance evaluation steps. The machine learning models applied herein for the first time were: i) logistic regression; ii) support vector machine (SVM); and iii) Random Forest. The SVM and Random Forest classifiers successfully identified accessory pathways in Wolff-Parkinson-White patients, characterized sinus rhythm in humans, and localized the pacing electrode location in left ventricular paced canines on the resulting isochrones. Nevertheless, the best performing classifier was proven to be Random Forest with a precision rising from 89.5% to 97%, obtained with the voting approach that sets a probability threshold upon ZC candidate selection. Furthermore, the predictivity was not dependent on the type of testing dataset it was applied to, contrary to SVM that exhibited a 5% drop in precision on the canine testing dataset. Finally, these findings indicate that a machine learning approach can reduce user variability and considerably decrease the durations required for isochrone generation, while preserving accurate activation patterns.

Mind-Body Connection: Cardiovascular Sequelae of Psychiatric Illness

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the world. Mental health disorders are associated with the onset and progression of cardiac disease. The adverse sequelae of this association include worsened quality of life, adverse cardiovascular outcomes, and heightened mortality. The increased prevalence of CVD is partly explained by increased rates of traditional cardiovascular risk factors including hypertension, hyperlipidemia, diabetes mellitus, obesity, and smoking, but mental illness is an independent risk factor for CVD and mortality. Given the association between mental health disorders and poor cardiovascular health, it is vital to have an early and accurate identification and treatment of these disorders. Our review article shares the current literature on the adverse cardiovascular events associated with psychiatric disorders. We present a review on depression, anxiety, bipolar disorder, schizophrenia, type A and D personality disorders, obsessive-compulsive disorder, and stress.

Arterial stiffness in underweight and weight-restored anorexia nervosa

Cardiovascular complications have been demonstrated in patients with anorexia nervosa (AN) in both the state of starvation and during weight restoration, however, the underlying mechanisms remain unclear. The current study aimed to assess arterial stiffness via carotid-femoral pulse wave velocity (cfPWV) in the acute and weight-restored states of AN. The study also aimed to determine the association between psychological distress and cfPWV. The sample included 37 participants; 10 participants with AN, 17 who were weight-restored (AN-WR; minimum body mass index >18.5 for at least 12 months) and 10 healthy controls (HCs). cfPWV via applanation tonometry was conducted to assess arterial stiffness. Psychological distress was assessed using the depression anxiety stress scale (DASS-21) and the state-trait anxiety inventory (STAI). Between-group comparisons were performed to determine differences between groups, a two-stage hierarchical regression model was performed to determine the contribution of physiological and psychological variables on cfPWV and correlation analyses were also performed. Vascular stiffness was significantly increased in the AN and AN-WR groups, relative to HCs. The total DASS score was the only significant predictor of cfPWV across the sample. There were positive associations between cfPWV and depression, anxiety and stress, as assessed by the DASS. Furthermore, cfPWV was positively associated with STAI trait anxiety. Arterial stiffness was increased in individuals in the acute and weight-restored states of AN, demonstrating early signs of the development of arteriosclerotic cardiovascular disease. Increased arterial stiffness was associated with increased psychological distress, which may be a contributing mechanism to the increased cardiovascular risk in AN.

Excess epicardial fat volume in women is a novel risk marker for microvascular dysfunction, which may be a contributing factor in the atypical chest pain syndrome

Background

Excess epicardial fat volume (EFV) has been recently implicated in cardiovascular structural and functional abnormalities. It has been associated with abnormal microvascular stiffness (as reflected by radial artery waveform; C2), which may result in microvascular dysfunction and contribute to the atypical chest pain syndrome without obstructive coronary artery disease (CAD). Women have been statistically shown to present with atypical chest pain more often than men and specifically without obstructive CAD. The aim of this study is to assess whether excess EFV in female subjects is associated with significant microvascular dysfunction (i.e., C2), in subjects without obstructive CAD.

Results

We screened 596 asymptomatic subjects, ages 20–79, using the Early Cardiovascular Health Risk Scoring System (ECVHRS), which has been reported. Out of the 596 total subjects, 230 subjects had a CACS. Out of these 230 subjects, 77 subjects (45 females; 32 males) had a 0 CACS. The 45 females from this cohort were the subjects of this study, and they were further categorized into 3 groups: group 1 (normal EFV, non-obese female subjects; n=16), females with ECVHRS < 3 and ACC/AHA risk score < 5%; group 2 (n = 9), females with elevated EFV and no abdominal visceral obesity; and group 3 (n=20), females with elevated EFV and abdominal visceral obesity. The average EFV was determined to be 72±20 cm³ among group 1, which indicates the values for normal EFV. The results in group 2 indicate that excess EFV is contributing to the development of microvascular dysfunction, resulting in abnormal micro-arterial (C2) elasticity (p< 0.00001), increase in resting blood pressure (p =0.0001), an abnormal rise in blood pressure (BP) at rest and post-mild protocol exercise (PME) (p = < 0.00001), and abnormal increase in carotid intima-media thickness (CIMT) (p = 0.000164).

Conclusion

Excess EFV appears to be not only a novel cardiovascular risk marker, but also the culprit for other cardiovascular risk markers. Based on these findings, elevated EFV may contribute to the development of the atypical chest pain syndrome in females without obstructive CAD. Additionally, EFV is emerging as a potential clinically relevant significant cardiovascular risk biomarker and may become a target to reduce cardiovascular morbidity and mortality.

Skin carotenoids status as a potential surrogate marker for cardiovascular disease risk determination in middle-aged and older adults

BACKGROUND AND AIMS

Upon consumption, carotenoids, which may attenuate cardiovascular disease (CVD) risk, diffuse from the blood and accumulate in the skin. This study aimed to assess the associations between dietary, plasma, and skin carotenoids with CVD risk indicators and to examine the mediational role of plasma carotenoids in the relationship between skin carotenoids status (SCS) and CVD risk.

METHODS AND RESULTS

Dietary, plasma, and skin carotenoids were assessed in a cross-sectional study from a community in Singapore (n = 103) aged 50 to 75 y. Multiple linear regression and binary logistics regression models were used to examine the associations between the carotenoids status with classical CVD risk factors and composite CVD risk indicators. After controlling for covariates, SCS and plasma carotenoids were inversely associated with systolic blood pressure (skin: P < 0.001; plasma: P < 0.05) and diastolic blood pressure (skin: P < 0.001; plasma: P < 0.005). Additionally, each increment of 1000 in SCS was associated with an odds ratio of 0.924 (P < 0.01) for metabolic syndrome diagnosis and 0.945 (P < 0.05) for moderate to high CVD risk classification. Associations between SCS and composite CVD risk indicators were null when adjusted for the corresponding plasma carotenoids, indicating complete mediation. Dietary carotenoids, however, showed no relationship with the CVD risk indicators.

CONCLUSION

Carotenoids bioavailability may be important for cardiovascular protection. SCS, driven by the corresponding plasma carotenoids, could be a potential noninvasive surrogate marker for CVD risk determination in middle-aged and older adults.

CLINICAL TRIAL REGISTRATION

NCT03554954, https://clinicaltrials.gov/.

TRIAL REGISTRATION DATE

13 June 2018.

Inflammation/bioenergetics-associated neurodegenerative pathologies and concomitant diseases: a role of mitochondria targeted catalase and xanthophylls

Various inflammatory stimuli are able to modify or even "re-program" the mitochondrial metabolism that results in generation of reactive oxygen species. In noncommunicable chronic diseases such as atherosclerosis and other cardiovascular pathologies, type 2 diabetes and metabolic syndrome, these modifications become systemic and are characterized by chronic inflammation and, in particular, "neuroinflammation" in the central nervous system. The processes associated with chronic inflammation are frequently grouped into "vicious circles" which are able to stimulate each other constantly amplifying the pathological events. These circles are evidently observed in Alzheimer's disease, atherosclerosis, type 2 diabetes, metabolic syndrome and, possibly, other associated pathologies. Furthermore, chronic inflammation in peripheral tissues is frequently concomitant to Alzheimer's disease. This is supposedly associated with some common genetic polymorphisms, for example, Apolipoprotein-E ε4 allele carriers with Alzheimer's disease can also develop atherosclerosis. Notably, in the transgenic mice expressing the recombinant mitochondria targeted catalase, that removes hydrogen peroxide from mitochondria, demonstrates the significant pathology amelioration and health improvements. In addition, the beneficial effects of some natural products from the xanthophyll family, astaxanthin and fucoxanthin, which are able to target the reactive oxygen species at cellular or mitochondrial membranes, have been demonstrated in both animal and human studies. We propose that the normalization of mitochondrial functions could play a key role in the treatment of neurodegenerative disorders and other noncommunicable diseases associated with chronic inflammation in ageing. Furthermore, some prospective drugs based on mitochondria targeted catalase or xanthophylls could be used as an effective treatment of these pathologies, especially at early stages of their development.

Computed Tomography Screening for Early Lung Cancer, COPD and Cardiovascular Disease in Shanghai: Rationale and Design of a Population-based Comparative Study

RATIONALE AND OBJECTIVES

To describe the rational and design of a population-based comparative study. The objective of the study is to assess the screening performance of volume-based management of CT-detected lung nodule in comparison to diameter-based management, and to improve the effectiveness of CT screening for chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD), in addition to lung cancer, based on quantitative measurement of CT imaging biomarkers in a Chinese screening setting.

MATERIALS AND METHODS

A population-based comparative study is being performed, including 10,000 asymptomatic participants between 40 and 74 years old from Shanghai urban population. Participants in the intervention group undergo a low-dose chest and cardiac CT scan at baseline and 1 year later, and are managed according to NELCIN-B3 protocol. Participants in the control group undergo a low-dose chest CT scan according to the routine CT protocol and are managed according to the clinical practice. Epidemiological data are collected through questionnaires. In the fourth year from baseline, the diagnosis of the three diseases will be collected.

RESULTS

The unnecessary referral rate will be compared between NELCIN-B3 and standard protocol for managing early-detected lung nodules. The effectiveness of quantitative measurement of CT imaging biomarkers for early detection of lung cancer, COPD and CVD will be evaluated.

CONCLUSION

We expect that the quantitative assessment of the CT imaging biomarkers will reduce the number of unnecessary referrals for early detected lung nodules, and will improve the early detection of COPD and CVD in a Chinese urban population.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03988322. Registered on 14 June 2019.

Early cardiovascular structural and functional abnormalities as a guide to future morbid events

Aims

Our aim was to evaluate the predictive value of a battery of 10 non-invasive tests of cardiovascular structural and functional health on the future risk of cardiovascular morbid events.

Methods and Results

A total of 1900 asymptomatic adults concerned about their risk for cardiovascular disease underwent non-invasive assessment with 10 tests of vascular and cardiac structure and function. A disease score (DS) was calculated for each individual based on these 10 tests. Follow-up (mean 9.2 years) for cardiovascular morbidity and mortality was available for 1442 individuals (mean age 53.2 years, 48.2% women). Those in the lowest DS tertile (0–2) experienced 0.16 cardiovascular events per 100 patient-years (PY), those in the middle tertile (3–5) experienced 0.86 events per 100 PY, and those in the highest tertile (6+) experienced 1.3 events per 100 PY (p &lt; .001). Sensitivity analysis, assuming a neutral effect of DS on projected events in subjects not followed, did not alter statistical significance. Risk assessment using the Framingham risk score (FRS) also predicted morbid events but the two methods differed in identifying individuals at high risk. The net reclassification index was improved by 0.11 (p = 0.01) when DS was added to FRS.

Conclusions

Assessing the biological disease process in the arteries and heart of asymptomatic adults provides a guide to the risk of a future cardiovascular morbid event. Larger and longer studies are needed to determine whether risk factor algorithms, the severity of the biological process or some combination is the optimal method for identifying individuals in need of intervention to delay morbid events.

Undiagnosed cardiovascular disease prior to cardiovascular death in individuals with severe mental illness

OBJECTIVE

To examine whether individuals with schizophrenia (SCZ) or bipolar disorder (BD) had equal likelihood of not being diagnosed with cardiovascular disease (CVD) prior to cardiovascular death, compared to individuals without SCZ or BD.

METHODS

Multivariate logistic regression analysis including nationwide data of 72 451 cardiovascular deaths in the years 2011-2016. Of these, 814 had a SCZ diagnosis and 673 a BD diagnosis in primary or specialist health care.

RESULTS

Individuals with SCZ were 66% more likely (OR: 1.66; 95% CI: 1.39-1.98), women with BD were 38% more likely (adjusted OR: 1.38; 95% CI: 1.04-1.82), and men with BD were equally likely (OR: 0.88, 95% CI: 0.63-1.24) not to be diagnosed with CVD prior to cardiovascular death, compared to individuals without SMI. Almost all (98%) individuals with SMI and undiagnosed CVD had visited primary or specialized somatic health care prior to death, compared to 88% among the other individuals who died of CVD.

CONCLUSION

Individuals with SCZ and women with BD are more likely to die due to undiagnosed CVD, despite increased risk of CVD and many contacts with primary and specialized somatic care. Strengthened efforts to prevent, recognize, and treat CVD in individuals with SMI from young age are needed.

Cardiovascular Disease Progression: A Target for Therapy?

Clinical research aimed at preventing cardiovascular disease has focused on the effect of interventions to reduce risk factors on the incidence of future morbid events. Disease progression, which likely serves as a necessary prerequisite for morbid events, has not served as a target for therapy. The Rasmussen Center at the University of Minnesota has, for the past 18 years, been performing a noninvasive cardiovascular evaluation in individuals with no history of cardiovascular disease. The studies, performed in 1 hour in one room, provide a comprehensive noninvasive assessment of the severity of functional and structural abnormalities in the small arteries, the large arteries and the left ventricle, the target organs for most cardiovascular morbid events. Preliminary follow-up data have revealed a striking relationship between the Disease Score, which represents the sum of the abnormal tests, and the risk of future morbid events. In order to develop strategies to prolong cardiovascular disease-free life expectancy, studies in early stages of disease aimed at slowing disease progression should be encouraged.

The role of noninvasive cardiovascular testing, applied clinical nutrition and nutritional supplements in the prevention and treatment of coronary heart disease

Numerous clinical trials suggest that we have reached a limit in our ability to decrease the incidence of coronary heart disease (CHD) and cardiovascular disease (CVD) utilizing the traditional diagnostic evaluation, prevention and treatment strategies for the top five cardiovascular risk factors of hypertension, diabetes mellitus, dyslipidemia, obesity and smoking. About 80% of heart disease (heart attacks, angina, coronary heart disease and congestive heart failure) can be prevented by optimal nutrition, optimal exercise, optimal weight and body composition, mild alcohol intake and avoiding smoking. Statistics show that approximately 50% of patients continue to have CHD or myocardial infarction (MI) despite presently defined 'normal' levels of the five risk factors listed above. This is often referred to as the 'CHD gap'. Novel and more accurate definitions and evaluations of these top five risk factors are required, such as 24 h ambulatory blood pressure (ABM) results, advanced lipid profiles, redefined fasting and 2 h dysglycemia parameters, a focus on visceral obesity and body composition and the effects of adipokines on cardiovascular risk. There are numerous traumatic insults from the environment that damage the cardiovascular system but there are only three finite vascular endothelial responses, which are inflammation, oxidative stress and immune vascular dysfunction. In addition, the concept of translational cardiovascular medicine is mandatory in order to correlate the myriad of CHD risk factors to the presence or absence of functional or structural damage to the vascular system, preclinical and clinical CHD. This can be accomplished by utilizing advanced and updated CV risk scoring systems, new and redefined CV risk factors and biomarkers, micronutrient testing, cardiovascular genetics, nutrigenomics, metabolomics, genetic expression testing and noninvasive cardiovascular testing.

Effect of nebivolol or atenolol vs. placebo on cardiovascular health in subjects with borderline blood pressure: the EVIDENCE study

Pharmacotherapy to protect the arteries may be appropriate for individuals with high-normal blood pressure who are at risk for future cardiovascular disease (CVD). Nebivolol (NEB) in contrast to atenolol (ATE) may have a beneficial effect on endothelial function and may be more effective than ATE in preventing CVD. Sixty subjects with preHTN or borderline BP and abnormal small artery elasticity (SAE) underwent evaluation with 10 tests, including large and small artery elasticity, resting and treadmill exercise BP, carotid intimal-media thickness, retinal vascular photography, micro-albuminuria, electrocardiography, echocardiography, and plasma B-type natriuretic peptide level. Each test scored as normal (0), borderline (1), or abnormal (2), and the total disease score (DS) was calculated by adding the test scores. Subjects were randomized double-blind to placebo (PLAC, n = 22), NEB 5/10 mg/day (n = 20), or ATE 25/50 mg/day (n = 18) once daily for 9 months. After 9 months, in the group receiving NEB the mean (standard deviation) DS decreased from baseline 4.3 (2.6) to 2.8 (2.4) (P < 0.007), with ATE from 5.4 (2.5) to 3.5 (1.9) (P = 0.0006), and with PLAC from 5.2 (3.0) to 4.5 (2.6) (P = 0.18). SAE increased in the NEB group from 6.0 (2.2) to 8.4 (3.4) ml/mmHg × 100 (P = 0.0001), whereas there was no significant change in the ATE and PLAC groups. Thus, nebivolol improves small artery function more than atenolol in asymptomatic subjects with preHTN or borderline BP, despite their similar BP-lowering effect.

Study to Predict Vascular Dysfunctions in High Risk Young Adults- An Immediate Non-Invasive Investigation to Prevent Early Vascular Ageing

INTRODUCTION

Normal vascular is associated with gradual change of vascular structure and function, resulting in increased arterial stiffening and decreased arterial compliance. Arterial stiffness is a marker of vascular ageing and a predictor of cardiovascular events. Premature or early vascular ageing is measured by pulse wave velocity or the arterial augmentation index based on pulse wave analysis.

AIM

To study the predictor of vascular dysfunctions in high risk young adult offsprings of type 2 diabetes mellitus and hypertensive parents.

MATERIALS AND METHODS

The analytical cross-sectional studies were carried out in 90 subjects (45 males and 45 females), aged 18-25 years. They were divided into three groups based on their family history, known case of type 2 DM or hypertension in their parents. Group 1- control, Group 2- DM, Group 3-Hypertensive. In all subjects, anthropometrical data, blood pressure and peripheral pulse wave velocity were measured. One-way ANOVA was applied to determine the predictor factors of pulse wave velocity within and between groups. The following parameters were included in these analyses: age, gender, body mass index, hip waist index, heart rate, blood pressure and pulse wave velocity.

RESULTS

A post-test analysis revealed that peripheral pulse wave velocity (PWV), early part of systolic phase (P1) was increased significantly than later part systolic phase (P2), p-value in both diabetic and hypertensive groups were compared with control group. (p≤0.001, ANOVA) Augmentation index (P2/P1) was also increased significantly in both diabetic and hypertensive groups than control group (p≤0.001, ANOVA).

CONCLUSION

The findings of present study suggest that, although related, peripheral augmentation index AIx and PWV provide early identification of high risk groups. Implication of life style modification is the first intervention to consider in adults followed by drug therapy to control risk factors. Specifically, AIx might provide a more sensitive marker of arterial aging in younger individuals.

Prevention of cardiovascular disease

Meaningful prevention of cardiovascular disease (CVD) requires prolongation of life to age 90 or 100 free of morbid events. This requires early detection of the CVD phenotypes and effective treatment to slow their progression. We present a strategy for screening and evaluation of the population that should accomplish that goal with potential benefits on both cost and cardiovascular health. Studies to document the effectiveness of this strategy are urgently needed.

WE-CARE: an intelligent mobile telecardiology system to enable mHealth applications

Recently, cardiovascular disease (CVD) has become one of the leading death causes worldwide, and it contributes to 41% of all deaths each year in China. This disease incurs a cost of more than 400 billion US dollars in China on the healthcare expenditures and lost productivity during the past ten years. It has been shown that the CVD can be effectively prevented by an interdisciplinary approach that leverages the technology development in both IT and electrocardiogram (ECG) fields. In this paper, we present WE-CARE , an intelligent telecardiology system using mobile 7-lead ECG devices. Because of its improved mobility result from wearable and mobile ECG devices, the WE-CARE system has a wider variety of applications than existing resting ECG systems that reside in hospitals. Meanwhile, it meets the requirement of dynamic ECG systems for mobile users in terms of the detection accuracy and latency. We carried out clinical trials by deploying the WE-CARE systems at Peking University Hospital. The clinical results clearly showed that our solution achieves a high detection rate of over 95% against common types of anomalies in ECG, while it only incurs a small detection latency around one second, both of which meet the criteria of real-time medical diagnosis. As demonstrated by the clinical results, the WE-CARE system is a useful and efficient mHealth (mobile health) tool for the cardiovascular disease diagnosis and treatment in medical platforms.

Is it the blood pressure or the blood vessel?

The physiologic link between vascular health and arterial pressure makes it difficult to separate the adverse effects of pressure and vascular functional and structural alterations in determining the adverse complications of hypertension. Since endothelial dysfunction and nitric oxide deficiency are characteristic features of hypertension and of other risk factors for morbid events, it is proposed that blood pressure elevation may be viewed in part as a complication of functional and structural changes in the microcirculation, and that structural changes in the conduit arteries leading to morbid events may be viewed as a complication of both pressure elevation and endothelial dysfunction. Improvement in endothelial dysfunction will relax the microcirculation and lower blood pressure. Thus pressure elevation and its lowering in resposne to treatment serves as a useful guide to the vascular abnormality and its amelioration, but vascular structural abnormalities are the proximate cause of vascular events and therapy aimed at the vasculature rather than the pressure may serve as a more sensitive and specific guide to treatment.

Underuse of cardiovascular preventive pharmacotherapy in patients presenting with ST-elevation myocardial infarction

BACKGROUND

Multiple medications have proven efficacy for the primary prevention of coronary heart disease (CHD), but the appropriate patient population remains controversial. Even in the presence of multiple cardiovascular risk factors, many patients are not considered high risk and are not offered preventive medications despite proven efficacy.

METHODS

We analyzed a prospective cohort of 1,710 consecutive ST-elevation myocardial infarction (STEMI) patients treated in a regional STEMI system from May 2007 to July 2010 and enrolled in a comprehensive database that includes preadmission medications.

RESULTS

Of the 1,707 patients analyzed, 1,180 (69.1%) did not have known CHD before their event; and 482 (41.7%) of those patients had premature events (men <55 years old, women <65 years old). In patients without known CHD, cardiovascular risk factors were abundant (52.1% had hypertension, 43.6% had dyslipidemia, 41.4% had a family history of CHD, 58.5% were current or former smokers, and 14.9% were diabetic). Despite the high prevalence of risk factors, only 24.1% were on aspirin, 16.1% were on a statin, and only 7.8% were taking an aspirin and statin. Use of preventive medications was even less common in patients with premature events, including aspirin (15.2% vs 30.2%, P value < .001), statins (11.1% vs 19.5%, P value < .001), and the combination (5.6% vs 9.4%, P value < .001).

CONCLUSIONS

Approximately 70% of a contemporary STEMI population did not have known CHD before their event, and >40% of those events would be considered premature. Despite the significant burden of cardiovascular risk factors, use of preventive therapy was alarmingly low in patients presenting with STEMI.

Touch screen computer health assessment in Australian general practice patients: a cross-sectional study protocol

INTRODUCTION

Cardiovascular disease (CVD) and cancer are leading causes of death globally. Early detection of cancer and risk factors for CVD may improve health outcomes and reduce mortality. General practitioners (GPs) are accessed by the majority of the population and play a key role in the prevention and early detection of chronic disease risk factors. This cross-sectional study aims to assess the acceptability of an electronic method of data collection in general practice patients. The study will describe the proportion screened in line with guidelines for CVD risk factors and cancer as well as report the prevalence of depression, lifestyle risk factors, level of provision of preconception care, cervical cancer vaccination and bone density testing. Lastly, the study will assess the level of agreement between GPs and patients perception regarding presence of risk factors and screening.

METHODS AND ANALYSIS

The study has been designed to maximise recruitment of GPs by including practitioners in the research team, minimising participation burden on GPs and offering remuneration for participation. Patient recruitment will be carried out by a research assistant located in general practice waiting rooms. Participants will be asked regarding the acceptability of the touch screen computer and to report on a range of health risk and preventive behaviours using the touch screen computer. GPs will complete a one-page survey indicating their perception of the presence of risk behaviours in their patients. Descriptive statistics will be generated to describe the acceptability of the touch screen and prevalence of health risk behaviours. Cohen's κ will be used to assess agreement between GP and patient perception of presence of health risk behaviours.

ETHICS AND DISSEMINATION

This study has been approved by the human research committees in participating universities. Findings will be disseminated via peer-reviewed publications, conference presentations as well as practice summaries provided to participating practices.

Arterial stiffness is associated with minimally elevated high-sensitivity cardiac, troponin T levels in a community-dwelling population

OBJECTIVES

Arterial stiffness predicts an increased risk of future cardiovascular events, possibly via myocardial damage. Minimally elevated levels of plasma cardiac troponin T (TnT), a marker of cardiomyocyte injury, can be detected by the high-sensitivity TnT (hsTnT) assay. The current study investigated the relationship between plasma hsTnT levels and alterations in arterial stiffness in a community-based population.

METHODS

We related levels of plasma hsTnT to measures of arterial stiffness (carotid-femoral pulse wave velocity [PWV], office pulse pressure [PP] and carotid-radial PWV) in 1479 participants (mean age, 62.3 years; 619 men, 860 women) from a community-based population in Beijing, China.

RESULTS

In multiple logistic regression models, carotid-femoral PWV (OR: 1.84; 95% CI: 1.06-3.17; P=0.028) and office PP (OR: 2.02; 95% CI: 1.31-3.11; P=0.002) were associated with a higher likelihood of detectable hsTnT. In addition, carotid-femoral PWV (OR: 2.34; 95% CI: 1.03-5.30; P=0.042) and office PP (OR: 2.30; 95% CI: 1.13-4.66; P=0.022) were significantly related to elevated hsTnT levels. A subsequent subgroup analysis found that, in subjects aged 60 years and older, the associations between carotid-femoral PWV and office PP and hsTnT levels were strengthened. The associations between hsTnT with any of the arterial stiffness measures were not present in the younger subgroup (<60 years old).

CONCLUSIONS

Carotid-femoral PWV and office PP are associated with minimally elevated hsTnT levels in the elderly, indicating a relationship between central artery stiffness and subclinical myocardial damage.

Socio-medical Characteristics of Coronary Disease in Bosnia and Herzegovina and the World

INTRODUCTION

Coronary heart disease and its etiology are complex socio-medical and clinical problem in this century. World Health Organization defined coronary artery disease as acute and chronic heart ailments due to disruption of flow and myocardial blood supply. Diseases of the cardiovascular system in spite of preventable risk factors are responsible for approximately 50% of all deaths in the developed world, and this ratio is higher in developing countries.

RISK FACTORS

CORONARY HEART DISEASE RISK FACTORS CAN BE DIVIDED IN THOSE WHICH ARE NOT PREVENTABLE SUCH AS: personal and family history of cardiovascular diseases, age and gender and preventable risk factors including: high blood pressure, elevated blood cholesterol, smoking, reduced physical activity, elevated blood sugar, increased body weight, alcohol use, psychosocial factors and nutrition. There are also newly emerging risk factors which includes increased homocysteine, thrombogenic and inflammatory factors. Prevention of coronary heart disease risk factors: The concept of risk assessment factors, their reduction, initially begun in the Framingham Heart Study and refined in other models. Primary prevention relates to changing lifestyle and influencing preventable risk factors. Numerous studies and meta-analysis showed that lifestyle modification, risk reduction factors, particularly by changing diet, stopping smoking, increasing physical activity, blood pressure control can be effective in the prevention and reduction of coronary heart disease. Primary health care physicians i.e. family physicians need to take an active role in assessment of risk factors for coronary heart disease.

CONCLUSION

The data in this paper, based on the findings from other studies, suggest the importance of using a modified algorithm in order to estimates the overall risk of coronary disease in high-risk groups among the patients in the primary health care settings.

Visceral adiposity and arterial stiffness: echocardiographic epicardial fat thickness reflects, better than waist circumference, carotid arterial stiffness in a large population of hypertensives

AIMS

Relationship between obesity and cardiovascular (CV) disease depends not only on the amount of body fat, but also on its distribution. For example, individuals with increased fat accumulation in the abdominal region have atherogenic lipid profiles and are at increased CV risk. The loss of elasticity in medium and large arteries is an early manifestation of atherosclerosis. The aim of this study was to evaluate whether echocardiographic epicardial adipose tissue, an index of cardiac adiposity, is related to carotid stiffness and carotid intima-media thickness (IMT), indexes of subclinical atherosclerosis, better than waist circumference in hypertensive patients.

METHODS AND RESULTS

We studied 459 patients with Grade I and II essential hypertension who were referred to our outpatient clinic over a period from May 2007 to March 2008. The population was first sorted by waist circumference and then by epicardial fat < or = 7 or >7 mm. We measured epicardial fat thickness, waist circumference, carotid artery stiffness, and carotid IMT in all patients. Patients divided according to waist circumference showed no statistical differences in carotid artery stiffness between the two groups. Subjects with epicardial fat >7 mm were older, had higher systolic, diastolic, and pulse pressure, increased left ventricular mass index, carotid IMT, diastolic parameters, and stiffness parameters compared with those with epicardial fat < or = 7 mm (P < 0.001). A positive correlation was found between epicardial fat and age, pulse pressure, stiffness parameters, carotid IMT, systolic blood pressure, and duration of hypertension, and a negative correlation was found with diastolic parameters. Age, carotid IMT, and stiffness parameters were independently related to epicardial fat.

CONCLUSION

Our findings indicate that epicardial fat reflects carotid artery stiffness in hypertension-induced organ damage.

Unconventional end points in cardiovascular clinical trials: should we be moving away from morbidity and mortality?

BACKGROUND

Mortality and irreversible or major morbid events are the end points conventionally chosen for cardiovascular clinical trials because they are considered to reflect the effects of intervention on the natural history of disease. Other end points are now being considered and implemented because of the recognized limitations associated with using mortality and morbidity as the sole measures of therapeutic efficacy.

METHODS AND RESULTS

This article reflects the discussion and recommendations regarding nontraditional end points for cardiovascular trials generated from a meeting of clinical trial experts convened to discuss this issue. Less common end points that have been used in cardiovascular clinical trials include composite clinical scores integrating measures of quality of life with mortality and morbidity or using the function of vital organs as end points. Appropriate measurement and applications of such end points is controversial.

CONCLUSIONS

More experience is needed in applying and analyzing results with these nontraditional end points to enable their optimal use in clinical trials in cardiology, but such approaches have the potential to redress many of the conceptual and actual deficiencies inherent in conventional measures of outcome.

Psychological stress, insulin resistance, inflammation and the assessment of heart disease risk. Time for a paradigm shift?

There is growing evidence that the present risk assessment protocol for coronary heart disease appears to underestimate the risk in general and the presence and progression of atherosclerosis in particular. Little or no correlation has been found between the 10-year risk based on the Framingham model and the extent or progression of coronary calcification. In addition, a number of studies find the protocol based on current guidelines leads to an under appreciation of the risk of symptomatic coronary heart disease or the associated fatal and non-fatal events, especially in younger asymptomatic individuals and women. Furthermore, the current guidelines give secondary importance to insulin resistance and inflammation and do not include psychosocial stress and depression, both of which are established and important risk factors for coronary heart disease. An alternative approach to risk assessment is proposed which emphasizes insulin resistance and psychological stress and depression and gives much greater recognition to inflammation as a root cause and target for intervention than is found in current guidelines. Consistent with this view, a revised assessment protocol is suggested which is still appropriate to the primary care setting and which might provide a different and perhaps more effective and relevant approach to primary prevention and risk reduction.

Beneficial Effects of Valsartan in Asymptomatic Individuals With Vascular or Cardiac Abnormalities

OBJECTIVES

We studied the efficacy of valsartan (Val) to slow cardiovascular disease progression in asymptomatic high-risk prehypertensive or hypertensive patients with blood pressure (BP) controlled to <140/90 mm Hg and with evidence for functional or structural alterations in the cardiovascular system.

BACKGROUND

Identifying individuals with early markers for cardiovascular disease raises the possibility for pharmacotherapy to slow progression and delay or prevent future morbid events.

METHODS

Seventy-six subjects with a Rasmussen Disease Score (RDS) of 6 or higher were randomized double-blind to receive placebo (Plac) or Val 160 mg once daily for 6 months followed by 6 months of single-blind Val in both groups. A panel of 10 tests, including large and small artery elasticity, resting and treadmill exercise BP, carotid intimal-media thickness, retinal vascular photography, micro-albuminuria, electrocardiography, echocardiography, and plasma B-type natriuretic peptide, was performed at baseline and after 6 and 12 months of treatment. Each test result was scored as normal (0), borderline (1), or abnormal (2), and the total RDS was calculated by adding all the scores of the individual tests.

RESULTS

Valsartan significantly reduced the RDS after 6 months versus Plac (p < 0.03) and at 12 months (either 12 or 6 months of Val, p < 0.0001). The major contribution in risk score reduction was due to an increase in small artery elasticity and a decrease in BP, and after 12 months there was a reduction in left ventricular mass index (p < 0.03).

CONCLUSIONS

Valsartan can slow progression and/or reverse early cardiovascular disease in asymptomatic high-risk patients with prehypertension or BP controlled to <140/90 mm Hg.

What is the role of angiotensin-receptor blockade in cardiovascular protection?

The role of angiotensin II, the key mediator of the renin-angiotensin-aldosterone system, in the pathophysiology of cardiovascular disease is well known. Pharmacologic interruption of the activity of angiotensin II, either through blockade of the angiotensin receptor or inhibition of angiotensin-converting enzyme, is associated with a reduction in cardiovascular disease morbidity and mortality, as evidenced by accumulated data from large-scale, well-controlled clinical trials in high-risk populations. As the underlying mechanisms of vascular disease and the effects of blockade of the renin-angiotensin-aldosterone system on these processes have been further defined, the therapeutic focus has begun to shift toward prevention of disease progression at earlier stages. Continued research has identified early signs of vascular disease, such as endothelial dysfunction and vascular and cardiac remodeling, which occur long before clinical manifestations of cardiovascular disease become evident. Diagnostic tests are now available to assess otherwise healthy individuals for these signs. A preliminary trial is under way to evaluate the role of angiotensin receptor blockade as preventive treatment of individuals with early signs of vascular or cardiac disease.

Efficacy and Safety in Clinical Trials in Cardiovascular Disease

Mortality and morbid events are insensitive guides to the efficacy and safety of interventions in chronic cardiovascular disease (CVD). To enhance the ability to find new and effective long-term treatments, especially for the early stages of CVD, a revised strategy for clinical trials should emphasize efficacy on disease progression while monitoring symptoms and quality of life as guides to clinical benefit. Mortality, which is uncommon except in acute or advanced disease, provides at best a crude guide to net efficacy and safety. It must be monitored to support demonstrated efficacy on disease progression without adverse safety effects. This revised approach, made possible by our enhanced ability to monitor the progression of disease, should make it possible to study earlier disease and to improve cardiovascular health while reducing health care costs.

Monitoring vascular health beyond blood pressure

It is well recognized that vascular changes, including atherosclerosis, begin early in life as a silent, asymptomatic disease process and are associated with cardiovascular (CV) risk factors. Importantly, CV risk factors persist or track from childhood to adulthood and are predictive of CV disease risk in adults. Evaluation of arterial stiffness and its predictors may help identify asymptomatic individuals at risk, before blood pressure is elevated above an "arbitrary" level that we currently identify as hypertension. Currently, measurements of arterial stiffness are being used in the research setting and also as part of cardiovascular risk prediction clinics. As the various techniques become more widely available, it is conceivable that the measurement of arterial stiffness could become an important part of the routine assessment of patients in daily practice, as a supplement to blood pressure measurement. Measurement of arterial stiffness will not only be helpful in the detection of early vascular disease but also will be a tool in the follow-up monitoring of strategies aimed at preventing hypertension or reducing further progression of vascular disease before blood pressure elevation can be detected.

Utility of brain natriuretic peptide (BNP) measurement in cardiovascular disease

Cardiac failure is a prevalent and costly condition in Western society. The ageing of the population, together with current medical options which improve, rather than eradicate heart failure, lead to the projection that this problem will increase substantially in the foreseeable future. The availability of a simple test to assist the diagnosis and effective management of heart failure would greatly assist the clinical approach to this problem. This review examines the physiological basis for the measurement of natriuretic peptides as markers of the presence or risk of heart failure. It considers its use in the hospital and non-hospital setting and examines the cost-effectiveness of current assays. It is possible that in future natriuretic peptides may offer a form of treatment for heart failure, but this is beyond the scope of this review. Nevertheless, the review highlights the potential benefits of this group of tests in the management of heart failure.

Markers for silent myocardial ischemia in diabetes. Are they helpful?

Silent myocardial ischemia (SMI) and silent coronary stenoses (CS) are two to seven times more frequent in diabetic patients than in non-diabetic patients. In addition to this, they have a higher predictive value for cardiovascular events than the classical cardiovascular risk factors, either taken alone or combined. Coronary arterial disease is the leading cause of mortality and morbidity in the diabetic population. Altogether, these data suggest that screening for SMI and silent CS is an important issue. We assume that detecting SMI and silent CS improves patient management, and leads to optimised follow-up, action taken on nutrition, exercise and lifestyle, management of the cardiovascular risk factors, and revascularisation procedures whenever possible. However, screening for SMI and silent CS is expensive and may induce morbidity. Selecting the patients with a high a priori risk of SMI and silent CS is therefore of major concern. Carotid or lower limb peripheral arterial disease, proteinuria, male gender, an age greater than 60 years, and two or more cardiovascular risk factors among smoking, microalbuminuria, dyslipidemia, hypertension, a family history of premature cardiac disease, and cardiac autonomic neuropathy have been demonstrated to be the best current predictors of SMI and silent CS. New markers, such as adhesion molecules, Lp(a), inflammation parameters or homocysteine, and endothelium function assessment might be of further help in the future.