European Society of Cardiology: cardiovascular disease statistics 2021

Psychometric Testing of the Mutuality Scale in Patients and Caregiver Dyads After the Onset of Coronary Heart Disease

This study investigates the psychometric properties of the Mutuality Scale in a sample of patient-caregiver dyads following a recent episode of coronary heart disease. A cross-sectional analysis was conducted. Factorial validity was tested with confirmatory factory analysis. Internal consistency reliability was investigated with the model-based internal consistency reliability index. Pearson's correlation coefficient was used to test convergent validity between mutuality and other theoretical and empirical variables associated with it. We included 150 patient-caregiver dyads (patient: mean age 65 years, 77% males, 71% married; caregiver: mean age 54 years, 21% males, 71% married). The CFA testing the theoretical four-factors (love, shared pleasurable activities, shared values, and reciprocity) of mutuality demonstrated adequate fit to the data in both the patient and caregiver version of the scale. Reliability estimates were adequate for the whole scale (model-based internal consistency index = 0.95). Significant positive correlations were observed between mutuality and self-care behaviors, and caregiver preparedness, supporting convergent validity. The Mutuality Scale demonstrated satisfactory structural and convergent validity and reliability in patient-caregiver dyads after the onset of a coronary heart disease event.

SIRE: Scale-invariant, rotation-equivariant estimation of artery orientations using graph neural networks

The orientation of a blood vessel as visualized in 3D medical images is an important descriptor of its geometry that can be used for centerline extraction and subsequent segmentation, labeling, and visualization. Blood vessels appear at multiple scales and levels of tortuosity, and determining the exact orientation of a vessel is a challenging problem. Recent works have used 3D convolutional neural networks (CNNs) for this purpose, but CNNs are sensitive to variations in vessel size and orientation. We present SIRE: a scale-invariant rotation-equivariant estimator for local vessel orientation. SIRE is modular and has strongly generalizing properties due to symmetry preservations. SIRE consists of a gauge equivariant mesh CNN (GEM-CNN) that operates in parallel on multiple nested spherical meshes with different sizes. The features on each mesh are a projection of image intensities within the corresponding sphere. These features are intrinsic to the sphere and, in combination with the gauge equivariant properties of GEM-CNN, lead to SO(3) rotation equivariance. Approximate scale invariance is achieved by weight sharing and use of a symmetric maximum aggregation function to combine predictions at multiple scales. Hence, SIRE can be trained with arbitrarily oriented vessels with varying radii to generalize to vessels with a wide range of calibres and tortuosity. We demonstrate the efficacy of SIRE using three datasets containing vessels of varying scales; the vascular model repository (VMR), the ASOCA coronary artery set, and an in-house set of abdominal aortic aneurysms (AAAs). We embed SIRE in a centerline tracker which accurately tracks large calibre AAAs, regardless of the data SIRE is trained with. Moreover, a tracker can use SIRE to track small-calibre tortuous coronary arteries, even when trained only with large-calibre, non-tortuous AAAs. Additional experiments are performed to verify the rotational equivariant and scale invariant properties of SIRE. In conclusion, by incorporating SO(3) and scale symmetries, SIRE can be used to determine orientations of vessels outside of the training domain, offering a robust and data-efficient solution to geometric analysis of blood vessels in 3D medical images.

Sex Differences in the Relationship of Socioeconomic Position With Cardiovascular Disease, Cardiovascular Risk Factors, and Estimated Cardiovascular Disease Risk: Results of the German National Cohort

BACKGROUND

Using data from the largest German cohort study, we aimed to investigate sex differences in the relationship of socioeconomic position (SEP) with cardiovascular disease (CVD), CVD risk factors, and estimated CVD risk.

METHODS AND RESULTS

A total of 204 780 (50.5% women) participants from the baseline examination of the population-based NAKO (German National Cohort) were included. Logistic, multinomial, and linear regression models were used to estimate sex-specific odds ratios (ORs) and β coefficients with 95% CIs of CVD, CVD risk factors, and very high-risk score (Systemic Coronary Risk Estimation-2) for CVD associated with SEP. Women-to-men ratios of ORs (RORs) with 95% CIs were estimated. In women compared with men, low versus high SEP (educational attainment and relative income) was more strongly associated with myocardial infarction, hypertension, obesity, overweight, elevated blood pressure, antihypertensive medication, and current alcohol consumption, but less strongly with current and former smoking. In women with the lowest versus highest educational level, the OR for a very high 10-year CVD risk was 3.61 (95% CI, 2.88-4.53) compared with 1.72 (95% CI, 1.51-1.96) in men. The women-to-men ROR was 2.33 (95% CI, 1.78-3.05). For the comparison of low versus high relative income, the odds of having a very high 10-year CVD risk was 2.55 (95% CI, 2.04-3.18) in women and 2.25 (95% CI, 2.08-2.42) in men (women-to-men ROR, 1.31 [95% CI, 1.05-1.63]).

CONCLUSIONS

In women and men, there was an inverse relationship between indicators of SEP and the likelihood of having several CVD risk factors and a very high 10-year CVD risk. This association was stronger in women, suggesting that CVD risk is more strongly influenced by SEP in women compared with men.

Novel metabolic indicators and the risk of cardiovascular disease in patients with hypertension: A primary-care cohort study

BACKGROUND AND AIMS

Data are limited on whether several easily measured indices serve as effective tools for Cardiovascular disease (CVD) risk assessment in hypertensive patients. This study aimed to assess the associations of metabolic score for insulin resistance (METS-IR), lipid accumulation product (LAP), and visceral adiposity index (VAI) with CVD risk in hypertensive patients.

METHODS AND RESULTS

Our data were drawn from the medical records of primary-care institutions in China. The present study included 306,680 individuals with hypertension attending primary healthcare centers. Cox regression analyses were applied to assess the associations of novel metabolic indicators with the risk of CVD. During a median follow-up of 1.98 years, 5820 participants developed CVD. When comparing with the lowest quartile of the indices, the highest quartile of METS-IR, LAP, and VAI was associated with 1.25-fold (95 % CI: 1.16-1.35), 1.15-fold (95 % CI: 1.05-1.25), and 1.19-fold (95 % CI: 1.10-1.28) risk of CVD after adjusting for potential confounders.

CONCLUSION

This study provided additional evidence that novel metabolic indicators like METS-IR, LAP, and VAI were associated with the risk of CVD. These results suggest that proactive assessment of visceral adiposity and insulin resistance could be helpful for the effective clinical management of the hypertensive population.

Global burden of non-rheumatic valvular heart disease in older adults (60-89 years old), 1990-2019: Systematic analysis of the Global Burden of Disease Study 2019

BACKGROUND

Understanding the global burden and risk factors of non-rheumatic valvular heart disease (NRVHD) in older adults is important for effective disease control. We wanted to analyze the prevalence, incidence, disability-adjusted life years (DALY) rate, mortality rate, and risk factors of NRVHD in older adults aged 60-89 years.

METHODS

Global Burden of Disease Study (GBD) 2019 was used as the data source. Age standardized incidence rate, prevalence, DALY rate, and mortality rate of NRVHD among older adults aged 60-89 years from 1990 to 2019. We analyzed different age groups, genders, regions, sociodemographic index (SDI) across 204 countries/territories. Proportional DALY and mortality attributable to risk factors were calculated.

RESULTS

Globally, age-standardized DALY rate (per 100,000 population) for NRVHD in older adults decreased significantly from 44.46 (95 % confidence interval 39.95 to 49.18) in 1990 to 35.94 (32.32 to 40.19) in 2019 with an average annual percent change (AAPC) of -0.19 % (-0.24 % to -0.14 %), and the mortality rate also decreased significantly from 2.48 (2.21 to 2.64) to 2.25 (1.89 to 2.47) with an AAPC of -0.09 % (-0.16 % to -0.03 %,). However, the age-standardized incidence rate (per 100,000 population) increased from 18.37 (17.41 to 19.35) in 1990 to 19.77(18.62 to 20.95) in 2019 with an AAPC of 0.08 % (0.05 % to 0.10 %), and the age-standardized prevalence rate significantly increased from 391.40 (372.71 to 411.20) to 399.50 (378.31 to 420.75) with an AAPC of 0.02 % (0.00 % to 0.05 %). At the regional level, the greatest burden of NRVHD was seen in parts of high-income North America. At the national level, the highest age standardized incidence rate, age standardized DALY rate, and age standardized mortality rate in 2019 were all from Niger, Philippines and Belarus, making it the region with the greatest burden of NRVHD. The age standardized incidence and DALY rate were higher in women 20.83 (19.68 to 22.02) than in men 18.64 (17.39 to 19.88) globally, while the mortality rate was similar in different genders. The differences between men and women in incidence, DALY and mortality were mainly found in age groups of 80-84 and 85-89 years. A significant negative association was found between estimated annual percentage change (EAPCs) and age standardized rate (q=-0.19, p = 0.00). A significant positive relation was detected between EAPCs and human development index (q = 0.17, p = 0.02). The main attributable risk factor for DALY was high body mass index in all regions by SDI.

CONCLUSION

There is a substantial global burden of NRVHD in older adults in 2019, which is varied by age, gender, SDI and region. NRVHD in older people should be paid attention to. Risk factors described here should provide more evidence and clues for disease prevention in the future.

Comparison between hybrid cardiac rehabilitation and center-based cardiac rehabilitation: a noninferiority randomized controlled trial

Cardiac rehabilitation (CR) is a cornerstone of heart disease (HD) management, enhancing functional capacity and quality of life. Hybrid cardiac rehabilitation (hCR), combining supervised center-based sessions with synchronous, real-time telerehabilitation at home, offers an alternative to conventional CR to overcome logistical barriers such as facility limitations, distance, and pandemic-related disruptions. This randomized controlled trial evaluated the noninferiority of hCR compared to standard CR in improving functional capacity in patients with chronic heart disease, including those with stable coronary artery disease. Seventy-five participants were randomized into two groups: the CR group, with exclusively center-based sessions, and the hCR group, with synchronous tele-rehabilitation sessions at home complemented by center-based sessions. Functional capacity was assessed using cardiopulmonary exercise testing, the six-minute walk test, and the wall squat test. Both groups showed significant improvements in functional outcomes, including walking distance (six-minute walk test), strength capacity (wall squat test), and cardiopulmonary exercise testing performance ( P  < 0.001). The improvements in the hCR group were statistically noninferior to those in the CR group. These findings demonstrate that hCR provides an effective alternative to conventional CR while addressing practical challenges in access to care. The hCR protocol represents a viable solution for expanding rehabilitation options without compromising outcomes, particularly for patients facing logistical constraints or during emergencies such as pandemics.

A common algorithm for cardiac troponin to rule-out and rule-in acute myocardial infarction

BACKGROUND

A limitation of diagnostic algorithms in suspected myocardial infarction (MI) is the requirement for assay-specific high-sensitivity cardiac troponin (hs-cTn) cut-off concentrations and change criteria. We sought to evaluate a common change criteria algorithm (3C) for hs-cTn and compared it to established algorithms for the rule-out and rule-in of MI.

METHODS

We applied the 3C algorithm in two prospective cohort studies (with 3 different hs-cTn assays) of patients presenting to the emergency department with suspected MI who had serial hs-cTn results available. Diagnostic performance measures (sensitivity, specificity, predictive values, likelihood ratios) for MI were obtained for both 3C (change criteria >|3| for under 10 ng/L, >|30|% between 10-100 ng/L and >|15|% for above 100 ng/L) and the ESC algorithms for rule-in and rule-out. Confusion matrices, net reclassification improvement (NRI), and effectiveness (percentage rule-in and rule-out) analyses were also performed.

RESULTS

In 5011 patients, the MI prevalence was 16.12% (n=811) . Comparable diagnostic accuracy in terms of sensitivity, specificity, and predictive values were observed between the 3C and ESC algorithms. Direct comparison of the algorithms via NRI showed no decisive advantage for either algorithm. Confusion matrices for all three assays for both 0/1h and 0/2h sampling identified that the 3C ruled-in more patients with a MI who were ruled-out with the ESC. Effectiveness was higher for 3C (83.2-88.8%) versus ESC (64.4-74.5%) for hs-cTnI but not for hs-cTnT (64.5-71.8% versus 72.4-80.6%, respectively).

CONCLUSIONS

The 3C algorithm offers a uniform, assay agnostic alternative to established algorithms, independent of timing of serial sampling.

Prognostic value of HALP score in predicting in-hospital mortality in patients with NSTEMI

AIMS

We aimed to investigate the association between the HALP score and in-hospital mortality in patients with non-ST segment myocardial infarction (NSTEMI).

MATERIALS AND METHODS

In this retrospective study participants were divided into two groups, based on the median HALP score. Findings were compared between the groups.

RESULTS

A total of 1648 patients included. The median HALP score cutoff value was 3.87. While the low HALP score group (<3.87) included 824 patients, the high HALP score group (>3.87) included 824 patients. Patients with the low HALP score were older and had a higher prevalence of comorbidities. A HALP score ≤ 2.62 predicted in-hospital mortality with sensitivity of 72.5% and a specificity of 77.3% (area under curve 0.809), according to ROC curve analysis. In multivariate analysis, age, diastolic blood pressure, Killip Class > 1 and Syntax Score, creatinine level, LVEF and HALP Score (OR: 0.504, 95% CI: 0.415-0.613; p < 0.001) were independently associated with in-hospital mortality.

CONCLUSIONS

According to the current study, the HALP score was independently associated with in-hospital mortality in patients with NSTEMI. Moreover, HALP score might be used as a predictor of in-hospital mortality in this population.

Health beliefs mediates the association between the number of non-communicable diseases and preventive behaviors in middle-aged and older adults in southern China

BACKGROUND

The triadic relationship among the number of NCDs, preventive behaviors and health beliefs has not been fully explored, especially the role of health beliefs.

AIMS

To explore the association between the number of NCDs and preventive behaviors, as well as the mediating effect of health beliefs and its dimensions among middle-aged and older adults. Provide scientific evidence for developing targeted behavior intervention.

METHODS

Data from 2095 middle-aged and older adults who completed demographic information, health beliefs and preventive behaviors questionnaire. Mediation analysis was used to explore the association of health beliefs and its dimensions between the number of NCDs and preventive behaviors.

RESULTS

Health beliefs and self-efficacy positively impacted preventive behaviors, whereas perceived severity, while perceived barriers had negative effects. Health beliefs (β = - 0.1809, 95% CI - 0.2658 to - 0.0960) and its dimensions(Perceived barriers:β = - 0.0881, 95% CI - 0.1533 to - 0.0232, self-efficacy: β = - 0.2706, 95% CI - 0.3592 to - 0.1892) partially mediated the associations between the number of NCDs and preventive behaviors. The negative mediation effects indicates that as the number of NCDs increases, preventive behaviors decrease, partly due to a decline in health beliefs and self-efficacy, as well as an increase in perceived barriers (scored inversely, meaning higher barriers). These mediation pathways exhibited modest strength, highlighting the importance of health beliefs on behavior change.

CONCLUSIONS

An increasing number of NCDs is associated with reduced engagement in preventive behaviors. Health beliefs and its dimensions play a partial mediating role in this relationship. Effective intervention targeting health beliefs may help promote positive behavioral changes.

Temporal and spatial self supervised learning methods for electrocardiograms

The limited availability of labeled ECG data restricts the application of supervised deep learning methods in ECG detection. Although existing self-supervised learning approaches have been applied to ECG analysis, they are predominantly image-based, which limits their effectiveness. To address these limitations and provide novel insights, we propose a Temporal-Spatial Self-Supervised Learning (TSSL) method specifically designed for ECG detection. TSSL leverages the intrinsic temporal and spatial characteristics of ECG signals to enhance feature representation. Temporally, ECG signals retain consistent identity information over time, enabling the model to generate stable representations for the same individual across different time points while isolating representations of different leads to preserve their unique features. Spatially, ECG signals from various leads capture the heart's activity from different perspectives, revealing both commonalities and distinct patterns. TSSL captures these correlations by maintaining consistency in the relationships between signals and their representations across different leads. Experimental results on the CPSC2018, Chapman, and PTB-XL databases demonstrate that TSSL introduces new capabilities by effectively utilizing temporal and spatial information, achieving superior performance compared to existing methods and approaching the performance of full-label training with only 10% of the labeled data. This highlights TSSL's ability to provide deeper insights and enhanced feature extraction beyond mere performance improvements. We make our code publicly available on https://github.com/cwp9731/temporal-spatial-self-supervised-learning.

Roadmap for alleviating the manifestations of ageing in the cardiovascular system

Ageing of the cardiovascular system is associated with frailty and various life-threatening diseases. As global populations grow older, age-related conditions increasingly determine healthspan and lifespan. The circulatory system not only supplies nutrients and oxygen to all tissues of the human body and removes by-products but also builds the largest interorgan communication network, thereby serving as a gatekeeper for healthy ageing. Therefore, elucidating organ-specific and cell-specific ageing mechanisms that compromise circulatory system functions could have the potential to prevent or ameliorate age-related cardiovascular diseases. In support of this concept, emerging evidence suggests that targeting the circulatory system might restore organ function. In this Roadmap, we delve into the organ-specific and cell-specific mechanisms that underlie ageing-related changes in the cardiovascular system. We raise unanswered questions regarding the optimal design of clinical trials, in which markers of biological ageing in humans could be assessed. We provide guidance for the development of gerotherapeutics, which will rely on the technological progress of the diagnostic toolbox to measure residual risk in elderly individuals. A major challenge in the quest to discover interventions that delay age-related conditions in humans is to identify molecular switches that can delay the onset of ageing changes. To overcome this roadblock, future clinical trials need to provide evidence that gerotherapeutics directly affect one or several hallmarks of ageing in such a manner as to delay, prevent, alleviate or treat age-associated dysfunction and diseases.

Obesity and cardiovascular disease: an ESC clinical consensus statement

The global prevalence of obesity has more than doubled over the past four decades, currently affecting more than a billion individuals. Beyond its recognition as a high-risk condition that is causally linked to many chronic illnesses, obesity has been declared a disease per se that results in impaired quality of life and reduced life expectancy. Notably, two-thirds of obesity-related excess mortality is attributable to cardiovascular disease. Despite the increasingly appreciated link between obesity and a broad range of cardiovascular disease manifestations including atherosclerotic disease, heart failure, thromboembolic disease, arrhythmias, and sudden cardiac death, obesity has been underrecognized and sub-optimally addressed compared with other modifiable cardiovascular risk factors. In the view of major repercussions of the obesity epidemic on public health, attention has focused on population-based and personalized approaches to prevent excess weight gain and maintain a healthy body weight from early childhood and throughout adult life, as well as on comprehensive weight loss interventions for persons with established obesity. This clinical consensus statement by the European Society of Cardiology discusses current evidence on the epidemiology and aetiology of obesity; the interplay between obesity, cardiovascular risk factors and cardiac conditions; the clinical management of patients with cardiac disease and obesity; and weight loss strategies including lifestyle changes, interventional procedures, and anti-obesity medications with particular focus on their impact on cardiometabolic risk and cardiac outcomes. The document aims to raise awareness on obesity as a major risk factor and provide guidance for implementing evidence-based practices for its prevention and optimal management within the context of primary and secondary cardiovascular disease prevention.

Evaluation of Hematological and Biochemical Parameters that Predict the No-reflow Phenomenon in Patients Undergoing Primary Percutaneous Coronary Intervention

Acute coronary syndromes (ACS) are one of the most common causes of morbidity and mortality worldwide. Primary percutaneous coronary intervention (pPCI) is the main treatment strategy to restore myocardial perfusion. However, the no-reflow phenomenon (NRP) may block coronary flow. The present study focused on assessing and contrasting predictive parameters for NRP in ACS patients. Our research is a retrospective analysis. We assessed the parameters significantly associated with NRP using Cox regression and Receiver operating characteristic (ROC) Curve analysis. The study included 5122 patients who met the criteria. The average age of the patients was 63.9 + 13.2, and 74.4% were male. It was observed that NRP developed in 1.8% of all patients. Age, hemoglobin (Hb), white blood cell (WBC), glucose and low density lipoprotein cholesterol (LDL-C) were determined to be independent predictors of NRP. The power of these parameters to predict NRP was similar, and WBC was the most predictive (Area Under Curve (AUC): 0.605 95% CI: 0.539-0.671, P = .001). We believe that the use of these simple, practical, and routinely used hematological and biochemical parameters will help us predict the risk of developing NRP before pPCI. This information should improve management.

Practices of low value or unnecessary practices in vascular prevention

BACKGROUND

Low-value practices are avoidable interventions that provide no health benefits. The objective of this study was to conduct a narrative review of the recommendations for practices of low value-care in vascular prevention.

METHODS

A narrative review of all low value-care recommendations for vascular prevention published in the main European and North American scientific societies for clinical practice guidelines between 2014 and 2024 was carried out.

RESULTS

A total of 38 clinical practice guidelines and consensus documents from international organizations in the United States, Canada, the United Kingdom, and Europe were reviewed, 28 of which included between 1 and 20 recommendations on practices of low value-care in vascular prevention. The total number of recommendations was 141. The American Heart Association is the society that offers the largest number of recommendations of low value-care, with 39 recommendations (27.7%) in 5 clinical practice guidelines (13.2% of the total guidelines with recommendations). The guideline for the management of arterial hypertension of the European Society of Hypertension is the guideline that concentrates the largest number of recommendations of low value-care in a single guideline, with 20 recommendations (14.2% of the total guidelines with recommendations).

CONCLUSIONS

There are more and more guidelines that explicitly describe diagnostic or pharmacological activities of low value-care or Do Not Do Class III or recommendation D. Some guidelines agree, but others show clear discrepancies, which can illustrate the uncertainty of the scientific evidence and the differences in its interpretation.

Intercellular NETwork-facilitated sarcoplasmic reticulum targeting for myocardial ischemia-reperfusion injury treatment

Myocardial ischemia-reperfusion injury (MIRI) often leads to irreversible myocardium dysfunction, while existing therapies are palliatives that transiently alleviate the disease symptoms. Repairing sarcoplasmic reticulum Ca2+-ATPase (SERCA) could reverse MIRI, which, however, requires precise drug delivery to the sarcoplasmic reticulum (SR). To this end, we leverage cell-cell "NETwork" of neutrophils to deliver SERCA activator-loaded SR-localized nanoparticles (L-P-NPs) to the damaged myocardial cells, following a hierarchical targeting process: (i) chemotactic neutrophils deliver L-P-NPs to ischemia-reperfused heart, achieving tissue level targeting; (ii) neutrophils produce neutrophil extracellular traps (NETs) to transport L-P-NPs to injured myocardial cell, achieving cellular level targeting; (iii) L-P-NPs escort therapeutic payloads to the SR, achieving subcellular targeting. We showed that this platform profoundly restored SERCA activity, augmented cardiac function, and ameliorated adverse heart remodeling. Our study provides insight into the direct restoration of SR for the effective treatment of MIRI and other muscle diseases.

Wearable device-measured moderate to vigorous physical activity and risk of degenerative aortic valve stenosis

BACKGROUND AND AIMS

Physical activity has proven effective in preventing atherosclerotic cardiovascular disease, but its role in preventing degenerative valvular heart disease (VHD) remains uncertain. This study aimed to explore the dose-response association between moderate to vigorous physical activity (MVPA) volume and the risk of degenerative VHD among middle-aged adults.

METHODS

A full week of accelerometer-derived MVPA data from 87 248 UK Biobank participants (median age 63.3, female: 56.9%) between 2013 and 2015 were used for primary analysis. Questionnaire-derived MVPA data from 361 681 UK Biobank participants (median age 57.7, female: 52.7%) between 2006 and 2010 were used for secondary analysis. The primary outcome was the diagnosis of incident degenerative VHD, including aortic valve stenosis (AS), aortic valve regurgitation (AR), and mitral valve regurgitation (MR). The secondary outcome was VHD-related intervention or mortality.

RESULTS

In the accelerometer-derived MVPA cohort, 555 incident AS, 201 incident AR, and 655 incident MR occurred during a median follow-up of 8.11 years. Increased MVPA volume showed a steady decline in AS risk and subsequent AS-related intervention or mortality risk, levelling off beyond approximately 300 min/week. In contrast, its association with AR or MR incidence was less apparent. The adjusted rates of AS incidence (95% confidence interval) across MVPA quartiles (Q1-Q4) were 11.60 (10.20, 13.20), 7.82 (6.63, 9.23), 5.74 (4.67, 7.08), and 5.91 (4.73, 7.39) per 10 000 person-years. The corresponding adjusted rates of AS-related intervention or mortality were 4.37 (3.52, 5.43), 2.81 (2.13, 3.71), 1.93 (1.36, 2.75), and 2.14 (1.50, 3.06) per 10 000 person-years, respectively. Aortic valve stenosis risk reduction was also observed with questionnaire-based MVPA data [adjusted absolute difference Q4 vs. Q1: AS incidence, -1.41 (-.67, -2.14) per 10 000 person-years; AS-related intervention or mortality, -.38 (-.04, -.88) per 10 000 person-years]. The beneficial association remained consistent in high-risk populations for AS, including patients with hypertension, obesity, dyslipidaemia, and chronic kidney disease.

CONCLUSIONS

Higher MVPA volume was associated with a lower risk of developing AS and subsequent AS-related intervention or mortality. Future research needs to validate these findings in diverse populations with longer durations and repeated periods of activity monitoring.

A scientific document for the remote monitoring of cardiac implantable electronic devices in Greece

It is estimated that the number of patients with a cardiac implantable electronic device (CIED) in Greece exceeds 120,000, and this population is expected to further rise by 5% annually. The importance of adequate monitoring and follow-up management of these devices is well-recognized. However, the increasing complexity and growing number of CIEDs makes their management a demanding medical service. Traditionally, interrogation and programming of CIEDS is performed through the use of a portable programmer by qualified personnel, requiring patient physical presence. During the last decade, remote monitoring (RM) of CIEDs tends to become more and more popular given the advantages and improved outcomes in many groups of patients. Currently, RM represents the standard of care for CIEDs follow-up, and it is recommended by major cardiology societies worldwide, including the European Society of Cardiology. The objective of this statement is to summarize current management of patients with CIED in Greece and the available evidence about clinical efficacy and safety of RM of CIEDs, present the most recent guideline recommendations, and finally, to propose actions to move towards widespread adoption of RM of CIEDs in Greece.

FORCETRACKER: A versatile tool for standardized assessment of tissue contractile properties in 3D Heart-on-Chip platforms

Engineered heart tissues (EHTs) have shown great potential in recapitulating tissue organization, functions, and cell-cell interactions of the human heart in vitro. Currently, multiple EHT platforms are used by both industry and academia for different applications, such as drug discovery, disease modelling, and fundamental research. The tissues' contractile force, one of the main hallmarks of tissue function and maturation level of cardiomyocytes, can be read out from EHT platforms by optically tracking the movement of elastic pillars induced by the contractile tissues. However, existing optical tracking algorithms which focus on calculating the contractile force are customized and platform-specific, often not available to the broad research community, and thus hamper head-to-head comparison of the model output. Therefore, there is the need for robust, standardized and platform-independent software for tissues' force assessment. To meet this need, we developed ForceTracker: a standalone and computationally efficient software for analyzing contractile properties of tissues in different EHT platforms. The software uses a shape-detection algorithm to single out and track the movement of pillars' tips for the most common shapes of EHT platforms. In this way, we can obtain information about tissues' contractile performance. ForceTracker is coded in Python and uses a multi-threading approach for time-efficient analysis of large data sets in multiple formats. The software efficiency to analyze circular and rectangular pillar shapes is successfully tested by analyzing different format videos from two EHT platforms, developed by different research groups. We demonstrate robust and reproducible performance of the software in the analysis of tissues over time and in various conditions. ForceTracker's detection and tracking shows low sensitivity to common incidental defects, such as alteration of tissue shape or air bubbles. Detection accuracy is determined via comparison with manual measurements using the software ImageJ. We developed ForceTracker as a tool for standardized analysis of contractile performance in EHT platforms to facilitate research on disease modeling and drug discovery in academia and industry.

Hamid A, Ugusman A. Prognostic Value of Lectin-like Oxidized Low-Density Lipoprotein Receptor-1 for Future Cardiovascular Disease Risk and Outcome: A Systematic Review and Meta-Analysis

Cardiovascular disease (CVD) remains a leading cause of mortality globally, underscoring the need for robust predictive biomarkers to enhance risk stratification. Soluble lectin-like oxidized low-density lipoprotein receptor-1 (sLOX-1) has emerged as a promising biomarker linked to oxidative stress and endothelial dysfunction, both critical mechanisms in atherogenesis and cardiovascular events. Objectives: This study aimed to evaluate the prognostic value of sLOX-1 in predicting major adverse cardiovascular and cerebrovascular events (MACCEs), myocardial infarction (MI), heart failure (HF), and stroke outcomes through a systematic review and meta-analysis. Methods: A systematic literature search was conducted across PubMed, Scopus, Web of Science, and Ovid databases for studies published between 2014 and October 2024. Eligible studies assessed the association between sLOX-1 levels and future CVD outcomes in adult populations. Meta-analysis pooled hazard ratios (HRs) were assessed using random- and fixed-effects models. Heterogeneity was evaluated using the I2 statistic, and study quality was assessed using the Newcastle-Ottawa Scale. Results: Fourteen studies were included, encompassing diverse populations with coronary artery disease (CAD), acute coronary syndrome (ACS), or stroke, with follow-up durations ranging from 30 days to 19.5 years. The meta-analysis of three studies on CAD patients demonstrated a significant association between elevated sLOX-1 levels and increased MACCE risk (HR: 2.3, 95% CI: 0.99-5.33, p = 0.05), albeit with high heterogeneity (I2 = 83%). The fixed-effects analysis yielded a more consistent HR of 1.47 (95% CI: 1.19-1.81, p < 0.01). Conclusions: sLOX-1 shows promising potential as a prognostic biomarker for CVD and is associated with an increased risk of MACCEs in CAD patients. However, the high heterogeneity among the included studies highlights the need for standardized protocols and larger, well-designed prospective studies to validate its clinical utility. The integration of sLOX-1 into risk prediction models could improve CVD management by identifying high-risk individuals for targeted interventions.

PlaqueViT: a vision transformer model for fully automatic vessel and plaque segmentation in coronary computed tomography angiography

OBJECTIVES

To develop and evaluate a deep learning model for segmentation of the coronary artery vessels and coronary plaques in coronary computed tomography angiography (CCTA).

MATERIALS AND METHODS

CCTA image data from the Swedish CardioPulmonary BioImage Study (SCAPIS) was used for model development (n = 463 subjects) and testing (n = 123) and for an interobserver study (n = 65). A dataset from Linköping University Hospital (n = 28) was used for external validation. The model's ability to detect coronary artery disease (CAD) was tested in a separate SCAPIS dataset (n = 684). A deep ensemble (k = 6) of a customized 3D vision transformer model was used for voxelwise classification. The Dice coefficient, the average surface distance, Pearson's correlation coefficient, analysis of segmented volumes by intraclass correlation coefficient (ICC), and agreement (sensitivity and specificity) were used to analyze model performance.

RESULTS

PlaqueViT segmented coronary plaques with a Dice coefficient = 0.55, an average surface distance = 0.98 mm and ICC = 0.93 versus an expert reader. In the interobserver study, PlaqueViT performed as well as the expert reader (Dice coefficient = 0.51 and 0.50, average surface distance = 1.31 and 1.15 mm, ICC = 0.97 and 0.98, respectively). PlaqueViT achieved 88% agreement (sensitivity 97%, specificity 76%) in detecting any coronary plaque in the test dataset (n = 123) and 89% agreement (sensitivity 95%, specificity 83%) in the CAD detection dataset (n = 684).

CONCLUSION

We developed a deep learning model for fully automatic plaque detection and segmentation that identifies and delineates coronary plaques and the arterial lumen with similar performance as an experienced reader.

KEY POINTS

Question A tool for fully automatic and voxelwise segmentation of coronary plaques in coronary CTA (CCTA) is important for both clinical and research usage of the CCTA examination. Findings Segmentation of coronary artery plaques by PlaqueViT was comparable to an expert reader's performance. Clinical relevance This novel, fully automatic deep learning model for voxelwise segmentation of coronary plaques in CCTA is highly relevant for large population studies such as the Swedish CardioPulmonary BioImage Study.

Prospective associations of genetic susceptibility to high blood pressure and muscle strength with incident cardiovascular disease outcomes

BACKGROUND

This study explored the prospective associations of genetic susceptibility to high blood pressure (BP) and muscle strength with cardiovascular disease (CVD) mortality, incident coronary heart disease (CHD) and incident stroke.

METHODS

This study included 349 085 white British individuals from the UK Biobank study. Genetic risk of high BP was estimated using a weighted polygenic risk score that incorporated 136 and 135 nonoverlapping single-nucleotide polymorphisms for systolic BP and diastolic BP, respectively. Muscle strength was assessed using a hand dynamometer and expressed relative to fat-free mass. Sex- and age-specific tertiles were used to classify muscle strength into three categories. Cox regressions with age as the underlying timescale were fit for CVD mortality ( n  = 8275), incident CHD ( n  = 14 503), and stroke ( n  = 7518).

RESULTS

Compared with the lowest genetic risk of high BP (bottom 20%), the highest (top 20%) had greater hazards of each outcome. Low muscle strength was associated with higher hazards of CVD mortality [hazard ratio (HR): 1.51, 95% confidence interval (CI): 1.43-1.59], incident CHD (HR: 1.16, 95% CI: 1.11-1.21), and stroke (HR: 1.20, 95% CI: 1.14-1.27), independently of confounders and genetic predisposition to high BP, compared with high muscle strength. Joint analyses revealed that the estimated 10-year absolute risks of each outcome were lower for high muscle strength combined with high genetic risk, compared with low muscle strength combined with low or medium genetic risk.

CONCLUSION

Individuals who are genetically predisposed to high BP but have high muscle strength could have lower risk of major CVD events, compared with those who have low or medium genetic risk but low muscle strength.

18F-NaF uptake on vascular PET imaging in symptomatic versus asymptomatic atherosclerotic disease: A meta-analysis

INTRODUCTION

18F-sodium fluoride (NaF) positron-emission tomography (PET) is increasingly being used to measure microcalcification in atherosclerotic disease in vivo. Correlations have been drawn between sodium fluoride uptake and the presence of high-risk plaque features, as well as its association with clinical atherosclerotic sequelae. The aim of this study was to perform a meta-analysis of NaF uptake on PET imaging and its relation to symptomatic and asymptomatic disease.

METHODS

A systematic review was performed according to PRISMA guidelines, via searching the Ovid MEDLINE, Ovid Embase, Cochrane Library, PubMed, Scopus, and Web of Science Core Collection databases up to May 2024. The search strategy included the terms 'NaF', 'PET', and 'plaque', and all studies with data regarding the degree of microcalcification, as measured by 18F-NaF uptake in symptomatic and asymptomatic atherosclerotic plaques, were included. Analysis involved calculating mean differences between uptake values and comparison using a random-effects model.

RESULTS

A total of 16 articles, involving 423 participants, were included in the meta-analysis (10 carotid artery studies, five coronary artery studies, and one in peripheral vascular disease). Comparing 18F-NaF uptake in symptomatic versus asymptomatic atherosclerotic plaques, a mean difference of 0.43 (95% CI 0.29 to 0.57; p < 0.0001, I2 = 65%) was noted in studies comparing symptomatic and asymptomatic plaques in the same participant, with a significant difference in effect based on arterial territory studied (χ2 = 12.68, p = 0.0018). In studies of participants with and without symptomatic disease, there was no significant difference between symptomatic and asymptomatic plaques (mean difference 0.27, 95% CI -0.26 to 0.80, p = 0.28, I2 = 85%).

CONCLUSIONS

PET imaging using 18F-NaF can detect differences in microcalcification between symptomatic and asymptomatic atherosclerotic plaques within, but not between, individuals, and thus, is a marker of symptomatic disease. The standardization of 18F-NaF PET imaging protocols, and its future use as a risk stratification tool or outcome measure, requires further study. (PROSPERO Registration ID: CRD42023451363).

[Management of acute coronary syndrome]

Coronary artery disease (CAD) is the leading cause of death worldwide. Acute coronary syndrome (ACS) encompasses a spectrum of diagnoses ranging from unstable angina pectoris to myocardial infarction with and without ST-segment elevation and frequently presents as the first clinical manifestation. It is crucial in this scenario to perform a timely and comprehensive assessment of patients by evaluating the clinical presentation, electrocardiogram and laboratory diagnostics using highly sensitivity cardiac troponin in order to initiate a timely and risk-adapted continuing treatment with immediate or early invasive coronary angiography. In addition to revascularization, the subsequent antithrombotic and lipid-lowering treatment plays a major role in the further secondary prevention of CAD. The choice and duration of medication over time should be tailored to the individual risk profile of the patient. Furthermore, appropriate patient education regarding risk factor management is of paramount importance.

Associations of step accelerations and cardiometabolic risk markers in early adulthood

Physical activity (PA) has a positive effect on risk factors related to cardiometabolic health yet amount of PA and time of onset is unclear. Therefore, we investigated the relationship of PA estimates and cardiometabolic risk factors in a large healthy population of an understudied age group of young adults using a standard gravity-based method on body adiposity and risk markers. In 856 (532 women, 324 men, 32-35 years) subjects we evaluated the association of PA and cardiometabolic risk factors in early adulthood. PA was measured using accelerometers for a period of two weeks. Step counts were divided into light (LPA), moderate (MPA), and vigorous (VPA) intensity classes. Income of the household was 63 446 ± 46 899€ and 57.5% had higher education. Total daily step numbers were 11962.5 ± 5163.2, LPA 5459.6 ± 2986.6, MPA 5932 ± 3404.6, and VPA 572.3 ± 668. Higher total PA volume was associated with lower weight, BMI, % body fat, smaller visceral fat area (VFA) and waist circumference, lower total cholesterol, LDL, and reflection coefficient of the pulse wave. LPA correlated with weight, BMI, waist circumference, total cholesterol, LDL, and central pulse pressure (cPP). Percent body fat (%BF), VFA, total cholesterol, LDL, reflection coefficient, heart minute index, and heart minute volume were significantly associated with MPA and VPA intensity PA volume. Lower PA in early adulthood correlates with increased cardiometabolic risk markers which should be translated into specific recommendations to thrive for a healthier lifestyle to delay and decrease their onset.

A gut pathobiont regulates circulating glycine and host metabolism in a twin study comparing vegan and omnivorous diets

Metabolic diseases including type 2 diabetes and obesity pose a significant global health burden. Plant-based diets, including vegan diets, are linked to favorable metabolic outcomes, yet the underlying mechanisms remain unclear. In a randomized trial involving 21 pairs of identical twins, we investigated the effects of vegan and omnivorous diets on the host metabolome, immune system, and gut microbiome. Vegan diets induced significant shifts in serum and stool metabolomes, cytokine profiles, and gut microbial composition. Despite lower dietary glycine intake, vegan diet subjects exhibited elevated serum glycine levels linked to reduced abundance of the gut pathobiont Bilophila wadsworthia. Functional studies demonstrated that B. wadsworthia metabolizes glycine via the glycine reductase pathway and modulates host glycine availability. Removing B. wadsworthia from a complex microbiota in mice elevated glycine levels and improved metabolic markers. These findings reveal a previously underappreciated mechanism by which diet regulates host metabolic status via the gut microbiota.

Towards Ultrasound Wearable Technology for Cardiovascular Monitoring: From Device Development to Clinical Validation

The advent of flexible, compact, energy-efficient, robust, and user-friendly wearables has significantly impacted the market growth, with an estimated value of 61.30 billion USD in 2022. Wearable sensors have revolutionized in-home health monitoring by warranting continuous measurements of vital parameters. Ultrasound is used to non-invasively, safely, and continuously record vital parameters. The next generation of smart ultrasonic devices for healthcare integrates microelectronics with flexible, stretchable patches and body-conformable devices. They offer not only wearability, and user comfort, but also higher tracking accuracy of immediate changes of cardiovascular parameters. Moreover, due to the fixed adhesion to the skin, errors derived from probe placement or patient movement are mitigated, even though placement at the correct anatomical location is still critical and requires a user's skill and knowledge. In this review, the steps required to bring wearable ultrasonic systems into the medical market (technologies, device development, signal-processing, in-lab validation, and, finally, clinical validation) are discussed. The next generation of vascular ultrasound and its future research directions offer many possibilities for modernizing vascular health assessment and the quality of personalized care for home and clinical monitoring.

A comprehensive analysis of stroke risk factors and development of a predictive model using machine learning approaches

Stroke is a leading cause of death and disability globally, particularly in China. Identifying risk factors for stroke at an early stage is critical to improving patient outcomes and reducing the overall disease burden. However, the complexity of stroke risk factors requires advanced approaches for accurate prediction. The objective of this study is to identify key risk factors for stroke and develop a predictive model using machine learning techniques to enhance early detection and improve clinical decision-making. Data from the China Health and Retirement Longitudinal Study (2011-2020) were analyzed, classifying participants based on baseline characteristics. We evaluated correlations among 12 chronic diseases and applied machine learning algorithms to identify stroke-associated parameters. A dose-response relationship between these parameters and stroke was assessed using restricted cubic splines with Cox proportional hazards models. A refined predictive model, incorporating age, sex, and key risk factors, was developed. Stroke patients were significantly older (average age 69.03 years) and had a higher proportion of women (53%) compared to non-stroke individuals. Additionally, stroke patients were more likely to reside in rural areas, be unmarried, smoke, and suffer from various diseases. While the 12 chronic diseases were correlated (p < 0.05), the correlation coefficients were generally weak (r < 0.5). Machine learning identified nine parameters significantly associated with stroke risk: TyG-WC, WHtR, TyG-BMI, TyG, TMO, CysC, CREA, SBP, and HDL-C. Of these, TyG-WC, WHtR, TyG-BMI, TyG, CysC, CREA, and SBP exhibited a positive dose-response relationship with stroke risk. In contrast, TMO and HDL-C were associated with reduced stroke risk. In the fully adjusted model, elevated CysC (HR = 2.606, 95% CI 1.869-3.635), CREA (HR = 1.819, 95% CI 1.240-2.668), and SBP (HR = 1.008, 95% CI 1.003-1.012) were significantly associated with increased stroke risk, while higher HDL-C (HR = 0.989, 95% CI 0.984-0.995) and TMO (HR = 0.99995, 95% CI 0.99994-0.99997) were protective. A nomogram model incorporating age, sex, and the identified parameters demonstrated superior predictive accuracy, with a significantly higher Harrell's C-index compared to individual predictors. This study identifies several significant stroke risk factors and presents a predictive model that can enhance early detection of high-risk individuals. Among them, CREA, CysC, SBP, TyG-BMI, TyG, TyG-WC, and WHtR were positively associated with stroke risk, whereas TMO and HDL-C were opposite. This serves as a valuable decision-support resource for clinicians, facilitating more effective prevention and treatment strategies, ultimately improving patient outcomes.

Improving Diagnostic Yield for Analyzing Periodic Electrograms in the Remote Detection of Pacemaker Lead Issues

Remote monitoring of pacemakers decreases patient complications and reduces public health expenses. The transmission of passive real-time electrograms (EGM) has been shown to increase the diagnostic yield, but this may add to the work burden. Passive EGMs provide snapshots without adjustments, while active EGMs modify pacemaker settings temporarily to encourage sensing and pacing, potentially revealing issues such as undersensing, oversensing, or loss of capture. The added value of active EGMs compared to the passive EGM remains to be shown. The objective of this multicenter observational study is to evaluate, in a large population of patients implanted with a pacemaker capable of transmitting both passive and active periodic EGMs, the added benefit of active periodic EGMs on diagnostic yield of pacemaker-related anomalies. In a retrospective analysis of 7068 EGMs from 2733 patients, active modes detected significantly more anomalies (6.7%) than passive alone (3.3%, p < 0.001), particularly for atrial leads. However, the extended duration of active EGMs (36 s versus 12 s) was the primary contributor to improved detection rates rather than the active pacing modes themselves. Our findings suggest that focusing on longer passive EGMs may enhance diagnostic yield, reducing the need for active pacing adjustments.

Global comparison of the economic costs of coronary heart disease: a systematic review and meta-analysis

OBJECTIVES

Coronary heart disease (CHD) is the leading cause of global morbidity and mortality, yet no comprehensive evaluation of its global economic costs exists. We conducted a systematic review with meta-analysis to examine the costs of CHD treatment by region and CHD subtypes, examine whether there are cost difference by sex, and examine costing methodologies.

DESIGN

We conducted a systematic review and meta-analysis of non-randomised studies.

DATA SOURCES

We searched Medline, Embase, CINAHL, EconLit and Google Scholar from 1 January 2000 to February 2023.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included observational studies reporting economic costs of CHD treatment and outcomes for adults that were published in English.

DATA EXTRACTION AND SYNTHESIS

Data extraction and quality assessment were independently undertaken by two reviewers. Costs were converted to percentage of gross domestic product (GDP) per capita of corresponding country. A random-effects model was used for meta-analysis using StataSE V.18 to calculate the pooled percentage. Heterogeneity was assessed using the I2 statistic. Meta-regression and bias assessment were performed.

RESULTS

Out of 20 100 records identified, 37 studies (including 2 564 189 individuals) from 22 countries were included in the qualitative synthesis and the quantitative meta-analysis. In most countries, the annual cost of CHD exceeds many times the total health expenditure per capita. The pooled direct annual cost of CHD per patient varied from 4.9% to 137.8% of GDP per capita (Int$ purchasing power parity), with pooled percentage of 21.7% (95% CI 15.3, 28.1) for those with CHD. Slight difference in the annual pooled cost of CHD was observed, with a 2% of GDP per capita higher cost in men (95% CI 0.8, 3.2). Most studies applied a top-down costing approach (n=21).

CONCLUSIONS

The review illustrates the expense associated with CHD, which is varied by region and CHD subtypes. The observed cost difference by sex warrants further exploration of sex-specific factors influencing cost disparities. Exploring advanced costing methods such as time-driven activity-based costing can optimise resource allocation and identify opportunities to reduce unnecessary costs and cost disparities.

PROSPERO REGISTRATION NUMBER

CRD42023412044.

Pre-Hospital Point-of-Care Troponin: Is It Possible to Anticipate the Diagnosis? A Preliminary Report

Background: Thanks to the evolution of laboratory medicine, point-of-care testing (POCT) for troponin levels in the blood (hs-cTn) has been greatly improved in order to quickly diagnose acute myocardial infarction (AMI) with an accuracy similar to standard laboratory tests. The rationale of the HEART POCT study is to propose the application of the 0/1 h European Society of Cardiology (ESC) algorithm in the pre-hospital setting using a POCT device (Atellica VTLi). Methods: This is a prospective study comparing patients who underwent pre-hospital point-of-care troponin testing (Atellica VTLi) with a control group that underwent standard hospital-based troponin testing (Elecsys). The primary objectives were to determine if the 0/1 h algorithm of the Atellica VTLi is non-inferior to the standard laboratory method for diagnosing AMI and to analyze rule-out/rule-in times and emergency department (ED) stay times. The secondary objective was to evaluate the feasibility of pre-hospital troponin testing. Results: The Atellica VTLi demonstrated reasonable sensitivity for detecting AMI, with sensitivity increasing from 60% at the first measurement (time 0) to 80% at the second measurement (time 1 h). Both the Atellica VTLi and the Elecsys method showed high negative predictive value (NPV), indicating that a negative troponin result effectively ruled out AMI in most cases. Patients in the Atellica VTLi group experienced significantly shorter times to diagnosis and discharge from the emergency department compared to the control group (Elecsys). This highlights a potential benefit of point-of-care testing: streamlining the diagnostic and treatment processes. Conclusions: POCT allows for rapid troponin measurement, leading to a faster diagnosis of non-ST-segment elevation myocardial infarction (NSTEMI). This enables earlier initiation of appropriate treatment, potentially improving patient outcomes and the efficiency of emergency department operations. POCT could be particularly beneficial in pre-hospital settings, enabling faster triage and transportation of patients to appropriate care centers.

Exercise type and settings, quality of life, and mental health in coronary artery disease: a network meta-analysis

BACKGROUND AND AIMS

Individuals with coronary artery disease have poorer mental health, health-related quality of life (HR-QoL), and cognition compared with (age-matched) controls. Exercise training may attenuate these effects. The aim is to systematically review and meta-analyse the effects of different exercise types and settings on brain structure/function, cognition, HR-QoL, mental health (e.g. depression, anxiety), and sleep in patients with coronary artery disease.

METHODS

A systematic search was conducted and a network meta-analysis compared (i) exercise types, high-intensity interval training (HIIT), HIIT + resistance (HIIT + R), moderate-intensity training (MIT), MIT + R and stretching-toning-balance training, and (ii) exercise settings, in-person and home-based.

RESULTS

A total of 42 randomized controlled trials with a parallel group design were identified, of which 36 were included in the meta-analysis. Few studies included cognition (n = 2), sleep (n = 2), and none brain structure/function (n = 0). Most studies examined HR-QoL (n = 30), depression (n = 15), and anxiety (n = 9), in which outcomes were meta-analysed. HIIT + R, HIIT, and MIT were associated with improved HR-QoL vs. no exercise (i.e. usual care) [standardized mean difference, SMD: 1.53 (95% confidence interval 0.83; 2.24), 0.44 (0.15; 0.73), and 0.44 (0.20; 0.67), respectively]. In-person exercise was associated with larger and significant improvements [HR-QoL SMD: 0.51 (0.28; 0.74), depressive SMD: -0.55 (-1.03; -0.07), and anxiety symptoms SMD: -1.16 (-2.05; -0.26)] compared with no exercise, whereas home-based programmes were not significantly associated with improvements in these outcomes. Findings were robust in secondary (i.e. intervention duration and volume) and sensitivity analyses excluding high risk of bias studies.

CONCLUSIONS

Exercise training, especially in-person sessions, was associated with improved HR-QoL, depression and anxiety, independently of exercise type. However, this study raises concern about the effectiveness of home-based programmes in improving these outcomes.Study protocol was registered in PROSPERO (ID: CRD42023402569).

Drug-Drug interactions prediction calculations between cardiovascular drugs and antidepressants for discovering the potential co-medication risks

Predicting Drug-Drug Interactions (DDIs) enables cost reduction and time savings in the drug discovery process, while effectively screening and optimizing drugs. The intensification of societal aging and the increase in life stress have led to a growing number of patients suffering from both heart disease and depression. These patients often need to use cardiovascular drugs and antidepressants for polypharmacy, but potential DDIs may compromise treatment effectiveness and patient safety. To predict interactions between drugs used to treat these two diseases, we propose a method named Multi-Drug Features Learning with Drug Relation Regularization (MDFLDRR). First, we map feature vectors representing drugs in different feature spaces to the same. Second, we propose drug relation regularization to determine drug pair relationships in the interaction space. Experimental results demonstrate that MDFLDRR can be effectively applied to two DDI prediction goals: predicting unobserved interactions among drugs within the drug network and predicting interactions between drugs inside and outside the network. Publicly available evidence confirms that MDFLDRR can accurately identify DDIs between cardiovascular drugs and antidepressants. Lastly, by utilizing drug structure calculations, we ascertained the severity of newly discovered DDIs to mine the potential co-medication risks and aid in the smart management of pharmaceuticals.

Inclisiran, Reasons for a Novel Agent in a Crowded Therapeutic Field

PURPOSE OF THE REVIEW

A significant number of patients fail to achieve target LDL cholesterol (LDL-C) levels. This review aims to explore why inclisiran, a novel class of LLT, should be considered a valuable addition to the current treatment options.

RECENT FINDINGS

Inclisiran is a small interfering RNA (siRNA) that targets PCSK9 synthesis specifically in the hepatocytes. The drug remains in circulation for less than 48 h, but its effect lasts for over six months. Two subcutaneous injections per year consistently lowers LDL-C by approximately 55% with a favorable safety profile. In combination with other LLTs, it can achieve LDL-C reductions of over 80%, supporting its role in high-intensity LLT strategies. Inclisiran represents a novel class of LLT. Administered biannually, reduces baseline LDL-C levels by half. Additionally, it has a strong safety profile. Due to its pharmacokinetic properties, is likely to improve adherence to LLT and persistently maintain low LDL-C levels.

Evaluation of ST-segment and T-wave changes associated with NSTE-ACS in patients with RBBB: a nested case-control study design

Patients presenting with suspected acute coronary syndrome (ACS) in the emergency department (ED) require rapid and accurate electrocardiographic (ECG) evaluation. This study aims to assess conventional ECG markers for diagnosing non-ST-elevation ACS (NSTE-ACS) in patients with chest discomfort and right bundle branch block (RBBB). A nested case-control design was employed to compare patients with RBBB admitted to the ED for suspected cardiac ischemia, focusing on those who developed NSTE-ACS versus those who did not. The sample consisted of 352 patients with suspected ACS and RBBB identified on ECG. Among them, 88 were diagnosed with NSTE-ACS. In the presence of RBBB, ST-segment elevation on the isoelectric line and/or positive T-waves on the ECG were significantly associated with the diagnosis of NSTE-ACS (p < 0.05). In patients who developed NSTE-ACS, the likelihood of an isoelectric ST-segment was 3.48 (95% CI 2.07-5.82) times higher, the likelihood of positive T-waves was 4.16 (95% CI 2.51-6.91) times higher, and the combination of an isoelectric ST-segment with positive T-waves was 4.81 (95% CI 2.28-8.25) times higher (p < 0.05). In addition, ST-segment depression and non-negative T-waves were significantly more frequent in patients who developed NSTE-ACS, with odds ratios of 5.78 (95% CI 3-11.3), compared to those who did not (p < 0.05). The odds ratios for ST-segment and T-wave changes were 2.81 and 3.47, respectively, with an 80% correct classification rate for predicting NSTE-ACS. Clinicians should closely monitor the presence of an isoelectric ST-segment and positive T-waves in patients with RBBB to assess for potential cardiac ischemia.

Extracellular matrix in vascular homeostasis and disease

The extracellular matrix is an essential component and constitutes a dynamic microenvironment of the vessel wall with an indispensable role in vascular homeostasis and disease. From early development through to ageing, the vascular extracellular matrix undergoes various biochemical and biomechanical alterations in response to diverse environmental cues and exerts precise regulatory control over vessel remodelling. Advances in novel technologies that enable the comprehensive evaluation of extracellular matrix components and cell-matrix interactions have led to the emergence of therapeutic strategies that specifically target this fine-tuned network. In this Review, we explore various aspects of extracellular matrix biology in vascular development, disorders and ageing, emphasizing the effect of the extracellular matrix on disease initiation and progression. Additionally, we provide an overview of the potential therapeutic implications of targeting the extracellular matrix microenvironment in vascular diseases.

Uncertainty Quantification and Sensitivity Analysis for Non-invasive Model-Based Instantaneous Wave-Free Ratio Prediction

The main objectives of this work are to validate a 1D-0D unsteady solver with a distributed stenosis model for the patient-specific estimation of resting haemodynamic indices and to assess the sensitivity of instantaneous wave-free ratio (iFR) predictions to uncertainties in input parameters. We considered 52 patients with stable coronary artery disease, for which 81 invasive iFR measurements were available. We validated the performance of our solver compared to 3D steady-state and transient results and invasive measurements. Next, we used a polynomial chaos approach to characterise the uncertainty in iFR predictions based on the inputs associated with boundary conditions (coronary flow, compliance and aortic/left ventricular pressures) and vascular geometry (radius). Agreement between iFR and the ratio between cardiac cycle averaged distal and aortic pressure waveforms (restingP d / P a $$ {P}_d/{P}_a $$ ) obtained through 1D-0D and 3D models was satisfactory, with a bias of 0.0-0.005 (±0.016-0.026). The sensitivity analysis showed that iFR estimation is mostly affected by uncertainties in vascular geometry and coronary flow (steady-state parameters). In particular, our 1D-0D method overestimates invasive iFR measurements, with a bias of -0.036 (±0.101), indicating that better flow estimates could significantly improve our modelling pipeline. Conversely, we showed that standard pressure waveforms could be used for simulations, since the impact of uncertainties related to inlet-pressure waveforms on iFR prediction is negligible. Furthermore, while compliance is the most relevant transient parameter, its effect on iFR estimates is negligible compared to that of vascular geometry and flow. Finally, we observed a strong correlation between iFR and restingP d / P a $$ {P}_d/{P}_a $$ , suggesting that steady-state simulations could replace unsteady simulations for iFR prediction.

Synthetic ECG signals generation: A scoping review

The scientific community has recently shown increasing interest in generating synthetic ECG data. In particular, synthetic ECG signals can be beneficial for understanding cardiac electrical activity, developing large and heterogeneous unbiased datasets, and anonymizing data to favour knowledge sharing and open science. In the present scoping review, various methodologies to generate synthetic ECG data have been thoroughly analysed, highlighting their limitations and possibilities. A total of 79 studies have been included and classified, depending on the methodology employed, the number of leads, the number of heartbeats, and the purpose of data synthesis. Three main categories have been identified: mathematical modelling, computer vision inherited methods, and deep generative models. This thorough analysis can assist in the choice of the most suitable technique for a specific application. The biggest challenge is identifying standardized metrics that can comprehensively and quantitatively assess the fidelity and variability of generated synthetic ECG data.

Tenecteplase vs Reteplase in Patients with Acute ST-Elevation Myocardial Infarction: A Retrospective Cohort Study

PURPOSE

The aim of this study is to compare the efficacy and safety of both agents in patients with acute STEMI.

METHODS

This was a multicenter retrospective observational study comparing tenecteplase and reteplase in patients with acute STEMI. The primary outcome was the incidence of failed thrombolysis. Secondary outcomes included the incidence of major bleeding, cardiogenic shock, re-infarction and mortality.

RESULTS

A total of 282 patients were included, 229 and 53 received tenecteplase and reteplase, respectively. The incidence of failed thrombolysis was 33.2% in the tenecteplase group compared to 20.8% in the reteplase group (adjusted odds ratio 0.53, 95% confidence interval 0.25-1.1; p = 0.089). The incidence of major bleeding was 0.9% in the tenecteplase group and 5.7% in the reteplase group (p = 0.017). There was no significant difference in mortality or other secondary outcomes.

CONCLUSION

There was no difference in the primary outcome of failed thrombolysis between tenecteplase and reteplase; however, major bleeding events were significantly higher in the reteplase group. Randomized controlled trials are needed to confirm our findings.

Contextual and clinical factors as explainers of stroke severity, residual motor impairments, and functional independence during hospitalization

OBJECTIVE

To investigate if contextual and clinical factors would explain stroke severity, residual motor impairments, and functional independence in people with stroke during hospitalization.

MATERIALS AND METHODS

This cross-sectional study retrieved data from medical records between January 2014 to December 2021. Explanatory independent variables were contextual (sex, age, marital status, occupation, and local of residence) and clinical (stroke type, length of hospital stay, and cognitive function) factors. Stroke severity (National Institutes of Health Stroke Scale), residual motor impairments (Fugl-Meyer scale), and functional independence (Functional Independence Measure) were the dependent variables. Stepwise multiple linear regression analysis was used (α=5%).

RESULTS

Data from 1.606 individuals (64±15 years old) were retrieved. Cognitive function was the strongest explainer of all models, as follows: severity (23%;p<0.001), residual motor impairment (16%;p<0.001), and functional independence (32%;p<0.001). Length of hospital stays was the second explainer, adding from 7% to 8% to the models, while stroke type was the third explainer, adding 1% to all models. Finally, age was the last explainer of the two models, adding 1% to the severity and functional independence model.

CONCLUSION

The clinical variables explained more the dependent variables (all three were included in the models), than contextual variables (only age was included). Lower cognitive function, a clinical variable that is quick and easy to evaluate, best explained worse severity, residual motor impairments, and functional independence in people with stroke during hospitalization. Although higher length of hospital stays, hemorrhagic stroke, and older age added little to the explained variance, they should not be underlooked.

Strategic Plan for Cardiovascular Health in Portugal - Portuguese Society of Cardiology (PESCP-SPC)

The Strategic Plan for Cardiovascular Health in Portugal is an initiative of the Portuguese Society of Cardiology, aligned with efforts by the European Society of Cardiology and the World Heart Federation to develop national plans, at a local level within the cultural and socio-economic contexts, focused on cardiovascular health. The overarching goal is to promote and ensure the continuous and sustained improvement of cardiovascular health in the Portuguese population. The methodology identified key challenges and opportunities for the medium term, highlighted priority areas for intervention, and proposed strategic lines of action. This article outlines the project's design and establishes a guiding framework for the proposed actions, which will be drawn up by designated expert groups and communicated subsequently.

Tuning Surface Chemistry Impacts on Cardiac Endothelial and Smooth Muscle Cell Development

Cardiovascular diseases (CVDs) are the leading causes of death worldwide, with approx. Twenty million deaths in 2021. Cardiovascular implants are among the most used biomaterials in the clinical world. However, poor endothelialisation and rapid thrombosis remains a challenge. Simple chemical surface modification techniques can be used to steer biological interactions without affecting the bioimplants' overall bulk characteristics such as radiopacity and flexibility. Although silanes are well studied for protein and cell interactions, the methodical investigation of cardiac endothelial cell (EC) alongside smooth muscle cell (SMC) to mimic natural arterial environments has been limited. In this study, these cells have been investigated on surfaces functionalized with methyl, amine, thiol, methacrylate, and fluorine organosilane groups. Cardiac EC and SMC growth was investigated with metabolic activity, time lapse imaging, and immunofluorescent staining techniques. The results demonstrated that the surfaces tested are able to selectively regulate the viability and growth of the cells. Aminosilane modified surfaces displayed 2-fold higher metabolic activity with HUVEC and 2-fold less metabolic activity with HCASMC cell lines, compared to tissue culture plastic controls. The amino-modification outperformed all other chemistries tested in terms of ability to promote the proliferation of ECs, while importantly reducing the activity of SMCs. This report demonstrates that aminosilane modified surfaces have the potential to be utilized in novel cardiovascular implants, which could improve biological integration in the short and possibly longer-term. The findings of this study suggest that specific chemical modifications of the surface can enhance endothelial cell activity while minimizing the proliferation of smooth muscle cells, which are often associated with thrombosis. This highlights the potential of carefully engineered surface chemistries to improve the clinical outcomes of cardiovascular implants.

Glycerol-plasticized silk fibroin vascular grafts mimic key mechanical properties of native blood vessels

Cardiovascular diseases are a major global health challenge. Blood vessel disease and dysfunction are major contributors to this healthcare burden, and the development of tissue-engineered vascular grafts (TEVGs) is required, particularly for the replacement of small-diameter vessels. Silk fibroin (SF) is a widely used biomaterial for TEVG fabrication due to its high strength and biocompatibility. However, the stiffness of SF is much higher than that of native blood vessels (NBVs), which limits its application for vascular tissue engineering. In this study, SF was plasticized with glycerol to produce TEVGs exhibiting similar stiffness and ultimate tensile strength to those of NBVs. The electrospun SF/glycerol TEVGs exhibited mechanical properties comparable to NBVs and supported the in vitro proliferation of essential vascular cells-endothelial and smooth muscle cells. After 5 days of culture, the TEVGs exhibited an endothelial monolayer in the lumen, demonstrating their potential for functional vascular tissue regeneration. Our study demonstrates the feasibility of producing TEVGs from SF with tailored mechanical properties, paving the way for more functional and durable TEVGs for future clinical applications.

Level of elderly-supportive infrastructure, fine particulate matter and cardiovascular disease hospitalisations: a time-stratified case-crossover study in Wuhan

BACKGROUND

Amid rapid urbanisation, the health effects of the built-environment have been widely studied, while research on elderly-supportive infrastructure and its interaction with PM2.5 (PM, Particulate Matter) exposure remains limited.

OBJECTIVES

To examine the effect of PM2.5 on cardiovascular hospitalisation risk among the elderly and the moderating role of elderly-supportive infrastructure in Wuhan, a city undergoing rapid urbanisation.

METHODS

A time-stratified case-crossover design was adopted in which the K-means cluster analysis was applied to categorize elderly-supportive infrastructure. The correlation of PM2.5 with cardiovascular hospitalisations and the moderating role of elderly-supportive infrastructure were elucidated through the conditional logistic regression and z-test. Nonlinear relationships among variables were determined using restricted cubic splines.

RESULTS

173,486 case days and 589,188 control days were included. The cumulative lag effect of PM2.5 increased over time, peaking at 5 days. For every 10 µg/m3 increase in PM2.5, the risk of hospitalisation rose by 1.5% (OR = 1.0150, 95% CI: 1.0113-1.0190). The aforementioned effect of PM2.5 exposure on health did not differ among varying levels of elderly-supportive infrastructure within a 300 m buffer zone. When the buffer zone was extended to 500 and 1000 m, a higher level of elderly-supportive infrastructure mitigated the adverse effects of short-term PM2.5 exposure on cardiovascular hospitalisations (p = 0.013), particularly for stroke (p = 0.017) and ischaemic heart disease (p = 0.026).

CONCLUSIONS

Our findings suggest that high-level elderly-supportive infrastructure may protect against the adverse effects of PM2.5 on cardiovascular hospitalisation, highlighting the need to optimize elderly-supportive infrastructure for its health benefits in the elderly.

Cardiovascular Disease Screening in Primary School Children

BACKGROUND

Screening for cardiovascular disease (CVD) and its associated risk factors in childhood facilitates early detection and timely preventive interventions. However, limited data are available regarding screening tools and their diagnostic yield when applied in unselected pediatric populations.

AIMS

To evaluate the performance of a CVD screening program, based on history, 12-lead ECG and phonocardiography, applied in primary school children.

METHODS

The methods used were prospective study, with voluntary participation of third-grade primary school children in the region of Crete/Greece, over 6 years (2018-2024). Personal and family history were collected by using a standardized questionnaire and physical evaluation (including weight, height, blood pressure measurement), and cardiac auscultation (digital phonocardiography (PCG)) and 12-lead electrocardiogram (ECG) were recorded at local health stations (Phase I). Following expert verification of responses and obtained data, assisted by designated electronic health record with incorporated decision support algorithms (phase II), pediatric cardiology evaluation at the tertiary referral center followed (phase III).

RESULTS

A total of 944 children participated (boys 49.6%). A total of 790 (83.7%) had Phase I referral indication, confirmed in 311(32.9%) during Phase II evaluation. Adiposity (10.8%) and hypertension (3.2%) as risk factors for CVD were documented in 10.8% and 3.2% of the total population, respectively. During Phase III evaluations (n = 201), the majority (n = 132, 14% of total) of children were considered as having a further indication for evaluation by other pediatric subspecialties for their reported symptoms. Abnormal CVD findings were present in 69 (7.3%) of the study population, including minor/trivial structural heart disease in 23 (2.4%) and 17 (1.8%), respectively, referred due to abnormal cardiac auscultation, and ECG abnormalities in 29 (3%), of which 6 (0.6%) were considered potentially significant (including 1 case of genetically confirmed channelopathy-LQT syndrome).

CONCLUSIONS

CVD screening programs in school children can be very helpful for the early detection of CVD risk factors and of their general health as well. Expert cardiac auscultation and 12-lead ECG allow for the detection of structural and arrhythmogenic heard disease, respectively. Further study is needed regarding performance of individual components, accuracy of interpretation (including computer assisted diagnosis) and cost-effectiveness, before large-scale application of CVD screening in unselected pediatric populations.

Inflammation in the Peri-ACS Period: Ready for Prime Time?

PURPOSE

Inflammation has been demonstrated to negatively impact patients in the peri-ACS period. This narrative review outlines the inflammatory response in ACS, highlighting the role of the NLRP3 inflammasome pathway following acute plaque rupture and coronary intervention and its potential as a pharmacologic target. RECENT: nvestigators have leveraged medications targeting the NLRP3 inflammasome currently used for other inflammatory pathologies, including colchicine, tocilizumab and anakinra. Investigation into these drugs in the peri-ACS period has yielded varying results, with the most encouraging findings in ACS patients treated with tocilizumab. More conflicting data exists for the role of colchicine and anakinra, with many studies limited in their power to detect clinical outcomes and heterogeneity in their patient populations and endpoints. Despite conflicting data, the NLRP3 remains an attractive therapeutic target in the peri-ACS period. Further investigation is required to prove benefit and safety with large clinical trials adequately powered for clinical outcomes.

Prevalence and Risk Factors for Atherosclerotic Cardiovascular Disease in 7704 Individuals: An Analysis from the Greek Registry for the Prevalence of Familial Hypercholesterolemia (GRegistry-FH)

The intention of this study was to profile the cohort from the Greek Registry for the prevalence of Familial Hypercholesterolemia (GRegistry-FH) by estimating the prevalence of coronary artery disease (CAD), myocardial infarction (MI), stroke, dyslipidemia, arterial hypertension, diabetes mellitus (DM), pre-DM, smoking, abnormal thyroid function (ATF), and lipid values. The GRegistry-FH is a prospective study involving door-to-door interviews conducted by trained interviewers. Overall, 7704 individuals aged ≥18 years, randomly selected from all the regions of Greece, participated. The prevalence of atherosclerotic cardiovascular disease (ASCVD) was 13.9% (CAD 6%, MI 3.2%, stroke 4.7%). Treated hypercholesterolemia was present in 20.1%, arterial hypertension in 24%, and DM in 11.3% individuals (25.5% had pre-DM). The prevalence of smoking was 37.9% (29% current) and the prevalence of ATF was 13.1% (hypothyroidism 11.3%). A family history of ASCVD was reported by 60.5% (CAD 32.2%, stroke 28.3%). The mean (SD) lipid values in mg/dL were as follows: total cholesterol of 201.8 (41.5), low-density lipoprotein cholesterol of 126.3 (30.1), high-density lipoprotein cholesterol of 51.9 (12.5), and triglycerides of 135.9 (64.7). The GRegistry-FH highlights the significant prevalence of ASCVD and its risk factors among Greek adults, indicating a pressing need for early detection and management strategies to mitigate ASCVD burden. This nationwide registry serves as a crucial tool for guiding public health policies and personalized preventive measures (NCT03140605).

Targeting Key Risk Factors for Cardiovascular Disease in At-Risk Individuals: Developing a Digital, Personalized, and Real-Time Intervention to Facilitate Smoking Cessation and Physical Activity

Health care is under pressure due to an aging population with an increasing prevalence of chronic diseases, including cardiovascular disease. Smoking and physical inactivity are 2 key preventable risk factors for cardiovascular disease. Yet, as with most health behaviors, they are difficult to change. In the interdisciplinary Perfect Fit project, scientists from different fields join forces to develop an evidence-based virtual coach (VC) that supports smokers in quitting smoking and increasing their physical activity. In this Viewpoint paper, intervention content, design, and implementation, as well as lessons learned, are presented to support other research groups working on similar projects. A total of 6 different approaches were used and combined to support the development of the Perfect Fit VC. The approaches used are (1) literature reviews, (2) empirical studies, (3) collaboration with end users, (4) content and technical development sprints, (5) interdisciplinary collaboration, and (6) iterative proof-of-concept implementation. The Perfect Fit intervention integrates evidence-based behavior change techniques with new techniques focused on identity change, big data science, sensor technology, and personalized real-time coaching. Intervention content of the virtual coaching matches the individual needs of the end users. Lessons learned include ways to optimally implement and tailor interactions with the VC (eg, clearly explain why the user is asked for input and tailor the timing and frequency of the intervention components). Concerning the development process, lessons learned include strategies for effective interdisciplinary collaboration and technical development (eg, finding a good balance between end users' wishes and legal possibilities). The Perfect Fit development process was collaborative, iterative, and challenging at times. Our experiences and lessons learned can inspire and benefit others. Advanced, evidence-based digital interventions, such as Perfect Fit, can contribute to a healthy society while alleviating health care burden.

Cost-effectiveness of metacognitive therapy for cardiac rehabilitation participants with symptoms of anxiety and/or depression: analysis of a randomised controlled trial

OBJECTIVES

The burden of cardiovascular disease (CVD) is increasing. Cardiac rehabilitation (CR) is a complex intervention offered to patients with CVD, following a heart event, diagnosis or intervention, and it aims to reduce mortality and morbidity. The objective of this within-trial economic evaluation was to compare the cost-effectiveness of metacognitive therapy (MCT) plus usual care (UC) to UC, from a health and social care perspective in the UK.

METHODS

A multicentre, single-blind, randomised controlled trial (ISRCTN74643496) was conducted in the UK involving 332 patients with CR with elevated symptoms of anxiety and/or depression and compared group-based MCT with UC. The primary outcome of the cost-effectiveness analysis was quality-adjusted life-years (QALYs). The time horizon of the primary analysis was a 12-month follow-up. Missing data were imputed using multiple imputation. Uncertainty was explored by probabilistic bootstrapping. Sensitivity analyses tested the impact of the study design and assumptions on the incremental cost-effectiveness ratio.

RESULTS

In the primary cost-effectiveness analysis, MCT intervention was dominant, with a cost-saving (net cost -£219; 95% CI -£1446, £1007) and QALY gains (net QALY 0.015; 95% CI -0.015, 0.045). However, there is a high level of uncertainty in the estimates. At a threshold of £30 000 per QALY, MCT intervention of around 76% was likely to be cost-effective.

CONCLUSIONS

Results suggest that intervention may be cost-saving and health-increasing; however, findings are uncertain and subject to limitations. Further research should aim to reduce the uncertainty in the findings (eg, with larger sample sizes) and explore potential longer-term economic benefits associated with MCT in this setting.