High-risk coronary plaque in SLE: low-attenuation non-calcified coronary plaque and positive remodelling index

Current understanding and management of cardiovascular involvement in rheumatic immune-mediated inflammatory diseases

Immune-mediated inflammatory diseases (IMIDs) are a spectrum of disorders of overlapping immunopathogenesis, with a prevalence of up to 10% in Western populations and increasing incidence in developing countries. Although targeted treatments have revolutionized the management of rheumatic IMIDs, cardiovascular involvement confers an increased risk of mortality and remains clinically under-recognized. Cardiovascular pathology is diverse across rheumatic IMIDs, ranging from premature atherosclerotic cardiovascular disease (ASCVD) to inflammatory cardiomyopathy, which comprises myocardial microvascular dysfunction, vasculitis, myocarditis and pericarditis, and heart failure. Epidemiological and clinical data imply that rheumatic IMIDs and associated cardiovascular disease share common inflammatory mechanisms. This concept is strengthened by emergent trials that indicate improved cardiovascular outcomes with immune modulators in the general population with ASCVD. However, not all disease-modifying therapies that reduce inflammation in IMIDs such as rheumatoid arthritis demonstrate equally beneficial cardiovascular effects, and the evidence base for treatment of inflammatory cardiomyopathy in patients with rheumatic IMIDs is lacking. Specific diagnostic protocols for the early detection and monitoring of cardiovascular involvement in patients with IMIDs are emerging but are in need of ongoing development. This Review summarizes current concepts on the potentially targetable inflammatory mechanisms of cardiovascular pathology in rheumatic IMIDs and discusses how these concepts can be considered for the diagnosis and management of cardiovascular involvement across rheumatic IMIDs, with an emphasis on the potential of cardiovascular imaging for risk stratification, early detection and prognostication.

Cardiovascular disease risk in systemic lupus erythematous: Certainties and controversies

Patients with systemic lupus erythematosus (SLE) experience greater cardiovascular morbidity and mortality compared to the general population. It is known that endothelial dysfunction, an early indicator of atherosclerosis development, can arise even without the presence of conventional cardiovascular risk factors. In fact, the risk factors contributing to cardiovascular disease can be classified into traditional risk factors and those uniquely associated with SLE such as disease activity, autoantibodies, etc.Furthermore, the pathogenesis of cardiovascular disease in SLE is linked to the activation of both the innate and adaptive immune systems. Given these findings, it is essential for clinicians to acknowledge the heightened CVD risk in SLE patients, perform comprehensive screenings for cardiovascular risk factors, and implement aggressive treatment strategies for those who exhibit signs of clinical CVD. The aim of this review is to summarize the findings on cardiovascular disease in SLE and to examine potential screening and therapeutic strategies for clinical practice.

Non-invasive imaging innovation: FFR-CT combined with plaque characterization, safeguarding your cardiac health

Studies have shown that high-risk plaque features (including thin fibrous caps, lipid-rich cores, large plaque volumes, and intraplaque microcalcifications) are closely associated with the occurrence of acute coronary events. CT-derived fractional flow reserve (CT-FFR) is a non-invasive imaging post-processing technique that utilizes artificial intelligence to analyze data obtained from conventional coronary CT angiography (CCTA). FFR-CT technology offers the hemodynamic assessment of coronary lesions, aiding in the prediction of potential cardiovascular risks. This review summarizes the latest research progress on the complex relationship between FFR-CT, plaque characteristics, and hemodynamics, closely linking plaque volume, composition, and distribution with the clinical significance of coronary artery stenosis. It is hoped that these research findings will provide valuable guidance for clinicians, promoting the application of CT in the non-invasive detection of vulnerable plaques, thereby more effectively preventing and managing coronary artery disease. In the future, further optimization of FFR-CT technology and expansion of its clinical application are expected to significantly reduce the incidence and mortality of coronary artery disease, offering new hope for the prevention and treatment of cardiovascular diseases.

Vascular damage in systemic lupus erythematosus

Vascular disease is a major cause of morbidity and mortality in patients with systemic autoimmune diseases, particularly systemic lupus erythematosus (SLE). Although comorbid cardiovascular risk factors are frequently present in patients with SLE, they do not explain the high burden of premature vascular disease. Profound innate and adaptive immune dysregulation seems to be the primary driver of accelerated vascular damage in SLE. In particular, evidence suggests that dysregulation of type 1 interferon (IFN-I) and aberrant neutrophils have key roles in the pathogenesis of vascular damage. IFN-I promotes endothelial dysfunction directly via effects on endothelial cells and indirectly via priming of immune cells that contribute to vascular damage. SLE neutrophils are vasculopathic in part because of their increased ability to form immunostimulatory neutrophil extracellular traps. Despite improvements in clinical care, cardiovascular disease remains the leading cause of mortality among patients with SLE, and treatments that improve vascular outcomes are urgently needed. Improved understanding of the mechanisms of vascular injury in inflammatory conditions such as SLE could also have implications for common cardiovascular diseases, such as atherosclerosis and hypertension, and may ultimately lead to personalized therapeutic approaches to the prevention and treatment of this potentially fatal complication.

Use of coronarycomputed tomography for cardiovascular risk assessment in immune-mediated inflammatory diseases

Immune-mediated inflammatory diseases (IMIDs) are recognised risk factors for accelerated atherosclerotic cardiovascular disease (CVD), particularly in younger individuals and women who lack traditional CVD risk factors. Reflective of the critical role that inflammation plays in the formation, progression and rupture of atherosclerotic plaques, research into immune mechanisms of CVD has led to the identification of a range of therapeutic targets that are the subject of ongoing clinical trials. Several key inflammatory pathways implicated in the pathogenesis of atherosclerosis are targeted in people with IMIDs. However, cardiovascular risk continues to be systematically underestimated by conventional risk assessment tools in the IMID population, resulting in considerable excess CVD burden and mortality. Hence, there is a pressing need to improve methods for CVD risk-stratification among patients with IMIDs, to better guide the use of statins and other prognostic interventions. CT coronary angiography (CTCA) is the current first-line investigation for diagnosing and assessing the severity of coronary atherosclerosis in many individuals with suspected angina. Whether CTCA is also useful in the general population for reclassifying asymptomatic individuals and improving long-term prognosis remains unknown. However, in the context of IMIDs, it is conceivable that the information provided by CTCA, including state-of-the-art assessments of coronary plaque, could be an important clinical adjunct in this high-risk patient population. This narrative review discusses the current literature about the use of coronary CT for CVD risk-stratification in three of the most common IMIDs including rheumatoid arthritis, psoriasis and systemic lupus erythematosus.

Pericardial fat volume and coronary risk factors as predictors of non-calcified coronary plaque presence among patients with coronary calcium score = 0

INTRODUCTION

There is scarce data linking pericardial fat volume (PFV) and classical coronary risk factors with non-calcified plaque presence among patients with CAC = 0 in the literature.

MATERIAL AND METHOD

A total of 811 patients with chest pain suggestive of angina underwent CT coronary angiography for the assessment of coronary artery disease were collected. Of these, 417 with CAC = 0 were included in the analysis.

RESULT

Patients with non-calcified plaque were older (54 ± 9 versus 50 ± 10, P = 0.01) and had a higher prevalence of diabetes mellitus (31% versus 17%, P = 0.02), high BMI (29.9 versus 28.3, P = 0.04), and increased PFV (123 cm3 versus 99 cm3, P < 0.01) compared to patients without plaque. In multivariate regression analysis, high BMI[OR(CI) = 1.1(1-1.3), P = 0.02] was an independent predictor of non-calcified coronary plaque presence among patients with CAC = 0 after adjustment to variables with P < 0.05 in the univariate analysis.

CONCLUSION

In patients with a CAC score of 0, advanced age, diabetes mellitus, increased PFV, and high BMI were all associated with the presence of non-calcified plaque. After multivariate adjustment, increased BMI remained a significant independent predictor for non-calcified plaque presence.

Atherosclerosis in Systemic Lupus Erythematosus

PURPOSE OF THE REVIEW

Systemic lupus erythematosus (SLE) patients are at increased risk of cardiovascular disease (CVD) compared to the general population, despite most patients being young females, who are not classically considered to be at high risk for cardiovascular disease using traditional risk assessment tools. The purpose of this review is to discuss the pathophysiology of atherosclerosis in SLE and raise awareness of the relationship between SLE and CVD.

RECENT FINDINGS

The increased risk of CVD in SLE patients is multifactorial, due to proatherogenic lipid profiles, immune dysregulation and inflammation, side effects of lupus treatment, and microvascular dysfunction. Conventional CV risk models often underperform in the identification of SLE patients at high risk of atherosclerosis. The use of non-invasive imaging serves as a strategy to identify patients with evidence of subclinical CVD and in the evaluation of symptomatic patients. Identification of subclinical atherosclerosis allows for aggressive management of CV risk factors. SLE patients experience an increased risk of atherosclerotic CVD, which is not solely explained by traditional CV risk factors. It is imperative that clinicians are aware of this association to implement prompt detection and treatment of atherosclerotic CVD in SLE patients.

Relationship of cardiovascular risk factors, pericardial fat, and carotid thickness with coronary plaque type in patients with diabetes mellitus

Background

There is paucity of data on the potential predictors of coronary plaque types among patients with diabetes mellitus(DM).

Aims

To assess the association of cardiovascular risk factors, pericardial fat volume (PFV) assessed by multi-detector CT(MDCT)angiography, and internal carotid intima media thickness with coronary atherosclerotic plaque types in patients with type 2 DM.

Patients and methods

Patients with suspected coronary artery disease who underwent 64-slice MDCT angiography were enrolled in this retrospective study.

Results

A total of 784 patients were enrolled in this study, 198 of whom had DM and 586 of whom did not. The prevalence of calcified and mixed plaques was significantly higher in the DM group than without DM group, while no significant difference was found in the distribution of non-calcified plaque between groups. There was significant association between smoking [OR(CI) = 4(2-10),P = 0.001] and increased age[OR(CI) = 1.1(1-1.3),P = 0.023] and calcified plaque presence. Regarding mixed and non-calcified plaque, increased PFV[OR(CI) = 1.1(1-1.3),P = 0.001] and positive family history[OR(CI) = 4(2-12),P = 0.049] showed a significant association with coronary mixed plaque presence while no significant association was observed between cardiovascular risk factors, PFV, and internal carotid intima media thickness and non-calcified plaque presence in patients with DM.

Conclusion

Increased PFV showed significant and independent association with mixed coronary plaques development, which suggests that PFV may be used as an imaging marker for early detection of increased risk for future coronary events in patients with DM.

High-risk Coronary Plaque Regression in Cash-based Contingency Management Intervention Among Cocaine Users With HIV-associated Subclinical Coronary Atherosclerosis

BACKGROUND

Cocaine use exacerbates human immunodeficiency virus (HIV)-associated subclinical coronary atherosclerosis. We investigated whether cocaine abstinence or reduced use achieved with contingency management (CM) intervention would retard high-risk coronary plaque progression among cocaine users with HIV and subclinical coronary atherosclerosis.

METHODS

Between March 2014 and August 2017, 76 cocaine users with HIV and coronary plaques were enrolled in a study designed to decrease cocaine use and determine whether doing so impacted progression of subclinical coronary atherosclerosis as measured by coronary artery computed tomography examinations. Of the 76, 7 did not complete the study, resulting in 69 participants. A 12-month cash-based CM intervention was implemented to promote cocaine abstinence or reduced cocaine use. Generalized estimating equation approach was used to perform longitudinal data analyses.

FINDINGS

During the 12-month CM, all 69 participants reduced cocaine use, and of these, 25 (36%; 95% confidence interval, 25%-49%) achieved cocaine abstinence. After adjusting for potential confounding factors, generalized estimating equation analyses showed that (1) endothelin-1 (ET-1) levels, a proinflammatory biomarker for endothelial dysfunction, at the 6-month and 12-month visits were significantly lower compared with baseline ET-1 ( P = 0.001 and P < 0.001, respectively), and (2) low-attenuation noncalcified coronary plaque volume, a predictor for myocardial infarction, at 12-month visit was significantly lower compared with baseline low-attenuation noncalcified coronary plaque volume ( P < 0.05).

CONCLUSIONS

The findings of this study have not only demonstrated that CM is effective in achieving a sustained reduction in cocaine use, but also provided compelling evidence that reduction in cocaine use leads to quantifiable cardiovascular health benefits, including concurrent decrease in high-risk plaque burden and ET-1, among cocaine users with HIV-associated coronary atherosclerosis.

Coronary plaque progression is greater in systemic lupus erythematosus than rheumatoid arthritis

BACKGROUND

Systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) are associated with a high incidence of cardiovascular disease. Coronary atherosclerosis, particularly total plaque and noncalcified plaque on coronary computed tomography angiography (CCTA) has been correlated with cardiovascular events. We compared baseline coronary plaque burden and progression by serial CCTA in SLE and RA patients.

METHODS

We prospectively evaluated 44 patients who underwent serial CCTA examinations to quantify coronary plaque progression, 22 SLE patients, and 22 age- and sex-matched RA patients. Semiautomated plaque software was used for quantitative plaque assessment. Linear regression examined the effect of SLE diagnosis (versus RA) on annualized change in natural log-transformed total normalized atheroma volume (ln-TAV norm ) for low-attenuation, fibrofatty, fibrous, total noncalcified, densely calcified, and total plaque.

RESULTS

No quantitative differences for any plaque types were observed at baseline between SLE and RA patients ( P  = 0.330-0.990). After adjustment for baseline plaque and cardiovascular risk factors, the increase in ln-TAV norm was higher in SLE than RA patients for fibrous [Exp-β: 0.202 (0.398), P  = 0.0003], total noncalcified [Exp-β: 0.179 (0.393), P  = 0.0001], and total plaque volume [Exp-β: 0.154 (0.501), P  = 0.0007], but not for low-attenuation, fibrofatty, or densely calcified plaque ( P  = 0.103-0.489). Patients with SLE had 80% more fibrous, 82% more noncalcified, and 85% more total plaque increase than those with RA.

CONCLUSION

Coronary plaque volume was similar in RA and SLE at baseline. Progression was greater in SLE, which may explain the greater cardiovascular risk in this disease. Further research to evaluate screening and management strategies for cardiovascular disease in these high-risk patients is warranted.

The role of MBL, PCT, CRP, neutrophil-lymphocyte ratio, and platelet lymphocyte ratio in differentiating infections from flares in lupus

BACKGROUND

The distinction between infection and flare in systemic lupus erythematosus (SLE) has always been a dilemma for clinicians as the clinical and biochemical profiles overlap. The present study evaluated affordable biomarkers to distinguish infection from flare in an SLE cohort in a tertiary care center in eastern India.

METHODS

One hundred and fifty-two SLE patients were clinically evaluated and enrolled in the present study. Hematological, immunological, and biochemical profiles and various biomarkers such as C reactive protein (CRP), procalcitonin (PCT), and Mannose-binding lectin (MBL) were quantified.

RESULTS

One hundred and fifty-two patients (152) were enrolled in the present study and all had SLEDAI scores of more than 4. From which 70 had infection, and the common infections were urinary tract infection (34.28%) followed by pneumonia (27.14%). Neutrophil-lymphocyte ratio (NLR) and C-reactive protein (CRP) were significantly elevated in SLE with infections (NLR: 5.84 ± 2.47; CRP: 30.56 ± 41.63) than those with flare (NLR: 3.87 ± 2.62; CRP: 8.73 ± 9.53). The receiver operating characteristic curve (ROC) analysis revealed CRP, PLR, and NLR as important markers for predicting infections (CRP: AUC = 0.682, p = 0.0001; PLR: AUC = 0.668, p = 0.0008; NLR: AUC = 0.742, p < 0.0001). The MBL and PCT levels were comparable among SLE flare and those with infections.

CONCLUSIONS

NLR and CRP levels are affordable biomarkers to distinguish infections from flares in SLE. MBL and PCT could not differentiate flare from an infection. Key Points • Biomarkers for the differentiation of infection and flare in SLE are limited. • NLR, PLR, and CRP are promising biomarkers to enable differentiation. • PCT and MBL are not ideal biomarkers to differentiate infection from flare.

Asymptomatic coronary artery disease assessed by coronary computed tomography in patients with systemic lupus erythematosus: A systematic review and meta-analysis

BACKGROUND

Coronary artery disease (CAD) assessed by coronary computed tomography (CT) in patients with systemic lupus erythematosus (SLE) has been investigated in several studies, but with conflicting results. The aim of this systematic review and meta-analysis of the literature was synthesize the evidence on this topic.

METHODS

The relevant literature was identified and evaluated from inception until January 2021 in PubMed, Embase, Web of Science and Cochrane library. Studies reporting coronary artery calcification (CAC), and its prevalence and extent using the coronary calcium score (CCS) were included. Data extracted from eligible studies were used to calculate effect estimates (ESs) and 95% confidence intervals (95%CI) and weighted mean differences (WMD) with 95%CI.

RESULTS

Twenty-four studies were eligible for inclusion. For the CAC prevalence, 11 studies were included (918 SLE patients and 3952 controls) and the pooled prevalence for the random effect was 29.8% (95%CI 25.7-32.9%) for SLE patients and 11.8% (95%CI 16.2-20.4%) in controls (RR 2.22, 95%CI 1.42 to 3.48; p= 0.0005) and no significant increase in the WMD for CCS (MD= 0.32, 95%CI -5.55 to 6.20, p= 0.91) compared with controls in seven studies. Greater organ damage and glucocorticoid use has been associated with a higher CCS. According to two studies, the coronary CT angiography calcified and non-calcified plaque burden were increased in SLE patients compared with controls.

CONCLUSIONS

In SLE, asymptomatic CAD by CAC is more prevalent and there is more multivessel disease compared with controls without lupus. However, the extent of CAC was not increased in SLE patients.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021228710.

Cardiovascular disease risk and pathogenesis in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) often features extensive cardiovascular (CV) comorbidity and patients with SLE are at significantly increased risk of CV event occurrence and CV-related mortality. While the specific mechanisms leading to this increased cardiovascular disease (CVD) risk remain to be fully characterized, this heightened risk cannot be fully explained by traditional CV risk factors and is likely driven by immunologic and inflammatory features of SLE. Widespread innate and adaptive immune dysregulation characterize SLE, and factors including excessive type I interferon burden, inappropriate formation and ineffective clearance of neutrophil extracellular traps, and autoantibody formation have been linked to clinical and metabolic features impacting CV risk in SLE and may represent pathogenic drivers of SLE-related CVD. Indeed, functional and phenotypic aberrations in almost every immune cell type are present in SLE and may impact CVD progression. As understanding of the contribution of SLE-specific factors to CVD in SLE improves, improved screening and monitoring of CV risk alongside development of therapeutic treatments aimed at prevention of CVD in SLE patients are required and remain the focus of several ongoing studies and lines of inquiry.

Cardiovascular disease risk and pathogenesis in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) often features extensive cardiovascular (CV) comorbidity and patients with SLE are at significantly increased risk of CV event occurrence and CV-related mortality. While the specific mechanisms leading to this increased cardiovascular disease (CVD) risk remain to be fully characterized, this heightened risk cannot be fully explained by traditional CV risk factors and is likely driven by immunologic and inflammatory features of SLE. Widespread innate and adaptive immune dysregulation characterize SLE, and factors including excessive type I interferon burden, inappropriate formation and ineffective clearance of neutrophil extracellular traps, and autoantibody formation have been linked to clinical and metabolic features impacting CV risk in SLE and may represent pathogenic drivers of SLE-related CVD. Indeed, functional and phenotypic aberrations in almost every immune cell type are present in SLE and may impact CVD progression. As understanding of the contribution of SLE-specific factors to CVD in SLE improves, improved screening and monitoring of CV risk alongside development of therapeutic treatments aimed at prevention of CVD in SLE patients are required and remain the focus of several ongoing studies and lines of inquiry.

Assessment and management of the heightened risk for atherosclerotic cardiovascular events in patients with lupus erythematosus or dermatomyositis

For patients with lupus erythematosus (LE) or dermatomyositis (DM), there is an urgent need to address a heightened risk of clinical events, chiefly heart attacks and strokes, caused by atherosclerotic cardiovascular disease (ASCVD). Patients with LE or DM frequently exhibit high levels of conventional risk factors for ASCVD events, particularly dyslipoproteinemia and hypertension; an amplified burden of atherosclerotic plaques; and increased age- and sex-adjusted rates of ASCVD events compared with the general population. The rate of ASCVD events exceeds what would be expected from conventional risk factors, suggesting that disease-specific autoimmune processes exacerbate specific, known pathogenic steps in atherosclerosis. Importantly, despite their heightened risk, patients with LE or DM are often undertreated for known causative agents and exacerbators of ASCVD. Herein, we propose an approach to assess and manage the heightened risk of ASCVD events in patients with LE or DM. Our approach is modeled in large part on established approaches to patients with diabetes mellitus or stage 3 or 4 chronic kidney disease, which are well-studied conditions that also show heightened risk for ASCVD events and have been explicitly incorporated into standard clinical guidelines for ASCVD. Based on the available evidence, we conclude that patients with LE or DM require earlier and more aggressive screening and management of ASCVD. We suggest that physicians consider implementing multipliers of conventional risk calculators to trigger earlier initiation of lifestyle modifications and medical therapies in primary prevention of ASCVD events, employ vascular imaging to quantify the burden of subclinical plaques, and treat to lower lipid targets using statins and newer therapies, such as PCSK9 inhibitors, that decrease ASCVD events in nonautoimmune cohorts. More clinical vigilance is needed regarding surveillance, prevention, risk modification, and treatment of dyslipidemias, hypertension, and smoking in patients with LE or DM. All of these goals are achievable.

Chronic inflammatory diseases and coronary heart disease: Insights from cardiovascular CT

Epidemiological and clinical studies have demonstrated a consistent relationship between increased systemic inflammation and increased risk of cardiovascular events. In chronic inflammatory states, traditional risk factors only partially account for the development of coronary artery disease (CAD) but underestimate total cardiovascular risk likely due to the residual risk of inflammation. Computed coronary tomography angiography (CCTA) may aid in risk stratification by noninvasively capturing early CAD, identifying high risk plaque morphology and quantifying plaque at baseline and in response to treatment. In this review, we focus on reviewing studies on subclinical atherosclerosis by CCTA in individuals with chronic inflammatory conditions including rheumatoid arthritis (RA), systemic lupus erythematous (SLE), human immunodeficiency virus (HIV) infection and psoriasis. We start with a brief review on the role of inflammation in atherosclerosis, highlight the utility of using CCTA to delineate vessel wall and plaque characteristics and discuss combining CCTA with laboratory studies and emerging technologies to complement traditional risk stratification in chronic inflammatory states.

Elucidating the Intriguing Association Between Systemic Lupus Erythematosus and Cardiovascular Disease

Systemic lupus erythematosus (SLE) patients have demonstrated a higher risk of developing cardiovascular disease (CVD), resulting in it being one of the leading causes of death in SLE patients. SLE itself acts as a sole risk factor influencing the prevalence and progression of CVD. However, conventional risk factors, such as age, hypertension, smoking, and obesity, play a crucial role as well. Therefore, this systematic review attempts to unravel the association of CVD in SLE patients while evaluating the role of conventional risk factors. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to search the PubMed database starting from March 2021 systematically. Original studies that evaluated the prevalence and progression of CVD in SLE patients were extracted by two reviewers independently. Quality in Prognostic Studies (QUIPS) tool was used to assess the risk of bias. Most studies have a moderate to low risk of bias. Among 3,653 studies identified by our search, 10 studies were included in the review. Strong epidemiologic evidence of SLE patients having an increased relative risk of CVD compared to controls was found. Traditional CVD risk factors, such as age, hypertension, obesity, and smoking, influence the prevalence of CVD among SLE patients. Several SLE-specific factors such disease activity, duration, and certain medications also acted as influencing factors. However, the relative risk of CVD was still higher in SLE patients after adjustment of certain risk factors. One study found that the odds of having a Coronary Artery Calcification (CAC) score greater than zero in women with SLE aged less than or equal to 45 years was 12.6 times higher than women in the Coronary Artery Risk Development in Young Adults (CARDIA) cohort (95% CI 5.2 to 30.7) (participants of CARDIA cohort acted as control). This finding was made after age, hypertension, total cholesterol levels, and aspirin use were adjusted, and the study was restricted to women. Although conventional risk factors increase CVD prevalence, SLE itself also dramatically increases the prevalence of CVD. Therefore, we recommend that SLE should be treated as a "CVD risk equivalent." SLE patients should be managed more extensively with greater emphasis given to cardiac health for better clinical outcomes.