Thrombosis, physical activity, and acute coronary syndromes

Physical activity lowers all-cause and cardio-cerebrovascular mortality in adults with coronary heart disease

BACKGROUND

The health outcomes and their adherence to guideline-based secondary prevention physical activity in US patients with coronary heart disease (CHD), together with the association between physical activity (PA) and mortality risk, were investigated.

METHODS

Data on CHD patients (aged 18 to 85 years) was acquired from the US National Health and Nutrition Examination Survey (NHANES) 1999-2018. The patients were divided into four groups according to the level and frequency of PA, namely, a) sedentary (n = 1178), b) moderate PA (moderate, n = 270), c) vigorous PA once or twice per week (vigorous ≤2×, n = 206), and d) vigorous PA three or more times per week (vigorous >2×, n = 598). Logistic analysis was used to determine the relationship between PA and all-cause or cardio-cerebrovascular mortality in CHD patients.

RESULTS

A total of 2252 patients with CHD were enrolled, of whom 47.69% reported adequate PA. During the investigation, there were 296 (13.14%) cardio-cerebrovascular and 724 (32.15%) all-cause deaths. The incidence of all-cause or cardio-cerebrovascular death was lowest in the vigorous ≤2× group. Patients who undertook vigorous PA ≤ 2× showed the lowest risk of all-cause (odds ratio 0.32; 95% confidence interval 0.22-0.47; P < 0.01) or cardio-cerebrovascular death (odds ratio 0.43; 95% confidence interval 0.25-0.73; P < 0.01) relative to those in the sedentary group. More frequent vigorous PA did not lead to improved benefits.

CONCLUSIONS

Vigorous PA once or twice per week was more effective for reducing all-cause and cardio-cerebrovascular mortality compared with patients performing no or a moderate level of PA in US adults with CHD.

The interplay of collagen, macrophages, and microcalcification in atherosclerotic plaque cap rupture mechanics

The rupture of an atherosclerotic plaque cap overlying a lipid pool and/or necrotic core can lead to thrombotic cardiovascular events. In essence, the rupture of the plaque cap is a mechanical event, which occurs when the local stress exceeds the local tissue strength. However, due to inter- and intra-cap heterogeneity, the resulting ultimate cap strength varies, causing proper assessment of the plaque at risk of rupture to be lacking. Important players involved in tissue strength include the load-bearing collagenous matrix, macrophages, as major promoters of extracellular matrix degradation, and microcalcifications, deposits that can exacerbate local stress, increasing tissue propensity for rupture. This review summarizes the role of these components individually in tissue mechanics, along with the interplay between them. We argue that to be able to improve risk assessment, a better understanding of the effect of these individual components, as well as their reciprocal relationships on cap mechanics, is required. Finally, we discuss potential future steps, including a holistic multidisciplinary approach, multifactorial 3D in vitro model systems, and advancements in imaging techniques. The obtained knowledge will ultimately serve as input to help diagnose, prevent, and treat atherosclerotic cap rupture.

Impact of pre-admission physical activity on benefits of physiology-guided complete revascularization in older patients with myocardial infarction: insights from the FIRE trial

AIMS

The present analysis from the Functional Assessment in Elderly Myocardial Infarction Patients with Multivessel Disease (FIRE) trial aims to explore the significance of pre-admission physical activity and assess whether the benefits of physiology-guided complete revascularization apply consistently to sedentary and active older patients.

METHODS AND RESULTS

Patients aged 75 years or more with myocardial infarction (MI) and multivessel disease were randomized to receive physiology-guided complete revascularization or culprit-only strategy. The primary outcome was a composite of death, MI, stroke, or any revascularization within a year. Secondary endpoints included the composite of cardiovascular death or MI, as well as single components of the primary endpoint. Pre-admission physical activity was categorized into three groups: (i) absent (sedentary), (ii) light, and (iii) vigorous. Among 1445 patients, 692 (48%) were sedentary, whereas 560 (39%) and 193 (13%) performed light and vigorous physical activity, respectively. Patients engaging in light or vigorous pre-admission physical activity exhibited a reduced risk of the primary outcome compared with sedentary individuals [light hazard ratio (HR) 0.70, 95% confidence interval (CI) 0.55-0.91 and vigorous HR 0.14, 95% CI 0.07-0.91, respectively]. These trends were also observed for death, cardiovascular death, or MI. When comparing physiology-guided complete revascularization vs. culprit-only strategy, no significant interaction was observed for primary and secondary endpoints when stratified by sedentary or active status.

CONCLUSION

In older patients with MI, pre-admission physical activity emerges as a robust and independent prognostic determinant. Physiology-guided complete revascularization stands out an effective strategy in reducing ischaemic adverse events, irrespective of pre-admission physical activity status.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT03772743.

Obesity, thrombosis, venous disease, lymphatic disease, and lipedema: An obesity medicine association (OMA) clinical practice statement (CPS) 2023

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) is intended to provide clinicians with an overview on obesity, thrombosis, venous disease, lymphatic disease, and lipedema.

Methods

The scientific support for this CPS is based upon published citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership.

Results

Topics in this CPS include obesity, thrombosis, venous disease, lymphatic disease, and lipedema. Obesity increases the risk of thrombosis and cardiovascular disease via fat mass and adiposopathic mechanisms. Treatment of thrombosis or thrombotic risk includes healthful nutrition, physical activity, and the requisite knowledge of how body weight affects anti-thrombotic medications. In addition to obesity-related thrombotic considerations of acute coronary syndrome and ischemic non-hemorrhagic stroke, this Clinical Practice Statement briefly reviews the diagnosis and management of clinically relevant presentations of deep vein thromboses, pulmonary embolism, chronic venous stasis, varicose veins, superficial thrombophlebitis, lipodermatosclerosis, corona phlebectatica, chronic thromboembolic pulmonary hypertension, iliofemoral venous obstruction, pelvic venous disorder, post-thrombotic syndrome, as well as lymphedema and lipedema - which should be included in the differential diagnosis of other edematous or enlargement disorders of the lower extremities.

Conclusions

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) on obesity, thrombosis, and venous/lymphatic disease is one of a series of OMA CPSs designed to assist clinicians in the care of patients with the disease of obesity.

Comparable effects of circuit and traditional resistance exercise on platelet α2bβ3 receptor and platelet activation and function

BACKGROUND

Resistance exercise induces thrombocytosis and increases platelet activation and function. These changes might be related to exercise variables including exercise intensity and type.

OBJECTIVE

We compared the effects of traditional resistance exercise (TRE) and circuit resistance exercise (CRE) on cellular markers of platelet activation and function.

METHODS

In this crossover study ten healthy male (mean±SD: age, 25.6±2.4 years) subjects performed TRE encompassed 3 sets of 10 repetitions at 100% of 10-RM (10 repetition maximum) for 6 exercises, and CRE protocols included 3 sets of 10 repetitions at 100% of 10-RM for all 6 exercises consecutively, in two separate weeks. To measure platelet indices, PAC1, CD41a, CD42b and CD62P three blood samples were taken before, immediately after exercise, and after 30 min recovery.

RESULTS

Lactate concentration, blood pressure, platelet count (PLT), and mean platelet volume (MPV) were significantly (p <  0.05) increased following both resistance exercise trials. Significant increases in PAC1, and CD62P; and significant reductions for CD42b and CD41a were detected following both REs (p <  0.05). However, changes in PAC1 and CD62P were significantly different between the two protocols (p <  0.05), with higher increases detected following CRE.

CONCLUSIONS

Acute RE increases platelet indices and platelet activation; and that CRE results in higher platelet activation than TRE, probably due to exercise-induced increases in shear stress.

Physicochemical Characterization of Fucoidans from Sargassum henslowianum C.Agardh and Their Antithrombotic Activity In Vitro

Sargassum fucoidan is a kind of sulfated heteropolysaccharide with a variety of biological activities. The aim of this study was to investigate the extraction, purification, physicochemical characterization and in vitro antithrombotic activity of fucoidan from Sargassum henslowianum C.Agardh. Hot-water-assisted ultrasound was used to extract fucoidan (F). Fucoidan was purified by DEAE cellulose 52 (F1), Vc-H2O2 (FD1) and Superdex 75 gel (FDS1). The physical and chemical properties of fucoidans were analyzed by chemical composition, monosaccharide composition, average molecular weight (Mw) and FTIR. The sulfate contents of F, F1, FD1 and FDS1 were 11.45%, 16.35% and 17.52%, 9.66%, respectively; the Mw was 5.677 × 105, 4.393 × 105, 2.176 × 104 and 6.166 × 103, respectively. The results of monosaccharide composition showed that the four fucoidans contained l-fucose, d-galactose, l-mannose, d-xylose, l-rhamnose and d-glucose, but the mass fraction ratio was different. The results of FTIR showed that fucoidan contained characteristic peaks of sugar and sulfate. In vitro, F1, FD1 and FDS1 could alleviate HUVEC damage induced by adrenaline (Adr). F1, FD1 and FDS1 decreased vWF and TF and increased the ratio of t-PA/PAI-1 in Adr-induced HUVEC.

Effectiveness of an individualized home-based physical activity program in surgery-free non-endarterectomized asymptomatic stroke patients: a study protocol for the PACAPh interventional randomized trial

Background

Carotid atherosclerotic plaques remain silent until their rupture, which may lead to detrimental ischemic events such as strokes. This is due, in part, to intraplaque hemorrhages (IPH) and the resulting inflammatory processes, which may promote carotid plaque vulnerability. Currently, the benefits of carotid endarterectomy remain unclear for asymptomatic patients. Interestingly, the completion of physical activity (PA) may have beneficial effects; however, the paucity of current data warrants robust longitudinal interventions. We therefore aim to study the effects of a 6-month longitudinal personalized home-based PA program on IPH, biological, and inflammatory markers in asymptomatic stroke patients.

Methods

Eighty patients (≥ 18 years old) will be recruited for the Physical Activity and Carotid Atherosclerotic Plaque Hemorrhage (PACAPh) clinical trial from the Hospices Civils de Lyon. Patients will be eligible if they present with carotid stenosis ≥ 50% and are asymptomatic from any ischemic events for at least 6 months. Recruited patients will be randomized into either a PA or a control group, and assessed at baseline and after 6 months. At both time points, all patients will be assessed using magnetic resonance imaging to assess IPH, blood sampling to measure inflammatory markers and monocytic phenotyping, PA and sedentary behavior questionnaires, 6-min walking test, and maximal isometric quadricep contraction test. The randomized PA intervention will consist of reaching a daily walking step goal individually tailored to each patient. Steps will be collected using a wirelessly connected wristband. The number of steps completed by individuals in the PA group will be re-evaluated bimonthly to encourage walking habits.

Discussion

The PACAPh study is the first of its kind representing a feasible, easily accessible therapeutic strategy for asymptomatic stroke patients. We hypothesize that the personalized home-based PA program will reduce IPH and modulate inflammatory and biological parameters in patients presenting with carotid plaques. If the results of the PACAPh study prove to be beneficial on such health parameters, the implementation of such kind of intervention in the daily treatment of these patients would be an advantageous and cost-effective practice to adopt globally.

Trial registration

This study has been approved by the National Ethics Committee (IDRCB:2019-A01543-54/SI:19.06.21.40640). ClinicalTrials.gov NCT04053166

Differences in Clinical Nature and Outcome Among Young Patients Suffering from an Acute Coronary Syndrome

Purpose

Acute coronary syndrome (ACS) is a life-threatening cardiac disease identified by acute, regional reductions in coronary blood flow, resulting in myocardial ischemia, or infarction, and manifesting as discomfort in the chest area, neck, or arms. Frequently, ACS is provoked by an atherosclerotic plaque; therefore, coronary atherosclerosis is converted into a chronic disease to an acute medical emergency. The purpose of this study was to explore the differences among these variables in patients less than 45 years of age suffering from this major health problem compared to older adults admitted with an ACS diagnosis, and to adopt an optimized temporary management.

Patients and Methods

A retrospective chart review study was conducted on a total of 652 ACS patients admitted at King Fahad Hospital of the University (KFHU) between 2015 and 2020. The patients' medical records were utilized for obtaining demographic data, presenting symptoms, risk factors, and clinical outcomes.

Results

Overall, 652 patients were enrolled. Of these, 109 patients (16.7%) were under 45, with a mean age of 38 ± 7. Younger patients showed a higher rate of palpitation (23.9% versus. 13.6%; P = 0.019). A positive smoking history and a family history of CAD were seen more often in younger patients (42.2% vs 27.3%, P < 0.001; 22.9% vs 9.4%, P < 0.001, respectively). Older patients had greater renal impairment with higher creatinine (median = 1.10 mg/dl (range, 0.3-13.0) vs 1.0 (0.3-19.0; p = 0. 001), BUN (median = 16.0 (mange, 0.9-141.0) vs 12.0 (0.9-49.0); P < 0.001)). Younger patients had higher levels of LDL and total cholesterol (median 138c. 115; p < 0.001) and cholesterol (median 209 vs 178.5; p < 0.001). Hospital mortality was 0.9% in younger patients versus 7.4% in older patients (P = 0.004).

Conclusion

Palpitations, smoking, family history, higher LDL levels, and total cholesterol levels were more prevalent in adults younger than 45 years old with ACS. Impaired renal function, hypertension, and diabetes were more in older patients with ACS.

Cardiovascular Aging and Longevity: JACC State-of-the-Art Review

Cardiovascular aging and longevity are interrelated through many pathophysiological mechanisms. Many factors that promote atherosclerotic cardiovascular disease are also implicated in the aging process and vice versa. Indeed, cardiometabolic disorders such as hyperglycemia, insulin resistance, dyslipidemia, and arterial hypertension share common pathophysiological mechanisms with aging and longevity. Moreover, genetic modulators of longevity have a significant impact on cardiovascular aging. The current knowledge of genetic, molecular, and biochemical pathways of aging may serve as a substrate to introduce interventions that might delay cardiovascular aging, thus approaching the goal of longevity. In the present review, the authors describe pathophysiological links between cardiovascular aging and longevity and translate these mechanisms into clinical data by reporting genetic, dietary, and environmental characteristics from long-living populations.

Murine models of vascular endothelial injury: Techniques and pathophysiology

Vascular endothelial injury (VEI) triggers pathological processes in various cardiovascular diseases, such as coronary heart disease and hypertension. To further elucidate the in vivo pathological mechanisms of VEI, many animal models have been established. For the easiness of genetic manipulation and feeding, murine models become most commonly applied for investigating VEI. Subsequently, countless valuable information concerning pathogenesis has been obtained and therapeutic strategies for VEI have been developed. This review will highlight some typical murine VEI models from the perspectives of pharmacological intervention, surgery and genetic manipulation. The techniques, pathophysiology, advantages, disadvantages and the experimental purpose of each model will also be discussed.

Physical activity in primary and secondary prevention of cardiovascular disease: Overview updated

Although the observed progress in the cardiovascular disease treatment, the incidence of new and recurrent coronary artery disease remains elevated and constitutes the leading cause of death in the developed countries. Three-quarters of deaths due to cardiovascular diseases could be prevented with adequate changes in lifestyle, including increased daily physical activity. New evidence confirms that there is an inverse dose-response relationship between physical activity and cardiovascular disease and mortality risk. However, participation in moderate to vigorous physical activity may not fully attenuate the independent effect of sedentary activities on increased risk for cardiovascular diseases. Physical activity also plays an important role in secondary prevention of cardiovascular diseases by reducing the impact of the disease, slowing its progress and preventing recurrence. Nonetheless, most of eligible cardiovascular patients still do not benefit from secondary prevention/cardiac rehabilitation programs. The present review draws attention to the importance of physical activity in the primary and secondary prevention of cardiovascular diseases. It also addresses the mechanisms by which physical activity and regular exercise can improve cardiovascular health and reduce the burden of the disease.

Moderate Exercise Attenuates Lipopolysaccharide-Induced Inflammation and Associated Maternal and Fetal Morbidities in Pregnant Rats

Fetal growth restriction (FGR) and coagulopathies are often associated with aberrant maternal inflammation. Moderate-intensity exercise during pregnancy has been shown to increase utero-placental blood flow and to enhance fetal nutrition as well as fetal and placental growth. Furthermore, exercise is known to reduce inflammation. To evaluate the effect of moderate-intensity exercise on inflammation associated with the development of maternal coagulopathies and FGR, Wistar rats were subjected to an exercise regime before and during pregnancy. To model inflammation-induced FGR, pregnant rats were administered daily intraperitoneal injections of E. coli lipopolysaccharide (LPS) on gestational days (GD) 13.5–16.5 and sacrificed at GD 17.5. Control rats were injected with saline. Maternal hemostasis was assessed by thromboelastography. Moderate-intensity exercise prevented LPS-mediated increases in white blood cell counts measured on GD 17.5 and improved maternal hemostasis profiles. Importantly, our data reveal that exercise prevented LPS-induced FGR. Moderate-intensity exercise initiated before and maintained during pregnancy may decrease the severity of maternal and perinatal complications associated with abnormal maternal inflammation.

[An effect of valdoxan on the hemostasis in patients with acute coronary syndrome in the combination with anxiety and depressive disorders]

OBJECTIVE

To explore the dynamics of hemostasis in patients with acute coronary syndrome (ACS) in the combination with anxiety and depressive disorders (ADD) during therapy with valdoxan (agomelatine).

MATERIAL AND METHODS

We examined 196 male and female patients (mean age 64.2 ± 0.8 years) in the first 24 hours of ACS. The patients were divided into three groups: patients with ACS without ADD (n=88), patients with ACS and ADD without valdoxan therapy (n=58) and patients with ACS and ADD treated with valdoxan (n=50). Coagulation and vascular-platelet hemostasis were studied in the first 24 hours of hospitalization and in the 10th day of hospitalization.

RESULTS

Patients with ACS revealed high levels of fibrinogen, soluble fibrin-monomer complexes, D-dimer at all stages of the study. In patients with ADD, these parameters were significantly higher compared to patients without ADD. The levels of D-dimer in the 10th day were similar in patients with ADD treated with valdoxan and in patients with ACS without ADD. In both groups of patients with ADD, the levels of spontaneous aggregation in the first and 10th days of hospitalization were not significantly higher than in the control group and in patients with ACS without ADD. All patients with ACS had high values of platelet aggregation stimulated by adenosine diphosphate in dose 0.1 uM. In patients with ACS and ADD treated with valdoxan, a significant reduction of these parameters was noted in the 10th day of treatment compared to the first day of hospitalization.

CONCLUSION

The high procoagulant activity of the hemostatic system was observed during all stages of the study in the patients with ACS and ADD who received a combined antithrombotic therapy without valdoxan.

Hormone therapy and hemostasis among postmenopausal women: a review

OBJECTIVE

Postmenopausal hormone therapy (HT), which consists of exogenous estrogens with or without combined progestogens, remains the most effective treatment of climacteric symptoms. Depending on its characteristics, it may nevertheless increase the risk of venous thromboembolism, and its effects on hemostasis have been studied for several decades. The aim of this review was to summarize current knowledge on the effects of HT on hemostasis, taking into account the route of estrogen administration, the daily dose and chemical structure of estrogens, and the pharmacologic class of progestogens.

METHODS

Data from randomized controlled trials that included a control group (either placebo or no treatment) were selected, and analysis was conducted on different generations of biomarkers.

RESULTS

Overall, studies showed a hemostasis imbalance among oral estrogen users with a decrease in coagulation inhibitors and an increase in markers of activation coagulation, leading to global enhanced thrombin generation. By contrast, transdermal estrogen use was associated with less change in hemostasis variables and did not activate coagulation and fibrinolysis. No clear difference in HT effects on hemostasis was highlighted between daily doses of estrogens, between estrogen compounds, and between pharmacologic classes of progestogens.

CONCLUSIONS

Changes in hemostasis are in accordance with clinical results showing an increased thrombotic risk with oral--but not transdermal--estrogen use.

Cardioprotection acquired through exercise: the role of ischemic preconditioning

A great bulk of evidence supports the concept that regular exercise training can reduce the incidence of coronary events and increase survival chances after myocardial infarction. These exercise-induced beneficial effects on the myocardium are reached by means of the reduction of several risk factors relating to cardiovascular disease, such as high cholesterol, hypertension, obesity etc. Furthermore, it has been demonstrated that exercise can reproduce the "ischemic preconditioning" (IP), which refers to the capacity of short periods of ischemia to render the myocardium more resistant to subsequent ischemic insult and to limit infarct size during prolonged ischemia. However, IP is a complex phenomenon which, along with infarct size reduction, can also provide protection against arrhythmia and myocardial stunning due to ischemia-reperfusion. Several clues demonstrate that preconditioning may be directly induced by exercise, thus inducing a protective phenotype at the heart level without the necessity of causing ischemia. Exercise appears to act as a physiological stress that induces beneficial myocardial adaptive responses at cellular level. The purpose of the present paper is to review the latest data on the role played by exercise in triggering myocardial preconditioning.

Association between the -794 (CATT)5-8 MIF gene polymorphism and susceptibility to acute coronary syndrome in a western Mexican population

The macrophage migration inhibitory factor (MIF) is related to the progression of atherosclerosis, which, in turn, is a key factor in the development of acute coronary syndrome (ACS). MIF has a CATT short tandem repeat (STR) at position -794 that might be involved in its expression rate. The aim of this study was to investigate the association between the -794 (CATT)5-8  MIF gene polymorphism and susceptibility to ACS in a western Mexican population. This research included 200 ACS patients classified according to the criteria of the American College of Cardiology (ACC) and 200 healthy subjects (HS). The -794 (CATT)5-8  MIF gene polymorphism was analyzed using a conventional polymerase chain reaction (PCR) technique. The 6 allele was the most frequent in both groups (ACS: 54% and HS: 57%). The most common genotypes in ACS patients and HS were 6/7 and 6/6, respectively, and a significant association was found between the 6/7 genotype and susceptibility to ACS (68% versus 47% in ACS and HS, resp., P = 0.03). We conclude that the 6/7 genotype of the MIF -794 (CATT)5-8 polymorphism is associated with susceptibility to ACS in a western Mexican population.

Effect of aerobic interval training and caffeine on blood platelet function

PURPOSE

Hyperactive platelets contribute to the thrombotic response in humans, and exercise transiently increases platelet function. Caffeine is routinely used by athletes as an ergogenic aid, but the combined effect of exercise and caffeine on platelet function has not been investigated.

METHODS

Twelve healthy males were randomly assigned to one of four groups and undertook four experimental trials of a high-intensity aerobic interval training (AIT) bout or rest with ingestion of caffeine (3 mg·kg(-1)) or placebo. AIT was 8 × 5 min at approximately 75% peak power output (approximately 80% V˙O2peak) and 1-min recovery (approximately 40% peak power output, approximately 50% V˙O2peak) intervals. Blood/urine was collected before, 60, and 90 min after capsule ingestion and analyzed for platelet aggregation/activation.

RESULTS

AIT increased platelet reactivity to adenosine diphosphate (placebo 30.3%, caffeine 13.4%, P < 0.05) and collagen (placebo 10.8%, caffeine 5.1%, P < 0.05) compared with rest. Exercise placebo increased adenosine diphosphate-induced aggregation 90 min postingestion compared with baseline (40.5%, P < 0.05), but the increase when exercise was combined with caffeine was small (6.6%). During the resting caffeine protocol, collagen-induced aggregation was reduced (-4.3%, P < 0.05). AIT increased expression of platelet activation marker PAC-1 with exercise placebo (P < 0.05) but not when combined with caffeine.

CONCLUSION

A single bout of AIT increases platelet function, but caffeine ingestion (3 mg·kg(-1)) does not exacerbate platelet function at rest or in response to AIT. Our results provide new information showing caffeine at a dose that can elicit ergogenic effects on performance has no detrimental effect on platelet function and may have the potential to attenuate increases in platelet activation and aggregation when undertaking strenuous exercise.

Pheidippides redux: reducing risk for acute cardiac events during marathon running

Prolonged strenuous exercise such as marathon running transiently increases the absolute and relative risk for sudden cardiac death. A 17-fold increase in the latter over resting baseline in previously sedentary middle-aged men is reduced due to cardioprotection from training in experienced marathon runners. Exertional rhabdomyolysis as a common occurrence during the race is accompanied by neutrophilia and elevated biomarkers of inflammation, including interleukin-6 and C-reactive protein. A hemostatic imbalance with prothrombotic effects includes in vivo platelet activation during the race. Suggesting a pathogenic role for these findings, plaque rupture due to atherothrombosis triggers acute exertional cardiac events, including sudden death, in low-risk runners as in high-risk patients such as those with diabetes mellitus. Strategies including prophylactic aspirin are considered to decrease the risk for acute cardiac events.