2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

Benefits of intensive lipid-lowering therapies in patients with acute coronary syndrome: a systematic review and meta-analysis

BACKGROUND

Previous meta-analyses have investigated the efficacy of lipid-lowering therapies for atherosclerotic cardiovascular disease; however, few have focused on patients with acute coronary syndrome (ACS). This meta-analysis aimed to compare the benefits of intensive lipid-lowering therapy with those of background statin therapy in patients with ACS.

METHODS

Searches were performed on PubMed, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases for articles published until April 13, 2023. Randomized controlled trials that compared intensive lipid-lowering therapies and background statin therapies in patients with prior ACS and recorded the outcome of three-point major cardiovascular events (MACE) were included. The risk ratio (RR) with 95% confidence interval (CI) was used as a measure of primary and secondary outcomes.

RESULTS

Nine trials involving 38,640 patients with ACS were identified. Pooled results suggested that intensive lipid-lowering therapies are associated with a reduction in the risk of three-point MACE (RR, 0.88; 95% CI, 0.83-0.94; p < 0.001), recurrent ACS (RR, 0.82; 95% CI, 0.71-0.96; p = 0.013), nonfatal myocardial infarction (MI) (RR, 0.87; 95% CI, 0.81-0.93; p < 0.001), stroke (RR, 0.83; 95% CI, 0.73-0.94; p = 0.003), and unstable angina-related hospitalization (RR, 0.57; 95% CI, 0.33-0.99; p = 0.046), but not all-cause mortality (RR, 0.94; 95% CI, 0.82-1.07; p = 0.329), cardiovascular disease-related mortality (RR, 0.96; 95% CI, 0.88-1.06; p = 0.457) or coronary revascularization (RR, 0.89; 95% CI, 0.79-1.00; p = 0.057).

CONCLUSIONS

Intensive lipid-lowering therapies may reduce the risk of three-point MACE, recurrent ACS, nonfatal MI, stroke, and hospitalization for unstable angina in patients with ACS undergoing background statin therapy. These results may assist in clinical decision-making for the secondary prevention of cardiovascular events to initiate intensive lipid-lowering therapies immediately after ACS.

The role of myocardial blood volume in the pathophysiology of angina with non-obstructed coronary arteries: The MICORDIS study

BACKGROUND

Angina with Non-Obstructed Coronary Arteries (ANOCA) involves abnormal vasomotor responses. While reduced coronary flow is an established contributor to myocardial hypoxia, myocardial blood volume (MBV) independently regulates myocardial oxygen uptake but its role in ANOCA remains unclear.

OBJECTIVES

We hypothesized that reduced MBV contributes to ANOCA, and associates with insulin resistance in ANOCA.

METHODS

MBV in ANOCA patients was compared to age- and sex-matched healthy controls. ANOCA patients underwent coronary angiography with invasive coronary function testing (CFT) to identify vasospasm and coronary microvascular dysfunction. In all subjects MBV was quantified at baseline, during hyperinsulinemia and during dobutamine-induced stress using myocardial contrast echocardiography (MCE). The hyperinsulinemic-euglycemic clamp was used to assess insulin resistance.

RESULTS

Twenty-eight ANOCA patients (21% men, 56.8 ± 8.6 years) and 28 healthy controls (21% men, 56.5 ± 7.0 years) were included. During CFT 11% of patients showed epicardial vasospasm, 39% microvascular vasospasm, 25% coronary microvascular dysfunction, and 11% of patients had a negative CFT. ANOCA patients had significant lower insulin-sensitivity (p < 0.01). During MCE, ANOCA patients showed a significantly lower MBV at baseline (0.388 vs 0.438 mL/mL, p = 0.04), during hyperinsulinemia (0.395 vs 0.447 mL/mL, p = 0.02), and during dobutamine-induced stress (0.401 vs 0.476 mL/mL, p = 0.030).

CONCLUSIONS

In ANOCA patients MBV is diminished at baseline, during hyperinsulinemia and dobutamine-induced stress in the absence of differences in microvascular recruitment. These findings support the presence of capillary rarefaction in ANOCA patients. ANOCA patients showed metabolic insulin resistance, but insulin did not acutely alter myocardial perfusion.

Lifestyle Medicine in Medical Education: Maximizing Impact

The relationship between lifestyle behaviors and common chronic conditions is well established. Lifestyle medicine (LM) interventions to modify health behaviors can dramatically improve the health of individuals and populations. There is an urgent need to meaningfully integrate LM into medical curricula horizontally across the medical domains and vertically in each year of school and training. Including LM content in medical and health professional curricula and training programs has been challenging. Barriers to LM integration include lack of awareness and prioritization of LM, limited time in the curricula, and too few LM-trained faculty to teach and role model the practice of LM. This limits the ability of health care professionals to provide effective LM and precludes the wide-reaching benefits of LM from being fully realized. Early innovators developed novel tools and resources aligned with current evidence for introducing LM into didactic and experiential learning. This review aimed to examine the educational efforts in each LM pillar for undergraduate and graduate medical education. A PubMed-based literature review was undertaken using the following search terms: lifestyle medicine, education, medical school, residency, and healthcare professionals. We map the LM competencies to the core competency domains of the Accreditation Council for Graduate Medical Education. We highlight opportunities to train faculty, residents, and students. Moreover, we identify available evidence-based resources. This article serves as a "call to action" to incorporate LM across the spectrum of medical education curricula and training.

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.

Impact of AKI on metabolic compensation for respiratory acidosis in ICU patients with AECOPD

PURPOSE

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) can result in severe respiratory acidosis. Metabolic compensation is primarily achieved by renal retention of bicarbonate. The extent to which acute kidney injury (AKI) impairs the kidney's capacity to compensate for respiratory acidosis remains unclear.

MATERIALS AND METHODS

This retrospective analysis covers clinical data between January 2009 and December 2021 for 498 ICU patients with AECOPD and need for respiratory support.

RESULTS

278 patients (55.8%) presented with or developed AKI. Patients with AKI exhibited higher 30-day-mortality rates (14.5% vs. 4.5% p = 0.001), longer duration of mechanical ventilation (median 90 h vs. 14 h; p = 0.001) and more severe hypercapnic acidosis (pH 7.23 vs. 7.28; pCO2 68.5 mmHg vs. 61.8 mmHg). Patients with higher AKI stages exhibited lower HCO3-/pCO2 ratios and did not reach expected HCO3- levels. In a mixed model analysis with random intercept per patient we analyzed the association of pCO2 (independent) and HCO3- (dependent variable). Lower estimates for averaged change in HCO3- were observed in patients with more severe AKI.

CONCLUSION

AKI leads to poor outcomes and compromises metabolic compensation of respiratory acidosis in ICU patients with AECOPD. While buffering agents may aid compensation for severe AKI, their use should be approached with caution.

Diagnostic Yield and Clinical Utility of Coronary Angiography Versus Coronary Function Testing in Women With Angina and Nonobstructive Coronary Arteries

BACKGROUND

Approximately 50% of women referred for invasive coronary angiography have angina and nonobstructive coronary arteries, which includes coronary microvascular dysfunction, vasospastic angina, and other vasomotor disorders. We sought to determine the real-world diagnostic yield of invasive coronary angiography and coronary function testing in women with angina and nonobstructive coronary arteries.

METHODS AND RESULTS

From 2018 to 2023, we enrolled 198 women who underwent either coronary angiography (CA) alone (n=99) or coronary function testing (CFT; n=99). Mean±SD age was 62±10 years (CA alone) compared with 57±10 years (CFT). Coronary angiography was interpreted as nonobstructive coronary artery disease more frequently after CA alone (79% versus 52%). Of the women who underwent CFT, 82% (N=81) were found to have vasomotor disorders, including coronary microvascular dysfunction (27%), vasospastic angina (32%), mixed coronary microvascular dysfunction/vasospastic angina (16%), endothelial dysfunction (10%; without spasm), elevated resting flow (2%), or symptomatic myocardial bridging (4%). Compared with women undergoing CA alone, medications were changed more frequently after CFT at 24 hours (41% versus 65%; P=0.001) and between 24 hours and 30 days (30% versus 44%; P=0.04) with intensification of antianginal therapy (79% versus 92%; P<0.0001) and increased use of calcium channel blockers (36% versus 63%; P<0.0001).

CONCLUSIONS

Our findings demonstrate that women presenting with suspected ischemic heart disease undergoing CA alone only received an anatomic diagnosis, whereas >80% of women undergoing CFT received a specific diagnosis of a coronary vasomotor disorder and greater intensification of antianginal therapy.

DCRM 2.0: Multispecialty practice recommendations for the management of diabetes, cardiorenal, and metabolic diseases

The spectrum of cardiorenal and metabolic diseases comprises many disorders, including obesity, type 2 diabetes (T2D), chronic kidney disease (CKD), atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), dyslipidemias, hypertension, and associated comorbidities such as pulmonary diseases and metabolism dysfunction-associated steatotic liver disease and metabolism dysfunction-associated steatohepatitis (MASLD and MASH, respectively, formerly known as nonalcoholic fatty liver disease and nonalcoholic steatohepatitis [NAFLD and NASH]). Because cardiorenal and metabolic diseases share pathophysiologic pathways, two or more are often present in the same individual. Findings from recent outcome trials have demonstrated benefits of various treatments across a range of conditions, suggesting a need for practice recommendations that will guide clinicians to better manage complex conditions involving diabetes, cardiorenal, and/or metabolic (DCRM) diseases. To meet this need, we formed an international volunteer task force comprising leading cardiologists, nephrologists, endocrinologists, and primary care physicians to develop the DCRM 2.0 Practice Recommendations, an updated and expanded revision of a previously published multispecialty consensus on the comprehensive management of persons living with DCRM. The recommendations are presented as 22 separate graphics covering the essentials of management to improve general health, control cardiorenal risk factors, and manage cardiorenal and metabolic comorbidities, leading to improved patient outcomes.

Food inequity and insecurity and MASLD: burden, challenges, and interventions

Liver disease prevalence, severity, outcomes and hepatic risk factors (for example, unhealthy diet) are heavily affected by socioeconomic status and food insecurity. Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most prevalent liver disease globally and is likely to co-occur with other liver diseases associated with food insecurity. Though weight reduction and adopting a healthy diet can reverse the course of MASLD, gaps between recommendations and practice transcend individual responsibility and preference. Broader sociocultural determinants of food choices (social nutrition) include food insecurity, community and social norms and the local environment, including commercial pressures that target people experiencing poverty, ethnic minorities and children. Food insecurity is a barrier to a healthy diet, as a low-quality diet is often less expensive than a healthy one. Consequently, food insecurity is an 'upstream' risk factor for MASLD, advanced fibrosis and greater all-cause mortality among patients with liver disease. Intervening on food insecurity at four major levels (environment, policy, community and health care) can reduce the burden of liver disease, thereby reducing social and health inequities. In this Review, we report on the current research in the field, the need for implementing proven interventions, and the role liver specialists can have.

Myocardial ischaemic syndromes: a new nomenclature to harmonize evolving international clinical practice guidelines

Since the 1960s, cardiologists have adopted several binary classification systems for acute myocardial infarction (MI) that facilitated improved patient management. Conversely, for chronic stable manifestations of myocardial ischaemia, various classifications have emerged over time, often with conflicting terminology-e.g. 'stable coronary artery disease' (CAD), 'stable ischaemic heart disease', and 'chronic coronary syndromes' (CCS). While the 2019 European guidelines introduced CCS to impart symmetry with 'acute coronary syndromes' (ACS), the 2023 American guidelines endorsed the alternative term 'chronic coronary disease'. An unintended consequence of these competing classifications is perpetuation of the restrictive terms 'coronary' and 'disease', often connoting only a singular obstructive CAD mechanism. It is now important to advance a more broadly inclusive terminology for both obstructive and non-obstructive causes of angina and myocardial ischaemia that fosters conceptual clarity and unifies dyssynchronous nomenclatures across guidelines. We, therefore, propose a new binary classification of 'acute myocardial ischaemic syndromes' and 'non-acute myocardial ischaemic syndromes', which comprises both obstructive epicardial and non-obstructive pathogenetic mechanisms, including microvascular dysfunction, vasospastic disorders, and non-coronary causes. We herein retain accepted categories of ACS, ST-segment elevation MI, and non-ST-segment elevation MI, as important subsets for which revascularization is of proven clinical benefit, as well as new terms like ischaemia and MI with non-obstructive coronary arteries. Overall, such a more encompassing nomenclature better aligns, unifies, and harmonizes different pathophysiologic causes of myocardial ischaemia and should result in more refined diagnostic and therapeutic approaches targeted to the multiple pathobiological precipitants of angina pectoris, ischaemia and infarction.

Vascular medicine in the 21st century: Embracing comprehensive vasculature evaluation and multidisciplinary treatment

The field of vascular medicine has undergone a profound transformation in the 21st century, transforming our approach to assessment and treatment. Atherosclerosis, a complex inflammatory disease that affects medium and large arteries, presents a major challenge for researchers and healthcare professionals. This condition, characterized by arterial plaque formation and narrowing, poses substantial challenges to vascular health at individual, national, and global scales. Its repercussions are far-reaching, with clinical outcomes including ischemic heart disease, ischemic stroke, and peripheral arterial disease-conditions with escalating global prevalence. Early detection of vascular changes caused by atherosclerosis is crucial in preventing these conditions, reducing morbidity, and averting mortality. This article underscored the imperative of adopting a holistic approach to grappling with the intricacies, trajectories, and ramifications of atherosclerosis. It stresses the need for a thorough evaluation of the vasculature and the implementation of a multidisciplinary treatment approach. By considering the entire vascular system, healthcare providers can explore avenues for prevention, early detection, and effective management of this condition, ultimately leading to improved patient outcomes. We discussed current practices and proposed new directions made possible by emerging diagnostic modalities and treatment strategies. Additionally, we considered healthcare expenditure, resource allocation, and the transformative potential of new innovative treatments and technologies.

Healthcare service utilisation among adults with coronary artery disease in rural Aluva, South India: a community-based cross-sectional study

OBJECTIVES

To assess the pattern and determinants of healthcare service utilisation among adults with coronary artery disease (CAD) in a rural setting in Kerala, India.

DESIGN

A community-based cross-sectional analysis conducted within a study cohort.

SETTING

The study was conducted from January 2022 to March 2022 within the ENDIRA Cohort (Epidemiology of Non-communicable Diseases In Rural Areas) in the rural part of Aluva municipality of Ernakulam district, Kerala, India, which comprises five adjacent panchayats with a population of approximately 100, 000 individuals.

PARTICIPANTS

Patients with CAD aged 35-80 years from the ENDIRA cohort with a history of at least one event of myocardial infarction in the past decade.

OUTCOME MEASURES

The main outcome measured was the inadequacy of healthcare service utilisation among patients with CAD. The factors evaluated included age, gender, socioeconomic status, insurance, out of pocket expenses, choice of health care facility for follow up, distance from health centre as well as reported alcohol use, tobacco use and healthcare satisfaction RESULTS: The study encompassed 623 participants with a mean age of 65.12 (±8.55) years, of whom 71% were males. The prevalence of inadequate utilisation of health services was 58.7%. The independent predictors of underutilisation included reported alcohol consumption (adjusted OR (AOR) 2.36; 95% CI 1.41 to 3.95), living more than 20 km from healthcare facilities (AOR 1.96; 95% CI 1.14 to 3.37) as well as the preferences for specific doctors and adequate services at healthcare facilities (AOR 3.43; 95% CI 1.46 to 8.04). The patients with monthly CAD medication expenses exceeding Rs4000 had 0.26 times lesser odds to underuse healthcare services (AOR 0.26; 95% CI 0.10 to 0.65).

CONCLUSION

The study reveals a suboptimal pattern of healthcare service utilisation among patients with CAD. Ensuring community access to standardised, high-quality follow-up care is crucial for enhancing healthcare utilisation following CAD.

Computed Tomography Evaluation of Coronary Atherosclerosis: The Road Travelled, and What Lies Ahead

Coronary CT angiography (CCTA) is now endorsed by all major cardiology guidelines for the investigation of chest pain and assessment for coronary artery disease (CAD) in appropriately selected patients. CAD is a leading cause of morbidity and mortality. There is extensive literature to support CCTA diagnostic and prognostic value both for stable and acute symptoms. It enables rapid and cost-effective rule-out of CAD, and permits quantification and characterization of coronary plaque and associated significance. In this comprehensive review, we detail the road traveled as CCTA evolved to include quantitative assessment of plaque stenosis and extent, characterization of plaque characteristics including high-risk features, functional assessment including fractional flow reserve-CT (FFR-CT), and CT perfusion techniques. The state of current guideline recommendations and clinical applications are reviewed, as well as future directions in the rapidly advancing field of CT technology, including photon counting and applications of artificial intelligence (AI).

Factors Influencing the Participation of Shared Decision Making in Stable Coronary Artery Disease Patient: Protocol of a Mixed Methods Study

INTRODUCTION

The "paternalistic decision-making model" is no longer well suited to the modern clinical environment, and therefore, shared decision making (SDM) has emerged as a key approach. Although the benefits of SDM have been largely reported, several studies have reported low participation in SDM in coronary artery disease (CAD) patients. The theory of planned behavior (TPB) model is one of the most frequently employed theoretical frameworks for predicting human behaviors. According to the TPB, intention is influenced by attitude, subjective norm, and perceived behavioral control, while behavior is influenced by both intention and perceived behavioral control. Therefore, we propose a mixed methods study based on TPB to investigate the status of Chinese stable coronary artery disease (SCAD) patients' participation in SDM, understand their experiences of SDM, and explore the factors that influence their participation in SDM.

MATERIALS AND METHODS

An explanatory sequential mixed methods design will be used to explore the study aims, including a quantitative phase, a subsequent qualitative phase, and the final integration study. The quantitative study will use convenient sampling from the Affiliated Hospital of Hangzhou Normal University to conduct a cross-sectional survey (n ≥ 252). The qualitative study will be sampled using the maximum difference sampling method from the quantitative study results, and then the data will be collected through semi-structured interviews (n = 10-20). This study will use descriptive statistics and test hypotheses while considering a p-value of <0.05, which will be considered statistically significant.

DISCUSSIONS

The study employs a mixed method approach with an explanatory sequential design, incorporating qualitative and quantitative methods to comprehensively understand the factors influencing SCAD patients' participation in SDM. Furthermore, these findings can inform the design of future intervention studies and provide healthcare providers with targeted information and communication to help SCAD patients make the most appropriate decisions. Study participants will be recruited using convenience sampling from just one single clinical setting, which may limit the findings' generalizability.

ETHICS AND DISSEMINATION

This study has been approved by the Ethical Committee of the School of Nursing, Hangzhou Normal University (Approval No.: 2024013). All the participants will sign an informed consent form before participating in the survey. The corresponding results and conclusions will be disseminated in journals and conferences after the completion of the study.

Target Heart Rate Formulas for Exercise Stress Testing: What Is the Evidence?

Exercise stress testing (EST) is commonly used to evaluate chest pain, with some labs using 85% of age-predicted maximum heart rate (APMHR) as an endpoint for EST. The APMHR is often calculated using the formula 220-age. However, the accuracy of this formula and 85% APMHR as an endpoint may be questioned. Moreover, failing to reach 85% APMHR (known as chronotropic insufficiency) may also indicate poor cardiovascular prognosis, but measurements, such as percentage heart rate reserve (%HRR), maximum rate pressure product (MRPP), and the maximum metabolic equivalent of tasks (METs) reached during EST may provide better prediction of cardiovascular outcomes than not reaching 85% of APMHR. There is a need to incorporate comprehensive measurements to improve the diagnostic and prognostic capabilities of EST.

Hospital and Physician Variability in Revascularization Decisions and Outcomes for Patients With 3-Vessel and Left Main Coronary Artery Disease: A Population-Based Cohort Study

BACKGROUND

Hospital- and physician-level variation for selection of percutaneous coronary intervention versus coronary artery bypass grafting (CABG) for patients with coronary artery disease has been associated with outcome differences. However, most studies excluded patients treated medically.

METHODS AND RESULTS

From 2010 to 2019, adults with 3-vessel or left main coronary artery disease at 3 hospitals (A, B, C) in Alberta, Canada, were categorized by treatment with medical therapy, percutaneous coronary intervention, or CABG. Multilevel regression models determined the proportion of variation in treatment attributable to patient, physician, and hospital factors, and survival models assessed outcomes including death and major adverse cardiovascular events over 5 years. Of 22 580 patients (mean age, 67 years; 80% men): 6677 (29%) received medical management, 9171 (41%) percutaneous coronary intervention, and 6732 (30%) CABG. Hospital factors accounted for 10.8% of treatment variation. In adjusted models (site A as reference), patients at sites B and C had 49% (95% CI, 44%-53%) and 43% (95% CI, 37%-49%) lower rates of medical therapy, respectively, and 31% (95% CI, 24%-38%) and 32% (95% CI, 24%-40%) lower rates of CABG. During 5.0 years median follow-up, 3287 (14.6%) patients died, with no intersite mortality differences. There were no between-site differences in acute coronary syndromes or stroke; patients at sites B and C had 24% lower risk (95% CI, 13%-34% and 11%-35%, respectively) of heart failure hospitalization.

CONCLUSIONS

Hospital-level variation in selection of percutaneous coronary intervention, CABG, or medical therapy for patients with complex coronary artery disease was not associated with differences in 5-year mortality rates. Research and quality improvement initiatives comparing revascularization practices should include medically managed patients.

Polypills in the Management of Cardiovascular Risk-A Perspective

Cardiovascular disease and cardiovascular risk factors are global healthcare problems, given their high prevalence and the recognized low rates of adequate control despite the abundant body of evidence on different therapeutic options. The World Heart Federation has scrutinized the reasons for poor control of cardiovascular risk factors. Among these reasons, patients' poor adherence to treatment regimens as well as limited rates of evidence-based therapy prescription from healthcare providers play a substantial role in the challenge of cardiovascular risk management. Polypills are fixed-dose combinations including two or more active drugs, from different pharmacological classes, combined in a single dosage form. Polypills were designed to simplify the clinical management of pharmacotherapy and increase adherence to treatment. From this perspective, we discuss the current literature on the use of polypills in the primary and secondary prevention of cardiovascular disease as well as future challenges and the potentials of this treatment strategy.

Myeloproliferative Neoplasms and Cardiovascular Disease: A Review

OPINION STATEMENT

Myeloproliferative neoplasms (MPN) are a heterogenous group of disorders of clonal hematopoiesis characterized by constitutive activation of the JAK/STAT signaling pathway leading to proliferation of blood cells. Cardiovascular disease (CVD) contributes significantly to the morbidity and mortality of patients with MPN. Particularly well-known CVD complications of MPNs are arterial and venous thrombotic events. However, MPNs are also associated with other forms of CVD including atrial fibrillation, heart failure, and pulmonary hypertension. Recent studies have characterized outcomes of patients with MPN and CVD, including acute myocardial infarction (AMI), heart failure, atrial fibrillation, and pulmonary hypertension. Additionally, optimal cardiovascular disease prevention strategies in patients with MPN are not yet clear. Further investigation is warranted to improve CVD outcomes in patients with MPN. Clinicians should be aware of cardiovascular complications of MPN, including thrombotic as well as non-thrombotic complications (heart failure, arrhythmias, pulmonary hypertension).

Very short-term blood pressure variability by pulse transit time-based measurements during night-time predicts future cardiovascular events in patients with ischemic heart disease

Blood pressure (BP) variability (BPV) is associated with an increased risk of cardiovascular events, independent of absolute BP values. However, the predictive significance of very short-term BPV, occurring within seconds or minutes, in patients with ischemic heart disease (IHD) has yet to be established. This prospective study involved 206 consecutive hospitalized patients with IHD (mean age 67.6 years, 78.2% male) who underwent pulse transit time (PTT)-based continuous BP recording during the night-time. Very short-term BPV was assessed by standard deviation (SD), coefficient of variation (CV), and variation independent of mean (VIM) of PTT-BP. Clinical outcome data were collected. When the patients were categorized into two groups according to the median value of very short-term BPV, Kaplan-Meier analysis revealed that patients with elevated SD, CV, and VIM of systolic and diastolic PTT-BP were associated with lower event-free survival rates from the composite cardiovascular events including cardiac deaths, worsening heart failure cases, nonfatal myocardial infarctions, unplanned revascularizations, and strokes over a median follow-up of 797 days. In a multivariate Cox proportional hazards analysis adjusting for confounding variables, each parameter as a continuous variable was independently associated with adverse events. Incorporating very short-term BPV into basic models had a significant impact on risk reclassification and integrated discrimination for cardiovascular outcomes. In conclusion, the identification of patients with elevated very short-term BPV during the night-time through a PTT-driven approach helps stratify the future risk in IHD patients.

Association Between Prior Antiplatelet Therapy and Prognosis in Patients With Intracerebral Hemorrhage: A Systematic Review and Meta-Analysis

PURPOSE

Approximately 20% to 30% of intracerebral hemorrhage (ICH) patients were reported to be on antiplatelet therapy (APT), and association between prior APT and prognosis was unclear. We aimed to clarify the impact of APT on the prognosis of ICH through an updated systematic review and meta-analysis, and to further compare the risk of single APT (SAPT) or dual APT (DAPT) prior to ICH as well as the risk associated with various antiplatelet drugs.

METHODS

EMBASE, MEDLINE via Ovid SP and Web of Science were searched from inception of each database to November 4, 2023. Included studies reported prognosis in both patients with prior APT and those without.

FINDINGS

A total of 433,103 patients from 43 studies were included in the meta-analysis. Both univariate and multivariate analyses demonstrated a significant association between prior-APT and an increased mortality risk (odd ratio [OR] 1.43, 95% confidence interval [CI] 1.28-1.59; OR 1.20, 95%CI 1.10-1.30, respectively). The risk was higher in short term follow-up (Univariate OR 1.73, 95%CI 1.22-2.46; Multivariate OR 1.94, 95%CI 1.48-2.55). A notably increased risk of hematoma expansion was also observed in patients previously treated with APT (Univariate OR 1.47, 95%CI 1.12-1.94; Multivariate OR 1.88, 95%CI 1.30-2.71), which were mainly attributed to events within 24 hours. The impact of prior-APT on poor functional outcome was inconsistent between univariate and multivariate analyses. Both direct and indirect comparisons showed that SAPT significantly reduced the risk of mortality (OR 0.67, 95%CI 0.64-0.70; OR 0.84, 95%CI 0.71-0.99) and poor functional outcome (OR 0.84, 95%CI 0.72-0.98; OR 0.81, 95%CI 0.72-0.91) compared to DAPT.

IMPLICATIONS

Prior-APT increased the risk of mortality and hematoma expansion in patients with ICH. The increased risk of mortality and hematoma expansion was more obvious in the short term follow-up and within 24 hours, respectively. The effect of APT on poor functional outcome exhibited inconsistency between univariate and multivariate analyses, suggesting that further investigation is warranted to clarify this relationship. In comparison with DAPT, SAPT could decrease the risk of mortality and poor functional outcome. Further studies focusing on antiplatelet drug response, racial differences, and specific APT regimens may help verify the influence.

Dynamic trends of ischemic heart disease mortality attributable to high low-density lipoprotein cholesterol: a joinpoint analysis and age-period-cohort analysis with predictions

AIMS

The purpose of this study was to analyze the dynamic trends of ischemic heart disease (IHD) mortality attributable to high low-density lipoprotein cholesterol (LDL-C).

METHODS

Data on IHD mortality attributable to high LDL-C from 1990 to 2021 were extracted from the global disease burden database. Joinpoint software was used to estimate the average annual percentage change (AAPC) in the age-standardized mortality rate (ASMR). An age‒period‒cohort model was used to analyze the impacts of age, period, and cohort on these changes. The Bayesian framework was used to predict IHD mortality attributable to high LDL-C from 2022 to 2040.

RESULTS

The overall ASMR of IHD attributable to high LDL-C decreased from 50. 479 per 100,000 people in 1990 to 32.286 per 100,000 people in 2021, and ASMR of IHD attributable to high LDL-C was higher in males than in females. The longitudinal age curves of the overall IHD mortality attributable to high LDL-C showed a monotonic upward trend, especially after 65 years of age. The period and cohort effect relative risk (RR) values of overall IHD mortality attributable to high LDL-C showed a downward trend. The overall ASMR of IHD attributable to high LDL-C is predicted to show a downward trend, and male IHD mortality attributable to high LDL-C is expected to be higher than that of females.

CONCLUSION

This study revealed a sustained decrease in IHD mortality attributable to high LDL-C over three decades, with a continued decline expected. Despite this, gender disparities persist, with males experiencing higher mortality rates and elderly individuals remaining a vulnerable group.

Routine beta-blocker therapy after acute coronary syndromes: The end of an era?

BACKGROUND

Beta-blocker therapy, a treatment burdened by side effects including fatigue, erectile dysfunction and depression, was shown to reduce mortality and cardiovascular events after acute coronary syndromes (ACS) in the pre-coronary reperfusion era. Potential mechanisms include protection from ventricular arrhythmias, increased ischaemia threshold and prevention of left ventricular (LV) adverse remodelling. With the advent of early mechanical reperfusion and contemporary pharmacologic secondary prevention, the benefit of beta-blockers after ACS in the absence of LV dysfunction has been challenged.

METHODS

The present narrative review discusses the contemporary evidence based on searching the PubMed database and references in identified articles.

RESULTS

Recently, the REDUCE-AMI trial-the first adequately powered randomized trial in the reperfusion era to test beta-blocker therapy after myocardial infarction with preserved left ventricular ejection fraction (LVEF)-showed no benefit on the composite of all-cause death or myocardial infarction over a median 3.5-year follow-up. While the benefit of beta-blockers in patients with reduced LVEF remains undisputed, their value in post-ACS patients with mildly reduced systolic function (LVEF 41%-49%) has not been studied in contemporary randomized trials; in this setting, observational studies have suggested a reduction in cardiovascular events with these agents. The adequate duration of beta-blocker therapy remains unknown, but observational data suggests that any mortality benefit may be lost beyond 1-12 months after ACS in patients with LVEF >40%.

CONCLUSION

We believe that there is sufficient evidence to abandon routine beta-blocker prescription in post-ACS patients with preserved LV systolic function.

Synergistic effects of xanthan gum and β-cyclodextrin on properties and stability of vegetable oil-based whipped cream

The synergistic effects between xanthan gum (XG) and β-cyclodextrin (β-CD) on the properties and stability of vegetable oil-based whipped cream stabilized by kidney bean protein aggregates was investigated. The visual appearance, SEM, TEM, CLSM, FT-IR and LF-NMR results showed that when the ratio of XG to β-CD in the XG-β-CD complex was appropriate, the hydrogen bonding effect between β-CD and XG was significant enhanced, the three-dimensional network structure has the highest density, the emulsion droplets were the smallest and evenly distributed. The unique tapered microstructure of β-CD acted as a bridge between the hydrophilic and hydrophobic components, effectively preventing the aggregation of oil droplets and establishing a flexible support system between oil droplets; while the flexible molecular structure of XG could support Pickering emulsion system. The XG-β-CD complex had a synergistic effect with protein aggregates, making it ideal for use in whipped cream products. This study explored the stability mechanism of β-CD in the Pickering emulsion-based whipped cream system, providing valuable insights into producing whole plant-based whipped cream by texturizing highly unsaturated oils. This effectively solves the problem of inadequate intake of unsaturated oil for individuals who consume excessive amounts of animal-derived fats.

Cost-effectiveness of Mediterranean diet and physical activity in secondary cardiovascular disease prevention: results from the UCC-SMART cohort study

AIMS

The efficacy of a healthy lifestyle in secondary prevention of cardiovascular disease (CVD) is well established and a first-line recommendation in CVD prevention guidelines. The aim of this study was to assess whether Mediterranean diet and physical activity are also cost-effective in patients with established CVD.

METHODS AND RESULTS

A cost-utility analysis (CUA) was performed comparing a combined Mediterranean diet and physical activity intervention to usual care in patients with CVD. The CUA had a healthcare perspective and lifetime horizon. Costs and utilities were estimated using a microsimulation on a cohort of 100 000 patients with CVD sampled from the Utrecht Cardiovascular Cohort-Secondary Manifestations of ARTerial disease study (n = 8947, mean age 62 ± 8.7 years, and 74% male). Cost-effectiveness was expressed as an incremental cost-effectiveness ratio (ICER), incremental net health benefit (INHB), and incremental net monetary benefit (INMB). Mediterranean diet and physical activity yielded 2.0 incremental quality-adjusted life years (QALYs) and cost reductions of €1236 per person compared with usual care, resulting in an ICER of €-626/QALY [95% confidence interval (CI) -1929 to 2673]. At a willingness-to-pay of €20 000/QALY, INHB was 2.04 (95% CI 0.99-3.58) QALYs and INMB was €40 757 (95% CI 19 819-71 605). The interventions remained cost-effective in a wide range of sensitivity analyses, including worst-case scenarios and scenarios with reimbursement for food and physical activity costs.

CONCLUSION

In patients with established CVD, a combined Mediterranean diet and physical activity intervention was cost-saving and highly cost-effective compared with usual care. These findings strongly advocate for the incorporation of lifestyle interventions as integral components of care for all patients with CVD.

Role of naringin in the treatment of atherosclerosis

Atherosclerosis (AS) is a major pathological basis of coronary heart disease. However, the currently available medications are unable to effectively reduce the incidence of cardiovascular events in the majority of patients with AS. Therefore, naringin has been attracting considerable attention owing to its anti-AS effects. Naringin can inhibit the growth, proliferation, invasion, and migration of vascular smooth muscle cells, ameliorate endothelial cell inflammation and apoptosis, lower blood pressure, halt the cell cycle at the G1 phase, and impede growth via its antioxidant and free radical scavenging effects. These activities suggest the potential anti-AS effects of naringin. In this review article, we comprehensively summarized the latest findings on the anti-AS effects of naringin and their underlying mechanisms, providing a crucial reference for future research on the anti-AS potential of this agent.

Exploring the underlying mechanisms of Danshen-Shanzha Decoction on coronary heart disease: An integrated analysis combining pharmacoinformatics and experimental validation

ETHNOPHARMACOLOGICAL RELEVANCE

The Danshen-Shanzha Decoction (DSD) is a renowned herbal combination consisting of the root of Salvia miltiorrhiza Bunge (known as Danshen in Chinese) and the fruits of Crataegus pinnatifida Bunge (known as Shanzha in Chinese), which has exhibited remarkable clinical efficacy in the treatment of coronary heart disease (CHD) in traditional Chinese medicine, with its earliest recorded application dating to around 202 BCE during the Han Dynasty. Despite significant advancements in the fundamental research and clinical applications of DSD over the past few decades, the precise bioactive components as well as the underlying mechanisms responsible for its protective effect on CHD remain unelucidated.

AIM OF THE STUDY

The present study was designed to elucidate the bioactive components and potential mechanism of DSD in the treatment of CHD using in silico technologies integrated with pharmacoinformatic methods and experimental validation.

MATERIALS AND METHODS

The chemical components of DSD were analyzed and identified using UPLC-Q-TOF-MS. Pharmacoinformatic-based methods were employed to comprehensively investigate the principal active components and targets of DSD for treating CHD. GO and KEGG pathway analyses were utilized to elucidate the underlying mechanism responsible for DSD's efficacy against CHD. Molecular docking and molecular dynamics simulation were performed to assess the binding affinity between active components and putative targets. Furthermore, surface plasmon resonance (SPR) was carried out to verify the affinity and kinetic characteristics of major components to STAT3 protein. Subsequently, a series of in vitro experiments, including cell viability test, flow cytometric analysis, ELISA and western blotting, were conducted to validate the predicted results in an oxygen-glucose deprivation (OGD)-stimulated H9c2 model.

RESULTS

A total of 96 compounds were characterized by UPLC-Q-TOF-MS, and 281 overlapping targets were identified through pharmacoinformatic-based methods. Among these, ten critical compounds were determined as the core active components of DSD. The core targets associated with the development of CHD included STAT3, SRC, TP53, JUN, and AKT1. Notably, Dihydrotanshinone I and (+)-Epicatechin exhibited strong binding affinity towards STAT3. The potential mechanisms by which DSD modulates the pathological progression of CHD were predicted to involve inflammation, oxidative stress, and apoptosis. Importantly, the cytoprotective effect of DSD against apoptosis was confirmed in OGD-stimulated H9c2 cells, as evidenced by the upregulation of Bcl-2 expression and downregulation of both Bax and cleaved caspase-3 expressions upon DSD treatment. Furthermore, DSD significantly enhanced the phosphorylated protein expressions of JAK2 and STAT3 compared to the OGD group, suggesting its potential role in modulating related signaling pathways.

CONCLUSIONS

The current study successfully fills the gap in the understanding of the chemical profiles of DSD, predicting its active components, potential targets, and molecular mechanisms in the treatment of CHD. These findings not only provide a valuable strategy but also robust data support for future investigations into DSD, thereby facilitating the identification of novel therapeutic targets for traditional Chinese medicines in the battle against CHD.

The plant extract PNS mitigates atherosclerosis via promoting Nrf2-mediated inhibition of ferroptosis through reducing USP2-mediated Keap1 deubiquitination

BACKGROUND AND PURPOSE

Atherosclerosis is the basis of cardiovascular disease. Ferroptosis is a form of programmed cell death characterized by lipid peroxidation, which contributes to atherogenesis. The plant extract PNS (Panax notoginseng saponins), containing the main active ingredients of Panax notoginseng, exhibits anti-atherogenic properties. Herein, we determined whether PNS and its major components could attenuate atherosclerosis by suppressing ferroptosis and revealed the underlying mechanism(s).

EXPERIMENTAL APPROACH

The anti-atherogenic effects of PNS and their association with inhibition of ferroptosis was determined in apoE-/- mice. In vitro, the anti-ferroptotic effect and mechanism(s) of PNS components were demonstrated in the presence of ferroptosis inducers. Expression of ferroptosis markers and the ubiquitination of Keap1 were evaluated in USP2-/- macrophages. Finally, the anti-atherogenic effect of USP2 knockout was determined by using USP2-/- mice treated with high-fat diet (HFD) and AAV-PCSK9.

KEY RESULTS

PNS inhibited ferroptosis and atherosclerosis in vivo. PNS suppressed ferroptosis and ferroptosis-aggravated foam cell formation and inflammation in vitro. Mechanistically, PNS and its components activated Nrf2 by antagonizing Keap1, which was attributed to the inhibition of USP2 expression. USP2 knockout antagonized ferroptosis and ferroptosis-aggravated foam cell formation and inflammation, thus mitigating atherosclerosis. USP2 knockout abolished inhibitory effects of PNS on foam cell formation and inflammation in vitro.

CONCLUSION AND IMPLICATIONS

PNS reduced USP2-mediated Keap1 de-ubiquitination and promoted Keap1 degradation, thereby activating Nrf2, improving iron metabolism and reducing lipid peroxidation, thus contributing to an anti-atherosclerotic outcome. Our study revealed the mechanism(s) underlying inhibition of ferroptosis and atherosclerosis by PNS.

Low-dose colchicine for the prevention of cardiovascular events after percutaneous coronary intervention: Rationale and design of the COL BE PCI trial

INTRODUCTION

Patients with coronary artery disease (CAD) remain vulnerable to future major atherosclerotic events after revascularization, despite effective secondary prevention strategies. Inflammation plays a central role in the pathogenesis of CAD and recurrent events. To date, there is no specific anti-inflammatory medicine available with proven effective, cost-efficient, and favorable benefit-risk profile, except for colchicine. Initial studies with colchicine have sparked major interest in targeting atherosclerotic events with anti-inflammatory agents, but further studies are warranted to enforce the role of colchicine role as a major treatment pillar in CAD. Given colchicine's low cost and established acceptable long-term safety profile, confirming its efficacy through a pragmatic trial holds the potential to significantly impact the global burden of cardiovascular disease.

METHODS

The COL BE PCI trial is an investigator-initiated, multicenter, double-blind, event-driven trial. It will enroll 2,770 patients with chronic or acute CAD treated with percutaneous coronary intervention (PCI) at 19 sites in Belgium, applying lenient in- and exclusion criteria and including at least 30% female participants. Patients will be randomized between 2 hours and 5 days post-PCI to receive either colchicine 0.5 mg daily or placebo on top of contemporary optimal medical therapy and without run-in period. All patients will have baseline hsCRP measurements and a Second Manifestations of Arterial Disease (SMART) risk score calculation. The primary endpoint is the time from randomization to the first occurrence of a composite endpoint consisting of all-cause death, spontaneous non-fatal myocardial infarction, non-fatal stroke, or coronary revascularization. The trial is event-driven and will continue until 566 events have been reached, providing 80% power to detect a 21 % reduction in the primary endpoint taking a premature discontinuation of 15% into account. We expect a trial duration of approximately 44 months.

CONCLUSION

The COL BE PCI Trial aims to assess the effectiveness and safety of administering low-dose colchicine for the secondary prevention in patients with both chronic and acute coronary artery disease undergoing PCI.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT06095765.

Ischemia with non-obstructive coronary artery (INOCA): Non-invasive versus invasive techniques for diagnosis and the role of #FullPhysiology

Ischemia with non-obstructive coronary arteries (INOCA) is an increasingly recognized entity. It encompasses different pathophysiological subtypes (i.e., endotypes), including coronary microvascular dysfunction (CMD), vasospastic angina (VSA) and mixed entities resulting from the variable combination of both. Diagnosing INOCA and precisely characterizing the endotype allows for accurate medical treatment and has proven prognostic implications. A breadth of diagnostic technique is available, ranging from non-invasive approaches to invasive coronary angiography adjuvated by functional assessment and provocative tests. This review summarizes the strength and limitations of these methodologies and provides the rationale for the routine referral for invasive angiography and functional assessment in this subset of patients.

Routine Stress Testing After PCI in Patients With and Without Acute Coronary Syndrome: A Secondary Analysis of the POST-PCI Randomized Clinical Trial

Importance

The appropriate follow-up surveillance strategy for patients with acute coronary syndrome (ACS) who have undergone percutaneous coronary intervention (PCI) remains unknown.

Objective

To assess clinical outcomes in patients with and without ACS who have undergone high-risk PCI according to a follow-up strategy of routine stress testing at 12 months after PCI vs standard care alone.

Design, Setting, and Participants

The POST-PCI (Pragmatic Trial Comparing Symptom-Oriented vs Routine Stress Testing in High-Risk Patients Undergoing Percutaneous Coronary Intervention) trial was a randomized clinical trial that compared follow-up strategies of routine functional testing vs standard care alone 12 months after high-risk PCI. Patients were categorized as presenting with or without ACS. Patients were enrolled in the trial from November 2017 through September 2019, and patients were randomized from 11 sites in South Korea; data analysis was performed in 2022.

Intervention

Patients categorized as presenting with or without ACS were randomized to either a routine functional testing or standard care alone follow-up strategy 12 months after high-risk PCI.

Main Outcomes and Measures

The primary outcome was a composite of death from any cause, myocardial infarction, or hospitalization for unstable angina at 2 years following randomization. Kaplan-Meier event rates through 2 years and Cox model hazard ratios (HRs) were generated, and interactions were tested.

Results

Of 1706 included patients, 350 patients (20.5%) were female, and the mean (SD) patient age was 64.7 (10.3) years. In total, 526 patients (30.8%) presented with ACS. Compared with those without ACS, patients with ACS had a 55% greater risk of the primary outcome (HR, 1.55; 95% CI, 1.03-2.33; P = .03) due to higher event rates in the first year. The 2-year incidences of the primary outcome were similar between strategies of routine functional testing or standard care alone in patients with ACS (functional testing: 16 of 251 [6.6%]; standard care: 23 of 275 [8.5%]; HR, 0.76; 95% CI, 0.40-1.44; P = .39) and in patients without ACS (functional testing: 30 of 598 [5.1%]; standard care: 28 of 582 [4.9%]; HR, 1.04; 95% CI, 0.62-1.74; P = .88) (P for interaction for ACS = .45). Although a landmark analysis suggested that the rates of invasive angiography and repeat revascularization were higher after 1 year in the routine functional testing group, the formal interactions between ACS status and either invasive angiography or repeat revascularization were not significant.

Conclusion and Relevance

Despite being at higher risk for adverse clinical events in the first year after PCI than patients without ACS, patients with ACS who had undergone high-risk PCI did not derive incremental benefit from routine surveillance stress testing at 12 months compared with standard care alone during follow-up.

Trial Registration

ClinicalTrials.gov Identifier: NCT03217877.

PCSK9 Inhibitors and Infection-Related Adverse Events: A Pharmacovigilance Study Using the World Health Organization VigiBase

AIMS

Protein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) are novel lipid-lowering agents used in patients with cardiovascular disease. Despite reassuring safety data from pivotal trials, increasing evidence from real-world studies suggests that PCSK9i increase the risk of bacterial and viral infections. Therefore, this study aimed to identify signals of infection-related adverse events (AEs) associated with PCSK9i.

METHODS

We performed an observational pharmacovigilance study using the World Health Organization's VigiBase, recorded up to December 2022. We included individual case safety reports (ICSRs) of PCSK9 inhibitors, alirocumab and evolocumab, and compared them with those of other drugs. Infection-related ICSRs were retrieved from the Medical Dictionary for Regulatory Activities System Organ Class 'infections and infestations.'

RESULTS

Among 114,293 reports (258,099 drug-AE pairs) related to PCSK9 inhibitors, 54% included female patients, 41% included patients aged ≥65 years, and 82% included patients who received evolocumab. Additionally, beyond AEs recognized by regulatory authorities, organ infections such as influenza (reporting odds ratio [ROR] 2.89, 95% confidence interval [CI] 2.74-3.05), gastric infections (ROR 2.47, 95% CI 1.63-3.75), and kidney infections (ROR 1.36, 95% CI 1.06-1.73) were observed. Sensitivity analysis indicated a heightened risk of infection-related AEs associated with PCSK9i regardless of the specific drug type.

CONCLUSIONS

In addition to the labelled respiratory infections, six infection-related symptoms in the gastrointestinal, urinary, and renal organs were identified. Our findings support the need for systematic surveillance of infections among PCSK9i users.

The Role of Social Determinants of Health in Atherosclerotic Cardiovascular Disease

PURPOSE OF REVIEW

This review seeks to provide important information on each of the major domains of social determinants of health (SDOH) in the context of atherosclerotic cardiovascular disease.

RECENT FINDINGS

SDOH can be classified into five domains: social and community context, health care access and quality, neighborhood and built environment, economic stability, and education access and quality. SDOH are major drivers for cardiovascular health outcomes that exceed the impact from traditional risk factors, and explain inequities in health outcomes observed across different groups of individuals. SDOH profoundly impacts healthcare's receipt, delivery, and outcomes. Many patients fall within various disenfranchised groups (e.g., identify with minority race, low socioeconomic status, low educational attainment, LGBTQ+), which impact overall health status and care. Learning to understand, recognize, and address SDOH as the driving force of disparities are critical for achieving health equity in the prevention and adequate treatment of ASCVD.

Role of physiology in the management of multivessel disease among patients with acute coronary syndrome

Multivessel coronary artery disease (CAD), defined as ≥50% stenosis in 2 or more epicardial arteries, is associated with a high burden of morbidity and mortality in acute coronary syndrome (ACS) patients. A salient challenge for managing this cohort is selecting the optimal revascularisation strategy, for which the use of coronary physiology has been increasingly recognised. Fractional flow reserve (FFR) is an invasive, pressure wire-based, physiological index measuring the functional significance of coronary lesions. Understanding this can help practitioners evaluate which lesions could induce myocardial ischaemia and, thus, decide which vessels require urgent revascularisation. Non-hyperaemic physiology-based indices, such as instantaneous wave-free ratio (iFR), provide valid alternatives to FFR. While FFR and iFR are recommended by international guidelines in stable CAD, there is ongoing discussion regarding the role of physiology in patients with ACS and multivessel disease (MVD); growing evidence supports FFR use in the latter. Compelling findings show FFR-guided complete percutaneous coronary intervention (PCI) can reduce adverse cardiovascular events, mortality, and repeat revascularisations in ACS and MVD patients compared to angiography-based PCI. However, FFR is limited in identifying non-flow-limiting vulnerable plaques, which can disadvantage high-risk patients. Here, integrating coronary physiology assessment with intracoronary imaging in decision-making can improve outcomes and quality of life. Further research into novel physiology-based tools in ACS and MVD is needed. This review aims to highlight the key evidence surrounding the role of FFR and other functional indices in guiding PCI strategy in ACS and MVD patients.

Deep learning-based rapid image reconstruction and motion correction for high-resolution cartesian first-pass myocardial perfusion imaging at 3T

PURPOSE

To develop and evaluate a deep learning (DL) -based rapid image reconstruction and motion correction technique for high-resolution Cartesian first-pass myocardial perfusion imaging at 3T with whole-heart coverage for both single-slice (SS) and simultaneous multi-slice (SMS) acquisitions.

METHODS

3D physics-driven unrolled network architectures were utilized for the reconstruction of high-resolution Cartesian perfusion imaging. The SS and SMS multiband (MB) = 2 networks were trained from 135 slices from 20 subjects. Structural similarity index (SSIM), peak SNR (PSNR), and normalized RMS error (NRMSE) were assessed, and prospective images were blindly graded by two experienced cardiologists (5, excellent; 1, poor). For respiratory motion correction, a 2D U-Net based motion corrected network was proposed, and the temporal fidelity and second-order derivative were calculated to assess the performance of the motion correction.

RESULTS

Excellent performance was demonstrated in the proposed technique with high SSIM and PSNR, and low NRMSE. Image quality scores were (4.3 [4.3, 4.4], 4.5 [4.4, 4.6], 4.3 [4.3, 4.4], and 4.5 [4.3, 4.5]) for SS DL and SS L1-SENSE, MB = 2 DL and MB = 2 SMS-L1-SENSE, respectively, showing no statistically significant difference (p > 0.05 for SS and SMS) between (SMS)-L1-SENSE and the proposed DL technique. The network inference time was around 4 s per dynamic perfusion series with 40 frames while the time of (SMS)-L1-SENSE with GPU acceleration was approximately 30 min.

CONCLUSION

The proposed DL-based image reconstruction and motion correction technique enabled rapid and high-quality reconstruction for SS and SMS MB = 2 high-resolution Cartesian first-pass perfusion imaging at 3T.

Managing Cluster Headache in Patients with Medical, Psychiatric, and Surgical Comorbidities

PURPOSE OF REVIEW

What should a provider know about medications and other treatments in patients with cluster headache who have medical, psychiatric, and surgical comorbidities? What conversations should providers have with patients about living with and managing cluster headache?

RECENT FINDINGS

While the number of treatments used in cluster headache is relatively small, numerous considerations were identified related to managing patients with comorbidities. Many of these touch on cardiac, cardiovascular, and cerebrovascular health, but full histories are needed to guide safe and effective treatment. Both older and newer treatments may be contraindicated in certain patients with cluster headache or should be considered carefully. In addition to incorporating medical, psychiatric, and surgical histories in the management plan, collaboration with other providers may be beneficial. Providers should also inquire about patient practices and discuss participation in clinical trials that might be a good fit for the individual.

Review of Recent Literature and Updates in Nonstatin Cholesterol Management

The guidelines for cholesterol management have been updated over the years from treat-to-target using any drug class to emphasis on statins without treatment targets to a hybrid of the 2 approaches. The most recent guideline updates include newer nonstatin lipid-lowering therapies (LLTs), low-density lipoprotein cholesterol (LDL-C) reduction goals, and LDL-C thresholds considering secondary prevention and cardiovascular risk. Although statins have been the mainstay of LLT for years, newer pharmacological agents such as proprotein convertase subtilisin-kexin type 9 inhibitor(s) (PCSK9i) monoclonal antibodies, small interfering RNA PCSK9i, and bempedoic acid to optimize LDL-C levels may be underutilized in clinical practice. To provide an updated review for clinicians, we performed a literature search in PubMed for articles published from January 1, 2000, to August 31, 2023, that included the terms cholesterol, LLT, bempedoic acid, inclisiran, or PCSK9 inhibitor. Studies were selected for inclusion according to relatedness to cholesterol management and outcomes with novel LLT agents. Optimization of statins can improve the lipid profile and contribute to primary and secondary atherosclerotic cardiovascular disease (ASCVD) prevention. The newest guidance combines anticipated LDL-C reduction from statins and LDL-C thresholds for primary and secondary prevention. Nonstatin agents such as PCSK9i monoclonal antibodies, small interfering RNA PCSK9i, and bempedoic acid are safe and effective LLTs that can be used in addition to statin therapy for additional LDL-C lowering and prevention of ASCVD. Additionally, these nonstatin agents are reasonable to initiate in patients who have not been able to tolerate statins due to myalgias, rhabdomyolysis, or contraindications. Cost may be a barrier to initiating these agents for patients who are underinsured or uninsured. Clinicians should reference the most up-to-date guidance for LLT for primary and secondary prevention of ASCVD. Additionally, clinicians must diligently continue to optimize statin and nonstatin LLT to improve cardiovascular health outcomes.

Design and rationale of the CLEAR SYNERGY (OASIS 9) trial: A 2x2 factorial randomized controlled trial of colchicine versus placebo and spironolactone vs placebo in patients with myocardial infarction

BACKGROUND

Patients experiencing myocardial infarction (MI) remain at high risk of future major adverse cardiovascular events (MACE). While low-dose colchicine and spironolactone have been shown to decrease post-MI MACE, more data are required to confirm their safety and efficacy in an unselected post-MI population. Therefore, we initiated the CLEAR SYNERGY (OASIS 9) trial to address these uncertainties.

METHODS

The CLEAR SYNERGY trial is a 2 × 2 factorial randomized controlled trial of low-dose colchicine 0.5 mg daily versus placebo and spironolactone 25 mg daily versus placebo in 7,062 post-MI participants who were within 72 hours of the index percutaneous coronary intervention (PCI). We blinded participants, healthcare providers, research personnel, and outcome adjudicators to treatment allocation. The primary outcome for colchicine is the first occurrence of the composite of cardiovascular death, recurrent MI, stroke, or unplanned ischemia-driven revascularization. The coprimary outcomes for spironolactone are (1) the composite of the total numbers of cardiovascular death or new or worsening heart failure and (2) the first occurrence of the composite of cardiovascular death, new or worsening heart failure, recurrent MI or stroke. We finished recruitment with 7,062 participants from 104 centers in 14 countries on November 8, 2022, and plan to present the results in the fall of 2024.

CONCLUSIONS

CLEAR SYNERGY is a large international randomized controlled trial that will inform the effects of low-dose colchicine and spironolactone in largely unselected post-MI patients who undergo PCI. (ClinicalTrials.gov Identifier: NCT03048825).

Improving Cardiac Rehabilitation Adherence in Patients With Lower Socioeconomic Status: A Randomized Clinical Trial

Importance

Participation in cardiac rehabilitation is associated with significant decreases in morbidity and mortality. Despite the proven benefits, cardiac rehabilitation is severely underutilized in certain populations, specifically those with lower socioeconomic status (SES).

Objective

To assess the efficacy of early case management and/or financial incentives for increasing cardiac rehabilitation adherence among patients with lower SES.

Design, Setting, and Participants

This randomized clinical trial enrolled patients from December 2018 to December 2022. Participants were followed up for 1 year with assessors and cardiac rehabilitation staff blinded to study condition. Patients with lower SES with a cardiac rehabilitation-qualifying diagnosis (myocardial infarction, coronary artery bypass graft, percutaneous coronary intervention, heart valve replacement/repair, or stable systolic heart failure) were recruited. Then patients attended one of 3 cardiac rehabilitation programs at 1 university or 2 community-based hospitals. A consecutively recruited sample was randomized and stratified by age (<57 vs ≥57 years) and smoking status (current smoker vs nonsmoker or former smoker).

Intervention

Participants were randomized 2:3:3:3 to either a usual care control, case management starting in-hospital, financial incentives for completing cardiac rehabilitation sessions, or both interventions (case management plus financial incentives). Interventions were in place for 4 months following informed consent.

Main Outcomes and Measures

The main outcome was cardiac rehabilitation adherence (proportion of patients completing ≥30 sessions). The a priori hypothesis was that interventions would improve adherence, with the combined intervention performing best.

Results

Of 314 individuals approached, 11 were ineligible, and 94 declined participation. Of the 209 individuals who were randomized, 17 were withdrawn. A total of 192 individuals (67 [35%] female; mean [SD] age, 58 [11] years) were included in the analysis. Interventions significantly improved cardiac rehabilitation adherence with 4 of 36 (11%), 13 of 51 (25%), 22 of 53 (42%), and 32 of 52 (62%) participants completing at least 30 sessions in the usual care, case management, financial incentives, and case management plus financial incentives conditions, respectively. The financial incentives and case management plus financial incentives conditions significantly improved cardiac rehabilitation adherence vs usual care (adjusted odds ratio [AOR], 5.1 [95% CI, 1.5-16.7]; P = .01; AOR, 13.2 [95% CI, 4.0-43.5]; P < .001, respectively), and the case management plus financial incentives condition was superior to both case management or financial incentives alone (AOR, 5.0 [95% CI, 2.1-11.9]; P < .001; AOR, 2.6 [95% CI, 1.2-5.9]; P = .02, respectively). Interventions were received well by participants: 86 of 105 (82%) in the financial incentives conditions earned at least some incentives, and 96 of 103 participants (93%) assigned to a case manager completed the initial needs assessment.

Conclusion and Relevance

In this randomized clinical trial, financial incentives improved cardiac rehabilitation adherence in a population with higher risk and lower SES with additional benefit from adding case management.

Trial Registration

ClinicalTrials.gov Identifier: NCT03759873.

Vitamin D treatment distinctly modulates cytokine production by peripheral blood mononuclear cells among patients with chronic cardiac and indeterminate clinical forms of Chagas disease

INTRODUCTION

Chagas disease is caused by the protozoan Trypanosoma cruzi and is clinically divided into acute and chronic phases. Chronic Chagas cardiomyopathy is the most studied manifestation of the disease. Vitamin D deficiency has been suggested as a risk factor for cardiovascular disease. No studies demonstrate the action of this hormone in the cells of patients with chronic Chagas heart disease.

OBJECTIVE

To evaluate the in vitro immunomodulatory effect of vitamin D on peripheral blood mononuclear cells of patients with the different chronic clinical forms of Chagas disease. Evaluating vitamin D's in vitro effect on blood cells by producing cytokines.

METHODS

Thirteen patients of the undetermined form (IND), 13 of the mild cardiac form (CARD1) and 14 of the severe cardiac form (CARD2) of Chagas disease, and 12 with idiopathic heart disease (CARDid) were included. The cells obtained from peripheral blood were treated in vitro with vitamin D (1 × 10-7 M) for 24 h and cytokines were dosed in the culture supernatant.

RESULTS

Although it was not possible to demonstrate statistically significant differences between the groups studied, our data showed that the cells treated with vitamin D modify (p < .05) the production of interferon-γ (IFN-γ) (decrease in IND), tumor necrosis factor-α (TNF-α) (decreased in CARD1 and CARDid), interleukin (IL)-6 (increased in all groups), and IL-10 (decreased in CARD1, CARD2, and CARDid) when compared to untreated cells.

CONCLUSION

In vitro treatment with vitamin D distinctly modulated the production of cytokines by mononuclear cells of peripheral blood among patients with chronic and indeterminate cardiac clinical forms of Chagas disease.

Clopidogrel Versus Aspirin as Monotherapy Following Dual Antiplatelet Therapy in Patients With Acute Coronary Syndrome Receiving a Drug-Eluting Stent: A Systematic Literature Review and Meta-Analysis

OBJECTIVE

This study aimed to evaluate the comparative effectiveness and safety of clopidogrel versus aspirin as monotherapy following adequate dual antiplatelet therapy (DAPT) in patients with acute coronary syndrome (ACS).

METHODS

MEDLINE, Embase, and CENTRAL were searched from database inception to September 1, 2023. Randomized controlled trials (RCTs) and observational studies evaluating the effectiveness or safety of clopidogrel versus aspirin as monotherapy following DAPT in patients with ACS who received a drug-eluting stent were included. Random-effects meta-analyses were conducted to compare risks of major adverse cardiovascular events (MACE) and clinically relevant bleeding.

RESULTS

Of 6242 abstracts identified, three unique studies were included: one RCT and two retrospective cohort studies. Studies included a total of 7081 post-percutaneous coronary intervention ACS patients, 4260 of whom received aspirin monotherapy and 2821 received clopidogrel monotherapy. Studies included variable proportions of patients with ST-elevation myocardial infarction (STEMI), non-STEMI, and unstable angina. From the meta-analysis, clopidogrel was associated with a 28% reduction in the risk of MACE compared with aspirin (hazard ratio [HR]: 0.72; 95% confidence interval [CI]: 0.54, 0.98), with no significant difference in clinically relevant bleeding (HR: 0.92; 95% CI: 0.68, 1.24).

CONCLUSION

Despite the paucity of published evidence on the effectiveness and safety of clopidogrel versus aspirin in patients with ACS post-drug-eluting stent implantation, this meta-analysis suggests that clopidogrel versus aspirin may result in a lower risk of MACE, with a similar risk of major bleeding. The present results are hypothesis-generating and further large RCTs comparing antiplatelet monotherapy options in ACS patients are warranted.

Edoxaban Antithrombotic Therapy for Atrial Fibrillation and Stable Coronary Artery Disease

BACKGROUND

Despite consistent recommendations from clinical guidelines, data from randomized trials on a long-term antithrombotic treatment strategy for patients with atrial fibrillation and stable coronary artery disease are still lacking.

METHODS

We conducted a multicenter, open-label, adjudicator-masked, randomized trial comparing edoxaban monotherapy with dual antithrombotic therapy (edoxaban plus a single antiplatelet agent) in patients with atrial fibrillation and stable coronary artery disease (defined as coronary artery disease previously treated with revascularization or managed medically). The risk of stroke was assessed on the basis of the CHA2DS2-VASc score (scores range from 0 to 9, with higher scores indicating a greater risk of stroke). The primary outcome was a composite of death from any cause, myocardial infarction, stroke, systemic embolism, unplanned urgent revascularization, and major bleeding or clinically relevant nonmajor bleeding at 12 months. Secondary outcomes included a composite of major ischemic events and the safety outcome of major bleeding or clinically relevant nonmajor bleeding.

RESULTS

We assigned 524 patients to the edoxaban monotherapy group and 516 patients to the dual antithrombotic therapy group at 18 sites in South Korea. The mean age of the patients was 72.1 years, 22.9% were women, and the mean CHA2DS2-VASc score was 4.3. At 12 months, a primary-outcome event had occurred in 34 patients (Kaplan-Meier estimate, 6.8%) assigned to edoxaban monotherapy and in 79 patients (16.2%) assigned to dual antithrombotic therapy (hazard ratio, 0.44; 95% confidence interval [CI], 0.30 to 0.65; P<0.001). The cumulative incidence of major ischemic events at 12 months appeared to be similar in the trial groups. Major bleeding or clinically relevant nonmajor bleeding occurred in 23 patients (Kaplan-Meier estimate, 4.7%) in the edoxaban monotherapy group and in 70 patients (14.2%) in the dual antithrombotic therapy group (hazard ratio, 0.34; 95% CI, 0.22 to 0.53).

CONCLUSIONS

In patients with atrial fibrillation and stable coronary artery disease, edoxaban monotherapy led to a lower risk of a composite of death from any cause, myocardial infarction, stroke, systemic embolism, unplanned urgent revascularization, or major bleeding or clinically relevant nonmajor bleeding at 12 months than dual antithrombotic therapy. (Funded by the CardioVascular Research Foundation and others; EPIC-CAD ClinicalTrials.gov number, NCT03718559.).

Sex and gender specific pitfalls and challenges in cardiac rehabilitation: a working hypothesis towards better inclusivity in cardiac rehabilitation programmes

Notwithstanding its acknowledged pivotal role for cardiovascular prevention, cardiac rehabilitation (CR) is still largely under prescribed, in almost 25% of patients owing an indication for. In addition, when considering differences concerning the two sexes, female individuals are underrepresented in CR programmes with lower referral rates, participation, and completion as compared to male counterpart. This picture becomes even more tangled with reference to gender, a complex socio-cultural construct characterized by four domains (gender identity, relation, role, and institutionalized gender). Indeed, each of them reveals several obstacles that considerably penalize CR adherence for different categories of people, especially those who are not identifiable with a non-binary gender. Aim of the present review is to identify the sex- (i.e. biological) and gender- (i.e. socio-cultural) specific obstacles to CR related to biological sex and sociocultural gender and then envision a likely viable solution through tailored treatments towards patients' well-being.

Left main revascularization guidelines: navigating the data

PURPOSE OF REVIEW

This article explores recent developments in left main revascularization, with a focus on appraising the latest American and European guidelines.

RECENT FINDINGS

Recent pooled data analysis from four major randomized controlled trials (RCTs) for left main coronary artery stenosis indicate an advantage for CABG over PCI in regard to freedom from major adverse cardiovascular events, despite no significant difference in mortality observed at 5 years. Additional data support the use of CABG for patients with left ventricular dysfunction, complex left main lesions, diffuse coronary disease, and diabetes.

SUMMARY

The data underpinning the guidelines on each revascularization modality (PCI versus CABG) must consider factors such as lesion complexity, diabetes, and left ventricular dysfunction. Additionally, the findings of the four major RCTs upon which the guidelines are based must be ascertained in light of the latest advancements in these revascularization techniques.

Health Benefits of a Plant-Based Dietary Pattern and Implementation in Healthcare and Clinical Practice

The American College of Lifestyle Medicine recommends eating a predominantly plant-based diet with a variety of minimally processed vegetables, fruits, whole grains, legumes, nuts and seeds. At any level, adoption of a plant-based diet can improve one's health through a variety of mechanisms. Increasing intake of plant-based foods often results in increases in fiber intake, decreases in saturated fat intake, and increased intake of essential vitamins and minerals, among other healthful benefits. Despite such potential benefits, many individuals are reluctant or resistant to change their usual dietary behaviors or unable to sustain diet changes over time. This is largely because an individual's decision to adopt a plant-based diet is influenced by a diverse array of motivating factors, priorities, and/or misconceptions about nutrient adequacy of plant-based diets. Here, we discuss key points from a session at the American College of Lifestyle Medicine's annual conference LM2023. Specifically, we review common preconceptions about plant-based diets, provide guidance on removing the barriers to adopting and adhering to plant-based diets, and highlight key literature findings supporting the health benefits of plant-based diets. Last, we discuss how plant-based diets are increasingly being implemented within health care and clinical practice to support Food is/as Medicine approaches.