Preventing heart disease in the 21st century: implications of the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) study

Development and validation of a risk prediction model for short-term progression of carotid atherosclerosis among early middle age adults

AIM

We aimed at creating and validating a prognostic model incorporating easily accessible clinical and laboratory parameters to forecast the likelihood of short-term progression of carotid atherosclerosis.

METHODS

A prediction model was developed and validated for carotid plaque progression within 2 years in an early middle-age population in China. Progression was defined as the new appearance of carotid plaque or stenosis among participants who had normal carotid status at baseline. Leveraging data from a health check-up chain, predictors were identified using statistical methods including stepwise logistic regression, Markov Chain Monte Carlo (MCMC) simulation, random forest analysis and least absolute shrinkage selection operator (Lasso). Model performance was assessed. Bootstrap internal validation, validation on another check-up population and subgroup analysis were also conducted.

RESULTS

Among 7765 participants, predictors including age, diastolic blood pressure, uric acid levels, high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) were identified for carotid plaque progression in 2 years. The developed prediction model demonstrated good discrimination (AUC = 0.755, 95%CI:0.736-0.774) and calibration ability (slope = 0.922 and interception = 0.007) among development data, as well as among validation data (AUC = 0.759, 95%CI:0.674-0.770; slope = 1.076 and intercept = -0.014). Internal validation using bootstrap method yielded an adjusted AUC of 0.753. The model's performance remained consistent across different subgroups.

CONCLUSIONS

Our study presents a validated risk prediction model for carotid plaque progression in an early middle age population, offering a valuable tool for early identification and monitoring of cardiovascular risks. The model's robustness and applicability across different subgroups highlight its potential utility in preemptive cerebrovascular and cardiovascular disease management.

Motion artifacts in capacitive ECG monitoring systems: a review of existing models and reduction techniques

Current research focuses on improving electrocardiogram (ECG) monitoring systems to enable real-time and long-term usage, with a specific focus on facilitating remote monitoring of ECG data. This advancement is crucial for improving cardiovascular health by facilitating early detection and management of cardiovascular disease (CVD). To efficiently meet these demands, user-friendly and comfortable ECG sensors that surpass wet electrodes are essential. This has led to increased interest in ECG capacitive electrodes, which facilitate signal detection without requiring gel preparation or direct conductive contact with the body. This feature makes them suitable for wearables or integrated measurement devices. However, ongoing research is essential as the signals they measure often lack sufficient clinical accuracy due to susceptibility to interferences, particularly Motion Artifacts (MAs). While our primary focus is on studying MAs, we also address other limitations crucial for designing a high Signal-to-Noise Ratio (SNR) circuit and effectively mitigating MAs. The literature on the origins and models of MAs in capacitive electrodes is insufficient, which we aim to address alongside discussing mitigation methods. We bring attention to digital signal processing approaches, especially those using reference signals like Electrode-Tissue Impedance (ETI), as highly promising. Finally, we discuss its challenges, proposed solutions, and offer insights into future research directions.

Fatty acid composition in erythrocytes and coronary artery disease risk: a case-control study in China

Background and aims: There is limited and conflicting evidence about the association of erythrocyte fatty acids with coronary artery disease (CAD), particularly in China where the CAD rates are high. Our study aimed to explore the association between erythrocyte fatty acid composition and CAD risk in Chinese adults. Methods: Erythrocyte fatty acids of 314 CAD patients and 314 matched controls were measured by gas chromatography. Multivariable conditional logistic regression and restricted cubic spline models were used to explore the odds ratio with 95% confidence interval (OR, 95% CI) and potential association between erythrocyte fatty acids and CAD risk. Principal component analysis (PCA) was used to analyze further the potential role of various erythrocyte fatty acid patterns in relation to CAD risk. Results: Significant inverse associations were observed between high levels of erythrocyte total n-3 polyunsaturated fatty acids (n-3 PUFA) [ORT3-T1 = 0.18 (0.12, 0.28)], monounsaturated fatty acids (MUFA) [ORT3-T1 = 0.21 (0.13, 0.32)], and the risk of CAD. Conversely, levels of saturated fatty acids (SFAs) and n-6 polyunsaturated fatty acids (n-6 PUFAs) were positively associated with CAD risk [ORT3-T1 = 3.33 (2.18, 5.13), ORT3-T1 = 1.61 (1.06, 2.43)]. No significant association was observed between CAD risk and total trans fatty acids. Additionally, the PCA identifies four new fatty acid patterns (FAPs). The risk of CAD was significantly positively associated with FAP1 and FAP2, while being negatively correlated with FAP3 and FAP4. Conclusion: The different types of erythrocyte fatty acids may significantly alter susceptibility to CAD. Elevated levels of n-3-PUFAs and MUFAs are considered as protective biomarkers against CAD, while SFAs and n-6 PUFAs may be associated with higher CAD risk in Chinese adults. The risk of CAD was positively associated with FAP1 and FAP2, and negatively associated with FAP3 and FAP4. Combinations of erythrocyte fatty acids may be more important markers of CAD development than individual fatty acids or their subgroups.

Cardiometabolic Risk Profiles of Adolescents Living With Perinatally Acquired HIV in South Africa

BACKGROUND

We assessed the Pathological Determinants of Atherosclerosis in Youth (PDAY) score and other potential cardiovascular disease risk factors in adolescents previously enrolled in the Children with HIV Early antiRetroviral (CHER) and International Maternal Pediatric Adolescent AIDS Clinical Trials Network P1060 clinical trials.

METHODS

Coronary artery and abdominal aorta (AA) PDAY scores were calculated for 56 participants over 15 years of age using a weighted combination of dyslipidemia, cigarette smoking, hypertension, obesity, and hyperglycemia. A PDAY score ≥1 is associated with early atherosclerosis.

RESULTS

Fifty-six participants were enrolled: 46 (82.1%) on a single-tablet regimen of tenofovir disoproxil fumarate, lamivudine and dolutegravir. Median time on antiretroviral therapy was 15.8 [interquartile range (IQR): 15.8-16.5] years and median time on dolutegravir was 14 (IQR: 10.0-19.0) months. Fasting median high-density lipoprotein cholesterol was 20.1 mg/dL (IQR: 16.0-23.7) and median non-high-density lipoprotein cholesterol was 38.3 mg/dL (IQR: 30.8-44.3). The median systolic blood pressure was 115 mm Hg (IQR: 107-121). Median body mass index was 21.3 kg/m 2 (IQR: 19.5-24.7) and median fasted serum glucose was 82.0 mg/dL (IQR: 75.7-87.3). Only 1 (2%) participant smoked cigarettes, but 5 (9%) smoked hookah pipe and 26 (46.4%) smoked cannabis. Thirty-one (55.4%) participants had coronary artery PDAY scores ≥1 and 33 (58.9%) had AA PDAY scores ≥1. Age was associated with an AA PDAY score ≥1 ( P = 0.02) with a 0.06 increase in AA PDAY score for every month of age (95% confidence interval: 0.01-0.12, P = 0.01).

CONCLUSIONS

Adolescents with perinatally acquired HIV appear at risk for cardiovascular disease. Specific tools for monitoring this risk are needed to institute appropriate preventive interventions.

Lipid Testing among Youth in Medicaid: The Role of Social Determinants of Health and Providers

OBJECTIVE

To assess recent temporal trends in guideline-compliant pediatric lipid testing, and to examine the influence of social determinants of health (SDoH) and provider characteristics on the likelihood of testing in youth.

STUDY DESIGN

In this observational, multiyear cross-sectional study, we calculated lipid testing prevalence by year among 268 627 12-year olds from 2015 through 2019 who were enrolled in Florida Medicaid and eligible for universal lipid screening during age 9 to 11, and 11 437 22-year olds (2017-2019) who were eligible for screening during age 17-21. We compared trends in testing prevalence by SDoH and health risk factors at two recommended ages and modeled the associations between patient characteristics and provider type on lipid testing using generalized estimating equations.

RESULTS

Testing among 12-year olds remained low between 2015 through 2019 with the highest prevalence in 2015 (8.0%) and lowest in 2017 (6.7%). Screening compliance among 22-year olds was highest in 2017 (21.1%) and fell to 17.8% in 2019. Hispanics and non-Hispanic Blacks in both age groups had about 2%-3% lower testing prevalence than non-Hispanic Whites. Testing in 12-year olds was 12.3% vs 7.7% with and without obesity, and 14.4% vs 7.6% with and without antipsychotic use. Participants who saw providers who were more likely to prescribe lipid testing were more likely to receive testing (OR = 2.3, 95% CI 2.0-2.8, P < .001).

CONCLUSIONS

Although lipid testing prevalence was greatest among high-risk children, overall prevalence of lipid testing in youth remains very low. Provider specialty and choices by individual providers play important roles in improving guideline-compliant pediatric lipid testing.

Evolving Strategies for Use of Phytochemicals in Prevention and Long-Term Management of Cardiovascular Diseases (CVD)

This report describes major pathomechanisms of disease in which the dysregulation of host inflammatory processes is a major factor, with cardiovascular disease (CVD) as a primary model, and reviews strategies for countermeasures based on synergistic interaction between various agents, including drugs and generally regarded as safe (GRAS) natural medical material (NMM), such as Ginkgo biloba, spice phytochemicals, and fruit seed flavonoids. The 15 well-defined CVD classes are explored with particular emphasis on the extent to which oxidative stressors and associated ischemia-reperfusion tissue injury contribute to major symptoms. The four major categories of pharmaceutical agents used for the prevention of and therapy for CVD: statins, beta blockers (β-blockers), blood thinners (anticoagulants), and aspirin, are presented along with their adverse effects. Analyses of major cellular and molecular features of drug- and NMM-mediated cardioprotective processes are provided in the context of their development for human clinical application. Future directions of the evolving research described here will be particularly focused on the characterization and manipulation of calcium- and calcineurin-mediated cascades of signaling from cell surface receptors on cardiovascular and immune cells to the nucleus, with the emergence of both protective and pathological epigenetic features that may be modulated by synergistically-acting combinations of drugs and phytochemicals in which phytochemicals interact with cells to promote signaling that reduces the effective dosage and thus (often) toxicity of drugs.

Tracking of serum lipid levels from childhood to adulthood: Systematic review and meta-analysis

BACKGROUND AND AIMS

The utility of lipid screening in pediatric settings for preventing adult atherosclerotic cardiovascular diseases partly depends on the lifelong tracking of lipid levels. This systematic review aimed to quantify the tracking of lipid levels from childhood and adolescence to adulthood.

METHODS

We systematically searched MEDLINE, Embase, Web of Science, and Google Scholar in March 2022. The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO; ID: CRD42020208859). We included cohort studies that measured tracking of lipids from childhood or adolescence (<18 years) to adulthood (≥18) with correlation or tracking coefficients. We estimated pooled correlation and tracking coefficients using random-effects meta-analysis. Risk of bias was assessed with a review-specific tool.

RESULTS

Thirty-three studies of 19 cohorts (11,020 participants) were included. The degree of tracking from childhood and adolescence to adulthood differed among lipids. Tracking was observed for low-density lipoprotein cholesterol (pooled r = 0.55-0.65), total cholesterol (pooled r = 0.51-0.65), high-density lipoprotein cholesterol (pooled r = 0.46-0.57), and triglycerides (pooled r = 0.32-0.40). Only one study included tracking of non-high-density lipoprotein cholesterol (r = 0.42-0.59). Substantial heterogeneity was observed. Study risk of bias was moderate, mostly due to insufficient reporting and singular measurements at baseline and follow-up.

CONCLUSIONS

Early-life lipid measurements are important for predicting adult levels. However, further research is needed to understand the tracking of non-high-density lipoprotein cholesterol and the stability of risk classification over time, which may further inform pediatric lipid screening and assessment strategies.

Tracking of apolipoprotein B levels measured in childhood and adolescence: systematic review and meta-analysis

To quantify the tracking of apolipoprotein B (apoB) levels from childhood and adolescence and compare the tracking of apoB with low-density lipoprotein (LDL) cholesterol, a systematic search of MEDLINE, Embase, Web of Science, and Google Scholar was performed in October 2023 (PROSPERO protocol: CRD42022298663). Cohort studies that measured tracking of apoB from childhood/adolescence (< 19 years) with a minimum follow-up of 1 year, using tracking estimates such as correlation coefficients or tracking coefficients, were eligible. Pooled correlations were estimated using random-effects meta-analysis. Risk of bias was assessed with a review-specific tool. Ten studies of eight unique cohorts involving 4677 participants met the inclusion criteria. Tracking of apoB was observed (pooled r = 0.63; 95% confidence interval [CI] = 0.53-0.71; I2 = 96%) with no significant sources of heterogeneity identified. Data from five cohorts with tracking data for both lipids showed the degree of tracking was similar for apoB (pooled r = 0.59; 95% CI = 0.55-0.63) and LDL cholesterol (pooled r = 0.58; 95% CI = 0.47-0.68). Study risk of bias was moderate, mostly due to attrition and insufficient reporting.

CONCLUSION

ApoB levels track strongly from childhood, but do not surpass LDL cholesterol in this regard. While there is strong evidence that apoB is more effective at predicting ASCVD risk than LDL cholesterol in adults, there is currently insufficient evidence to support its increased utility in pediatric settings. This also applies to tracking data, where more comprehensive data are required.

WHAT IS KNOWN

• Apolipoprotein B is a known cause of atherosclerotic cardiovascular disease. • Apolipoprotein B levels are not typically measured in pediatric settings, where low-density lipoprotein cholesterol remains the primary lipid screening measure.

WHAT IS NEW

• This meta-analysis of 10 studies showed apolipoprotein B levels tracked strongly from childhood but did not exceed low-density lipoprotein cholesterol in this regard. • More comprehensive tracking data are needed to provide sufficient evidence for increased utility of apolipoprotein B in pediatric settings.

Attention-Based Deep Learning Model for Prediction of Major Adverse Cardiovascular Events in Peritoneal Dialysis Patients

Major adverse cardiovascular events (MACE) encompass pivotal cardiovascular outcomes such as myocardial infarction, unstable angina, and cardiovascular-related mortality. Patients undergoing peritoneal dialysis (PD) exhibit specific cardiovascular risk factors during the treatment, which can escalate the likelihood of cardiovascular events. Hence, the prediction and key factor analysis of MACE have assumed paramount significance for peritoneal dialysis patients. Current pathological methodologies for prognosis prediction are not only costly but also cumbersome in effectively processing electronic health records (EHRs) data with high dimensionality, heterogeneity, and time series. Therefore in this study, we propose the CVEformer, an attention-based neural network designed to predict MACE and analyze risk factors. CVEformer leverages the self-attention mechanism to capture temporal correlations among time series variables, allowing for weighted integration of variables and estimation of the probability of MACE. CVEformer first captures the correlations among heterogeneous variables through attention scores. Then, it analyzes the correlations within the time series data to identify key risk variables and predict the probability of MACE. When trained and evaluated on data from a large cohort of peritoneal dialysis patients across multiple centers, CVEformer outperforms existing models in terms of predictive performance.

A life-course approach to tackling noncommunicable diseases in women

Women's health has been critically underserved by a failure to look beyond women's sexual and reproductive systems to adequately consider their broader health needs. In almost every country in the world, noncommunicable diseases are the leading causes of death for women. Among these, cardiovascular disease (including heart disease and stroke) and cancer are the major causes of mortality. Risks for these conditions exist at each stage of women's lives, but recognition of the unique needs of women for the prevention and management of noncommunicable diseases is relatively recent and still emerging. Once they are diagnosed, treatments for these diseases are often costly and noncurative. Therefore, we call for a strategic, innovative life-course approach to identifying disease triggers and instigating cost-effective measures to minimize exposure in a timely manner. Prohibitive barriers to implementing this holistic approach to women's health exist in both the social arena and the medical arena. Recognizing these impediments and implementing practical approaches to surmounting them is a rational approach to advancing health equity for women, with ultimate benefits for society as a whole.

Personalized Machine Learning-Coupled Nanopillar Triboelectric Pulse Sensor for Cuffless Blood Pressure Continuous Monitoring

A wearable system that can continuously track the fluctuation of blood pressure (BP) based on pulse signals is highly desirable for the treatments of cardiovascular diseases, yet the sensitivity, reliability, and accuracy remain challenging. Since the correlations of pulse waveforms to BP are highly individualized due to the diversity of the patients' physiological characteristics, wearable sensors based on universal designs and algorithms often fail to derive BP accurately when applied on individual patients. Herein, a wearable triboelectric pulse sensor based on a biomimetic nanopillar layer was developed and coupled with Personalized Machine Learning (ML) to provide accurate and continuous monitoring of BP. Flexible conductive nanopillars as the triboelectric layer were fabricated through soft lithography replication of a cicada wing, which could effectively enhance the sensor's output performance to detect weak signal characteristics of pulse waveform for BP derivation. The sensors were coupled with a personalized Partial Least-Squares Regression (PLSR) ML to derive unknown BP based on individual pulse characteristics with reasonable accuracy, avoiding the issue of individual variability that was encountered by General PLSR ML or formula algorithms. The cuffless and intelligent design endow this ML-sensor as a highly promising platform for the care and treatments of hypertensive patients.

Cumulative burden and trajectories of body mass index and blood pressure from childhood and carotid intima-media thickness in young adulthood

There are significant gaps in understanding of the association between levels and rate of change of body mass index (BMI) and blood pressure (BP) at different ages during childhood and carotid intima-media thickness (CIMT) in adulthood. We investigated the association between trajectories of BMI and BP from childhood to adulthood and adult CIMT among Iranian participants in the Tehran Lipid and Glucose Study (TLGS) cohort. A total of 1334 participants (692 men), from the TLGS cohort (1999-2018) with repeated measurements of BMI and BP (2-6 times) from childhood (3-18 years) to young adulthood (20-40 years) were selected. Trajectory parameters included levels and linear slopes of BMI and BP growth curve models, and cumulative burden defined as the area under those curves (AUC). After adjusting for confounders, AUC of BMI and diastolic blood pressure (DBP) were significantly associated with high CIMT in adulthood, with the standardized odds ratios (OR) and 95% confidence interval (95% CI) of 1.35 (1.12-1.62) and 1.27 (1.01-1.60), respectively. Associations between level-independent slopes of BMI and adult CIMT were significantly positive (ORs: 1.27 to 1.26) during childhood ages (3-18 years). Further, levels of BMI (ORs: 1.23 to 1.29) and DBP (ORs: 1.25 to 1.33) during the ages of 13-18 and 11-17 years, respectively, were significantly associated with CIMT in adulthood (all P < 0.05). The cumulative burden of BMI and DBP was associated with CIMT in adulthood. Adolescence is a crucial period for high CIMT, which has implications for early prevention of atherosclerosis.

Knowledge of Cardiovascular Disease Risk Factors and Its Primary Prevention Practices Among the Saudi Public - A Questionnaire-Based Cross-Sectional Study

Background and Objectives

In response to the aging population and rapid rise of chronic diseases, it is important to understand the knowledge about primary prevention. We aim to explore Saudi adults' knowledge of cardiovascular disease (CVD) risk factors and its primary prevention practices among the Saudi public.

Methods

This is a cross-sectional community-based study, conducted among people living in Saudi Arabia to assess the knowledge of CVD risk factors using a total of 24-item questionnaires divided into two sections using the Likert scale, true /False/I do not know. The data were analyzed using the statistical software SPSS v. 26.0 (SPSS Inc., Chicago, IL, USA).

Results

In this study, the 81.8% of participants (n=296) agreed that high blood pressure was a risk factor for CVD, while more than two-thirds (68.8%; n=249) believed that diabetes was a risk factor for CVD. Furthermore, about the same proportion of respondents ((79.8%; n=289) and (78.7%; n=285)) agreed that physical inactivity and smoking were risk factors for CVD. In addition, the vast majority of them (n=324; 89.5%) believed that regular exercise aids in the prevention of CVD. In contrast, 74.9% (n=271) of individuals agreed that quitting smoking helps prevent CVD. This study indicated that 55.8% (n=202) of respondents had strong knowledge of CVD, while 44.2% (n=160) had inadequate awareness of CVD risk factors and prevention methods. In terms of the association between socio-demographic factors and overall participants' knowledge of CVD risk factors and preventative measures, we discovered that age (p=0.000), gender (p=0.011), educational status (p=0.000), and the presence of chronic disease (p=0.000) were all significantly associated with CVD knowledge score levels.

Conclusion

Saudi adults have adequate knowledge of CVD risk factors and prevention interventions, but more effort is needed to raise continuous awareness to reduce the prevalence of CVD.

Selecting cardiac magnetic resonance images suitable for annotation of pulmonary arteries using an active-learning based deep learning model

An increasing and aging patient population poses a growing burden on healthcare professionals. Automation of medical imaging diagnostics holds promise for enhancing patient care and reducing manpower required to accommodate an increasing patient-population. Deep learning, a subset of machine learning, has the potential to facilitate automated diagnostics, but commonly requires large-scaled labeled datasets. In medical domains, data is often abundant but labeling is a laborious and costly task. Active learning provides a method to optimize the selection of unlabeled samples that are most suitable for improvement of the model and incorporate them into the model training process. This approach proves beneficial when only a small number of labeled samples are available. Various selection methods currently exist, but most of them employ fixed querying schedules. There is limited research on how the timing of a query can impact performance in relation to the number of queried samples. This paper proposes a novel approach called dynamic querying, which aims to optimize the timing of queries to enhance model development while utilizing as few labeled images as possible. The performance of the proposed model is compared to a model trained utilizing a fully-supervised training method, and its effectiveness is assessed based on dataset size requirements and loss rates. Dynamic querying demonstrates a considerably faster learning curve in relation to the number of labeled samples used, achieving an accuracy of 70% using only 24 samples, compared to 82% for a fully-supervised model trained on the complete training dataset of 1017 images.

Self-Powered Textile Triboelectric Pulse Sensor for Cardiovascular Monitoring

Cardiovascular diseases have become a severe threat to human health. Fortunately, most of them can be effectively assessed and prevented through long-term monitoring of cardiovascular signals. Wearable medical sensors play an essential role in monitoring human physiological health, which are heading towards ultra-low power consumption, high sensitivity and stability. Furthermore, a comfortable wearable sensor also needs to be flexible and breathable. Here, a self-powered textile pulse sensor (STPS) based on triboelectric nanogenerator (TENG) is demonstrated for real-time monitoring of the radial artery pulse waveform. STPS can directly convert tiny pressure signals into electrical signals with excellent linearity (R2 = 0.996), low detection limit, and long-term stable performance (5×104 cycles). The flexible textile-based STPS can be conformally attached to the human body for continuously and stably recording physiological mechanical signals, which is expected to be utilized in the personalized cardiovascular pulse monitoring wearable devices in the Internet of Things era.

Stakeholder-led understanding of the implementation of digital technologies within heart disease diagnosis: a qualitative study protocol

INTRODUCTION

Cardiovascular diseases are highly prevalent among the UK population, and the quality of care is being reduced due to accessibility and resource issues. Increased implementation of digital technologies into the cardiovascular care pathway has enormous potential to lighten the load on the National Health Service (NHS), however, it is not possible to adopt this shift without embedding the perspectives of service users and clinicians.

METHODS AND ANALYSIS

A series of qualitative studies will be carried out with the aim of developing a stakeholder-led perspective on the implementation of digital technologies to improve holistic diagnosis of heart disease. This will be a decentralised study with all data collection being carried out online with a nationwide cohort. Four focus groups, each with 5-6 participants, will be carried out with people with lived experience of heart disease, and 10 one-to-one interviews will be carried out with clinicians with experience of diagnosing heart diseases. The data will be analysed using an inductive thematic analysis approach.

ETHICS AND DISSEMINATION

This study received ethical approval from the Sciences and Technology Cross Research Council at the University of Sussex (reference ER/FM409/1). Participants will be required to provide informed consent via a Qualtrics survey before being accepted into the online interview or focus group. The findings will be disseminated through conference presentations, peer-reviewed publications and to the study participants.

Imaging Early Life Cardiovascular Phenotype

The growing epidemics of obesity, hypertension, and diabetes, in addition to worsening environmental factors such as air pollution, water scarcity, and climate change, have fueled the continuously increasing prevalence of cardiovascular diseases (CVDs). This has caused a markedly increasing burden of CVDs that includes mortality and morbidity worldwide. Identification of subclinical CVD before overt symptoms can lead to earlier deployment of preventative pharmacological and nonpharmacologic strategies. In this regard, noninvasive imaging techniques play a significant role in identifying early CVD phenotypes. An armamentarium of imaging techniques including vascular ultrasound, echocardiography, magnetic resonance imaging, computed tomography, noninvasive computed tomography angiography, positron emission tomography, and nuclear imaging, with intrinsic strengths and limitations can be utilized to delineate incipient CVD for both clinical and research purposes. In this article, we review the various imaging modalities used for the evaluation, characterization, and quantification of early subclinical cardiovascular diseases.

A utility-based machine learning-driven personalized lifestyle recommendation for cardiovascular disease prevention

In recent decades, cardiovascular disease (CVD) has become the leading cause of death in most countries of the world. Since many types of CVD are preventable by modifying lifestyle behaviors, the objective of this paper is to develop an effective personalized lifestyle recommendation algorithm for reducing the risk of common types of CVD. However, in practice, the underlying relationships between the risk factors (e.g., lifestyles, blood pressure, etc.) and disease onset is highly complex. It is also challenging to identify effective modification recommendations for different individuals due to individual's effort-benefits consideration and uncertainties in disease progression. Therefore, to address these challenges, this study developed a novel data-driven approach for personalized lifestyle behaviors recommendation based on machine learning and a personalized exponential utility function model. The contributions of this work can be summarized into three aspects: (1) a classification-based prediction model is implemented to predict the CVD risk based on the condition of risk factors; (2) the generative adversarial network (GAN) is incorporated to learn the underlying relationship between risk factors, as well as quantifying the uncertainty of disease progression under lifestyle modifications; and (3) a novel personalized exponential utility function model is proposed to evaluate the modifications' utilities with respect to CVD risk reduction, individual's effort-benefits consideration, and disease progression uncertainty, as well as identify the optimal modification for each individual. The effectiveness of the proposed method is validated through an open-access CVD dataset. The results demonstrate that the personalized lifestyle modification recommended by the proposed methodology has the potential to effectively reduce the CVD risk. Thus, it is promising to be further applied to real-world cases for CVD prevention.

Drug loaded implantable devices to treat cardiovascular disease

INTRODUCTION

It is widely acknowledged that cardiovascular diseases (CVDs) continue to be the leading cause of death globally. Furthermore, CVDs are the leading cause of diminished quality of life for patients, frequently as a result of their progressive deterioration. Medical implants that release drugs into the body are active implants that do more than just provide mechanical support; they also have a therapeutic role. Primarily, this is achieved through the controlled release of active pharmaceutical ingredients (API) at the implementation site.

AREAS COVERED

In this review, the authors discuss drug-eluting stents, drug-eluting vascular grafts, and drug-eluting cardiac patches with the aim of providing a broad overview of the three most common types of cardiac implant.

EXPERT OPINION

Drug eluting implants are an ideal alternative to traditional drug delivery because they allow for accurate drug release, local drug delivery to the target tissue, and minimise the adverse side effects associated with systemic administration. Despite the fact that there are still challenges that need to be addressed, the ever-evolving new technologies are making the fabrication of drug eluting implants a rewarding therapeutic endeavour with the possibility for even greater advances.

Controlled supramolecular interactions for targeted release of Amiodarone drug through Graphyne to treat cardiovascular diseases: An in silico study

In the current study, the drug loading ability of graphyne (GY) for the amiodarone (AMD) drug is investigated for the first time. The efficacy of GY as a carrier for amiodarone (a cardiovascular drug) is evaluated by calculating its electronic, energetic, optimized, and excited state properties with help of the density functional theory (DFT). The AMD drug interacted with the GY molecule with an adsorption energy of about -0.19 eV (gas-phase) and -1.92 eV (aqueous phase), suggesting that the AMD@GY complex is stable in water-phase. The HOMO (highest-occupied molecular-orbital) of the AMD@GY complex is concentrated on the AMD drug while the LUMO (lowest-unoccupied molecular-orbital) is centralized on GY with absolute charge separation, indicating charge transfer will occur between AMD and GY. The charge-transfer process is further studied with the aid of charge-decomposition analysis (CDA). The non-covalent interaction analysis (NCI) exposed that non-covalent forces exist between the GY carrier and AMD drug. These non-covalent forces between AMD drug and GY carrier play a significant role in drug unloading at the targeted or diseased site. Likewise, the calculations at excited-state, charge-state (+1 and -1) influence on GY and AMD@GY complex structures, and photo-induced electron transfer analysis (PET) are also studied for the graphyne-based drug-delivery system. According to PET and electron-hole analysis, fluorescence-quenching will occur upon interaction. Overall, it is concluded that graphyne can be exploited as a drug carrier for amiodarone drug delivery. Researchers will be fascinated to look at alternative 2D nanomaterials for drug delivery applications as a result of this theoretical work.

Chrysin protects cardiac H9c2 cells against H2O2-induced endoplasmic reticulum stress by up-regulating the Nrf2/PERK pathway

Oxidative and endoplasmic reticulum (ER) stress-mediated cardiac apoptosis is an essential pathological process in cardiovascular diseases (CVDs). Chrysin (Chy) is a natural flavonoid that exerts several health benefits, particularly anti-oxidative and anti-apoptotic effects. However, its protective effect against CVDs and its mechanism of action at a molecular level remains unclear. Therefore, the present study aimed to investigate the interaction of ER stress response protein with Chy by computational analysis and molecular action in H₂O₂-induced oxidative and ER stress in cardiomyoblast cells. H9c2 cells were pre-treated with 50 μM of Chy for 24 h and exposed to H₂O₂ for 1 h. Explore the Chy-mediated Nrf2 signalling on ER stress reduction, H9c2 cell lines were transfected with Nrf2 siRNA for 48 h and further treated with Chy for 24 h and subjected to H₂O₂ for 1 h. Chy pre-treatment increased the Nrf2-regulated gene expression, reduced the ER stress signalling genes such as CHOP and GRP78, and increased the PERK and AFT6 expression compared to H₂O₂-treated cells. Chy preincubation down-regulated the expression of PI3K, NF-κB, and caspase-3. Fluorescence staining revealed that Chy reduced intracellular ROS generation, ER stress, apoptosis, and increased MMP. This beneficial effect of Chy was abolished when silencing Nrf2 in H9c2 cells. Overall, the present study confirmed that Chy showed the cardioprotective effect by attenuating ER stress via the activation of Nrf2 signalling. Therefore, the study concluded that improving Nrf2 signalling by Chy supplementation could provide a promising therapeutic target in oxidative and ER stress-mediated CVDs complications.

High Plasma Levels of Soluble Lectin-like Oxidized Low-Density Lipoprotein Receptor-1 Are Associated With Inflammation and Cardiometabolic Risk Profiles in Pediatric Overweight and Obesity

Background Lectin-like oxidized low-density lipoprotein (ox-LDL) receptor-1 is a scavenger receptor for oxidized low-density lipoprotein. In adults, higher soluble lectin-like ox-LDL receptor-1 (sLOX-1) levels are associated with cardiovascular disease, type 2 diabetes, and obesity, but a similar link in pediatric overweight/obesity remains uncertain. Methods and Results Analyses were based on the cross-sectional HOLBAEK Study, including 4- to 19-year-olds from an obesity clinic group with body mass index >90th percentile (n=1815) and from a population-based group (n=2039). Fasting plasma levels of sLOX-1 and inflammatory markers were quantified, cardiometabolic risk profiles were assessed, and linear and logistic regression analyses were performed. Pubertal/postpubertal children and adolescents from the obesity clinic group exhibited higher sLOX-1 levels compared with the population (P<0.001). sLOX-1 positively associated with proinflammatory cytokines, matrix metalloproteinases, body mass index SD score, waist SD score, body fat %, plasma alanine aminotransferase, serum high-sensitivity C-reactive protein, plasma low-density lipoprotein cholesterol, triglycerides, systolic and diastolic blood pressure SD score, and inversely associated with plasma high-density lipoprotein cholesterol (all P<0.05). sLOX-1 positively associated with high alanine aminotransferase (odds ratio [OR], 1.16, P=4.1 E-04), insulin resistance (OR, 1.16, P=8.6 E-04), dyslipidemia (OR, 1.25, P=1.8 E-07), and hypertension (OR, 1.12, P=0.02). Conclusions sLOX-1 levels were elevated during and after puberty in children and adolescents with overweight/obesity compared with population-based peers and associated with inflammatory markers and worsened cardiometabolic risk profiles. sLOX-1 may serve as an early marker of cardiometabolic risk and inflammation in pediatric overweight/obesity. Registration The HOLBAEK Study, formerly known as The Danish Childhood Obesity Biobank, ClinicalTrials.gov identifier number NCT00928473, https://clinicaltrials.gov/ct2/show/NCT00928473 (registered June 2009).

Direct Cardiac Reprogramming: Current Status and Future Prospects

Advances in cellular reprogramming articulated the path for direct cardiac lineage conversion, bypassing the pluripotent state. Direct cardiac reprogramming attracts major attention because of the low or nil regenerative ability of cardiomyocytes, resulting in permanent cell loss in various heart diseases. In the field of cardiology, balancing this loss of cardiomyocytes was highly challenging, even in the modern medical world. Soon after the discovery of cell reprogramming, direct cardiac reprogramming also became a promising alternative for heart regeneration. This review mainly focused on the various direct cardiac reprogramming approaches (integrative and non-integrative) for the derivation of induced autologous cardiomyocytes. It also explains the advancements in cardiac reprogramming over the decade with the pros and cons of each approach. Further, the review highlights the importance of clinically relevant (non-integrative) approaches and their challenges for the prospective applications for personalized medicine. Apart from direct cardiac reprogramming, it also discusses the other strategies for generating cardiomyocytes from different sources. The understanding of these strategies could pave the way for the efficient generation of integration-free functional autologous cardiomyocytes through direct cardiac reprogramming for various biomedical applications.

Mortality risk prediction of the electrocardiogram as an informative indicator of cardiovascular diseases

Background

The electrocardiogram (ECG) may be the most popular test in the management of cardiovascular disease (CVD). Although wide applications of artificial intelligence (AI)-enabled ECG have been developed, an integrating indicator for CVD risk stratification was not investigated. Since mortality may be the most important global outcome, this study aimed to develop a survival deep learning model (DLM) to establish a critical ECG value and explore the associations with various CVD events.

Methods

We trained a DLM with 451,950 12-lead resting ECGs obtained from 210,552 patients, for whom 23,592 events occurred. The internal validation set included 27,808 patients with one ECG for each patient. The external validations were performed in a community hospital with 33,047 patients and two transnational data sets with 233,647 and 1631 ECGs. We distinguished the cause of mortality and additionally investigated CVD-related outcomes, including new-onset acute myocardial infarction (AMI), stroke (STK), and heart failure (HF).

Results

The DLM achieved C-indices of 0.858/0.836 in internal/external validation sets by using ECG over a 10-year period. The high-mortality-risk group identified by the proposed DLM presented a hazard ratio (HR) of 14.16 (95% confidence interval (CI): 11.33-17.70) compared to the low-risk group in the internal validation and presented a higher risk of cardiovascular (CV) mortality (HR: 18.50, 95% CI: 9.82-34.84), non-CV mortality (HR: 13.68, 95% CI: 10.76-17.38), AMI (HR: 4.01, 95% CI: 2.24-7.17), STK (HR: 2.15, 95% CI: 1.70-2.72), and HF (HR: 6.66, 95% CI: 4.54-9.77), which was consistent in an independent community hospital. The transnational validation also revealed HRs of 4.91 (95% CI: 2.63-9.16) and 2.29 (95% CI: 2.15-2.44) for all-cause mortality in the SaMi-Trop and Clinical Outcomes in Digital Electrocardiography 15% (CODE15) cohorts.

Conclusions

The mortality risk by AI-enabled ECG may be applied in passive electronic-health-record-based CVD risk screening, which may identify more asymptomatic and unaware high-risk patients.

Cardiovascular Risk Assessment and Management for Pediatricians

Childhood and adolescence provide a unique window of opportunity to prevent atherosclerotic cardiovascular disease later in life, especially for pediatric groups at risk. The growing list of pediatric groups at risk includes individuals with chronic inflammatory disorders, organ transplants, familial hypercholesterolemia, endocrine disorders, childhood cancer, chronic kidney diseases, congenital heart diseases, and premature birth, as well as increasing numbers of children and adolescents with traditional risk factors such as obesity, hypertension, hyperlipidemia, and hyperglycemia. Here, we focus on recent advances in cardiovascular risk assessment and management and their implications for pediatric practice. First, hyperlipidemia and hyperglycemia are highly prevalent in the young, with hyperlipidemia occurring in 14.6% and hyperglycemia in 16.4% of children and adolescents with a normal weight. Implementation of nonfasting lipid and glycated hemoglobin screening in youth at risk is emerging as a promising avenue to improve testing compliance and lipid and glucose management. Second, blood pressure, lipid, and glucose management in youth at risk are reviewed in depth. Third, multisite and multimodal assessment of early atherosclerosis is discussed as a way to capture the complexity of atherosclerosis as a systemic disease. In addition to conventional carotid intima-media thickness measurements, the measurement of aortic pulse wave velocity and peripheral arterial tonometry can advance the assessment of early atherosclerosis in pediatrics. Finally, we make a plea for lifetime atherosclerotic cardiovascular disease risk stratification that integrates disease-associated risk factors and traditional risk factors and could facilitate tailored cardiovascular risk management in growing numbers of children and adolescents at risk.

Highly Sensitive Self-Powered Biomedical Applications Using Triboelectric Nanogenerator

The triboelectric nanogenerator (TENG) is a promising research topic for the conversion of mechanical to electrical energy and its application in different fields. Among the various applications, self-powered bio-medical sensing application has become popular. The selection of a wide variety of materials and the simple design of devices has made it attractive for the applications of real-time self-powered healthcare sensing systems. Human activity is the source of mechanical energy which gets converted to electrical energy by TENG fitted to different body parts for the powering up of the biomedical sensing and detection systems. Among the various techniques, wearable sensing systems developed by TENG have shown their merit in the application of healthcare sensing and detection systems. Some key studies on wearable self-powered biomedical sensing systems based on TENG which have been carried out in the last seven years are summarized here. Furthermore, the key features responsible for the highly sensitive output of the self-powered sensors have been briefed. On the other hand, the challenges that need to be addressed for the commercialization of TENG-based biomedical sensors have been raised in order to develop versatile sensitive sensors, user-friendly devices, and to ensure the stability of the device over changing environments.

Atherosclerotic Cardiovascular Risk as an Emerging Priority in Pediatrics

Over the last decades, childhood and adolescence have emerged as an important window of opportunity to prevent atherosclerotic cardiovascular disease (ASCVD) later in life. Here, we discuss the underlying advances in the field. First, atherosclerosis development starts as early as childhood. Atherogenesis initiates in the iliac arteries and abdominal aorta and subsequently develops in higher regions of the arterial tree, as has been demonstrated in nonhuman primate studies and human autopsy studies. Obesity, hypertension, hyperlipidemia, and hyperglycemia at a young age can accelerate atherogenesis. Children and adolescents with obesity have a relative risk of ∼ 2.5 for ASCVD mortality later in life, compared to peers with a normal weight. Conversely, early prevention improves long-term cardiovascular outcomes. Second, we review disease-associated factors that add to the traditional risk factors. Various pediatric disorders carry similar or even higher risks of ASCVD than obesity, including chronic inflammatory disorders, organ transplant recipients, familial hypercholesterolemia, endocrine disorders, childhood cancer survivors, chronic kidney diseases, congenital heart diseases, and premature birth, especially after fetal growth restriction. The involved disease-associated factors that fuel atherogenesis are diverse and include inflammation, vascular, and endothelial factors. The diverse and growing list of pediatric groups at risk underscores that cardiovascular risk management has solidly entered the realm of general pediatrics. In a second review in this series, we will, therefore, focus on recent advances in cardiovascular risk assessment and management and their implications for pediatric practice.

PDAY risk score predicts cardiovascular events in young adults: the CARDIA study

AIMS

Atherosclerotic cardiovascular disease (ASCVD) risk prediction equations apply to older adults. For this study, the Pathobiologic Determinants of Atherosclerosis in Youth (PDAY) risk score, based on post-mortem measurements of atherosclerosis in 15-34-year olds dying accidentally, was used to predict ASCVD events, specifically myocardial infarction and revascularization, in middle age, from risk measured at ≤40 years of age.

METHODS AND RESULTS

The Coronary Artery Risk Development in Young Adults Study (CARDIA) collected longitudinal cardiovascular risk data, coronary artery calcium (CAC) scores, and ASCVD data beginning at age 18 and 30 years with 30-year follow-up. Predictive accuracy for ASCVD of the PDAY risk score, calculated at baseline (mean age 24) and at all six CARDIA examinations up until year 15, was examined. We also examined whether the presence of CAC improved model discrimination. The cohort for this study comprised 5004 Black and White men and women, at baseline and 3558 with data at year 15. Each standard deviation increase in PDAY score, at each examination, was significantly associated with future ASCVD. Hazard ratios (per standard deviation) increased from 1.74 to 2.04 from year 0 to year 15. C-statistics ranged from 0.771 to 0.794. Coronary artery calcium measurement at age 33-45 years improved risk prediction only if the score was 0. Cumulative risk exposure over the first 15 years of the CARDIA study also had high-predictive value (c-statistic 0.798, 95% confidence interval 0.762-0.835).

CONCLUSION

The PDAY risk score may be used in young adults, prior to age 40 years to predict ASCVD events.

Olive oil protects against progression of heart failure by inhibiting remodeling of heart subsequent to myocardial infarction in rats

We examined the beneficial effects of olive oil against heart failure post-myocardial infarction (PMI), induced by coronary artery ligation in rats. Animals were divided into sham and ligated groups and fed either regular chow, olive oil (10% wt/wt), or corn oil (10% wt/wt) and were followed up to 16 weeks. On the echocardiography at 3 days (PMI), in the ligated regular chow (LRC), ligated olive oil (LOO), and ligated corn oil (LCO) left ventricular ejection fraction (LVEF) decrease was 12.14%, 16.42%, and 17.53% from the baseline, respectively. However, only LOO group improved LVEF significantly at 16 weeks PMI and became comparable with all sham groups. Both scar formation and collagen deposition at 16 weeks PMI were less pronounced in the LOO group. Myocardial TNF-α level at 4 weeks of PMI increased by 176%, 11%, and 181% in the LRC, LOO, and LCO groups, respectively. Plasma TNF-α levels in LOO were significantly lower than LRC group after 4 weeks of PMI. Myocardial redox ratio (reduced glutathione/oxidized glutathione) decreased at 4 weeks PMI by 44.4%, 16.4%, and 36.9% in the LRC, LOO, and LCO groups, respectively, compared to the baseline. These changes in the redox ratio at 16 weeks PMI were further exacerbated in the LRC and LCO groups. Lipid hydroperoxides formation increased at 4 weeks PMI by 137.4%, 14.6%, and 97.1% in the LRC, LOO, and LCO groups, respectively. Since coronary artery ligation decreased left ventricular ejection fraction, increased myocardial TNF-α and oxidative stress, and since olive oil was able to inhibit these effects, it is proposed that dietary olive oil modulates cardiac remodeling and heart failure subsequent to myocardial infarction.

Preclinical Aortic Atherosclerosis in Adolescents With Chronic Disease

Background

Adolescents with chronic disease are often exposed to inflammatory, metabolic, and hemodynamic risk factors for early atherosclerosis. Since postmortem studies have shown that atherogenesis starts in the aorta, the CDACD (Cardiovascular Disease in Adolescents with Chronic Disease) study investigated preclinical aortic atherosclerosis in these adolescents.

Methods and Results

The cross‐sectional CDACD study enrolled 114 adolescents 12 to 18 years old with chronic disorders including juvenile idiopathic arthritis, cystic fibrosis, obesity, corrected coarctation of the aorta, and healthy controls with a corrected atrial septal defect. Cardiovascular magnetic resonance was used to assess aortic pulse wave velocity and aortic wall thickness, as established aortic measures of preclinical atherosclerosis. Cardiovascular magnetic resonance showed a higher aortic pulse wave velocity, which reflects aortic stiffness, and higher aortic wall thickness in all adolescent chronic disease groups, compared with controls ( P <0.05). Age (β=0.253), heart rate (β=0.236), systolic blood pressure (β=−0.264), and diastolic blood pressure (β=0.365) were identified as significant predictors for aortic pulse wave velocity, using multivariable linear regression analysis. Aortic wall thickness was predicted by body mass index (β=0.248) and fasting glucose (β=0.242), next to aortic lumen area (β=0.340). Carotid intima‐media thickness was assessed using ultrasonography, and was only higher in adolescents with coarctation of the aorta, compared with controls ( P <0.001).

Conclusions

Adolescents with chronic disease showed enhanced aortic stiffness and wall thickness compared with controls. The enhanced aortic pulse wave velocity and aortic wall thickness in adolescents with chronic disease could indicate accelerated atherogenesis. Our findings underscore the importance of the aorta for assessment of early atherosclerosis, and the need for tailored cardiovascular follow‐up of children with chronic disease.

Increased Remnant Lipoproteins in Apo E Deficient Mice Induce Coronary Atherosclerosis following Transverse Aortic Constriction and Aggravate the Development of Pressure Overload-Induced Cardiac Hypertrophy and Heart Failure

Murine coronary arteries are very resistant to the development of atherosclerosis, which may be related to their intramyocardial course. Blood pressure promotes atherosclerotic plaque formation by acting as a physical force that potentiates the migration of pro-atherogenic lipoproteins across the endothelium. C57BL/6N apolipoprotein (apo) E deficient mice have increased remnant lipoproteins that are a risk factor for coronary atherosclerosis. In this study, our aim was to quantify coronary atherosclerosis and artery remodeling following transverse aortic constriction (TAC) in C57BL/6N apo E−/− mice and to evaluate the impact of increased remnant lipoproteins on the development of pressure overload-induced cardiac hypertrophy and heart failure. Advanced atherosclerotic lesions were observed in the left coronary artery of C57BL/6N apo E−/− TAC mice but not in C57BL/6N TAC mice. Pressure overload resulted in markedly increased cardiac hypertrophy and more pronounced heart failure in C57BL/6N apo E−/− TAC mice in comparison to C57BL/6N TAC mice. Pathological hypertrophy, as evidenced by increased myocardial fibrosis and capillary rarefaction, was more prominent in C57BL/6N TAC apo E−/− than in C57BL/6N TAC mice and led to more marked cardiac dysfunction. In conclusion, TAC in apo E deficient mice induces coronary atherosclerosis and aggravates the development of pathological cardiac hypertrophy and heart failure.

Height-based equations as screening tools for high blood pressure in pediatric practice, the GENOBOX study

Due to the absence of easily applicable cut‐off points to determine high blood pressure or hypertension in children, as in the adult population, blood pressure is rarely measured in the pediatrician's clinical routine. This has led to an underdiagnosis of high blood pressure or hypertension in children. For this reason, the present study evaluate the utility of five equations for the screening of high blood pressure in children: blood pressure to height ratio, modified blood pressure to height ratio, new modified blood pressure to height ratio, new simple formula and height‐based equations. The authors evaluated 1599 children between 5 and 18 years. The performance of the five equations was analyzed using the receiver‐operating characteristics curves for identifying blood pressure above P90th according to the American Academy of Pediatrics Clinical Practice Guideline 2017. All equations showed an area under the curve above 0.882. The new modified blood pressure to height ratio revealed a high sensitivity whereas the height‐based equations showed the best performance, with a positive predictive value above 88.2%. Finally, all equations showed higher positive predictive values in children with overweight or obesity. The height‐based equation obtained the highest PPV values above 71.1% in children with normal weight and above 90.2% in children with overweight or obesity. In conclusions, the authors recommend the use of the height‐based equations equation because it showed the best positive predictive values to identify children with elevated blood pressure, independently of their sex, pubertal and weight status.

An Artifact-Resistant Feature SKNAER for Quantifying the Burst of Skin Sympathetic Nerve Activity Signal

Evaluation of sympathetic nerve activity (SNA) using skin sympathetic nerve activity (SKNA) signal has attracted interest in recent studies. However, signal noises may obstruct the accurate location for the burst of SKNA, leading to the quantification error of the signal. In this study, we use the Teager−Kaiser energy (TKE) operator to preprocess the SKNA signal, and then candidates of burst areas were segmented by an envelope-based method. Since the burst of SKNA can also be discriminated by the high-frequency component in QRS complexes of electrocardiogram (ECG), a strategy was designed to reject their influence. Finally, a feature of the SKNA energy ratio (SKNAER) was proposed for quantifying the SKNA. The method was verified by both sympathetic nerve stimulation and hemodialysis experiments compared with traditional heart rate variability (HRV) and a recently developed integral skin sympathetic nerve activity (iSKNA) method. The results showed that SKNAER correlated well with HRV features (r = 0.60 with the standard deviation of NN intervals, 0.67 with low frequency/high frequency, 0.47 with very low frequency) and the average of iSKNA (r = 0.67). SKNAER improved the detection accuracy for the burst of SKNA, with 98.2% for detection rate and 91.9% for precision, inducing increases of 3.7% and 29.1% compared with iSKNA (detection rate: 94.5% (p < 0.01), precision: 62.8% (p < 0.001)). The results from the hemodialysis experiment showed that SKNAER had more significant differences than aSKNA in the long-term SNA evaluation (p < 0.001 vs. p = 0.07 in the fourth period, p < 0.01 vs. p = 0.11 in the sixth period). The newly developed feature may play an important role in continuously monitoring SNA and keeping potential for further clinical tests.

Childhood Cardiovascular Risk Factors and Adult Cardiovascular Events

BACKGROUND

Childhood cardiovascular risk factors predict subclinical adult cardiovascular disease, but links to clinical events are unclear.

METHODS

In a prospective cohort study involving participants in the International Childhood Cardiovascular Cohort (i3C) Consortium, we evaluated whether childhood risk factors (at the ages of 3 to 19 years) were associated with cardiovascular events in adulthood after a mean follow-up of 35 years. Body-mass index, systolic blood pressure, total cholesterol level, triglyceride level, and youth smoking were analyzed with the use of i3C-derived age- and sex-specific z scores and with a combined-risk z score that was calculated as the unweighted mean of the five risk z scores. An algebraically comparable adult combined-risk z score (before any cardiovascular event) was analyzed jointly with the childhood risk factors. Study outcomes were fatal cardiovascular events and fatal or nonfatal cardiovascular events, and analyses were performed after multiple imputation with the use of proportional-hazards regression.

RESULTS

In the analysis of 319 fatal cardiovascular events that occurred among 38,589 participants (49.7% male and 15.0% Black; mean [±SD] age at childhood visits, 11.8±3.1 years), the hazard ratios for a fatal cardiovascular event in adulthood ranged from 1.30 (95% confidence interval [CI], 1.14 to 1.47) per unit increase in the z score for total cholesterol level to 1.61 (95% CI, 1.21 to 2.13) for youth smoking (yes vs. no). The hazard ratio for a fatal cardiovascular event with respect to the combined-risk z score was 2.71 (95% CI, 2.23 to 3.29) per unit increase. The hazard ratios and their 95% confidence intervals in the analyses of fatal cardiovascular events were similar to those in the analyses of 779 fatal or nonfatal cardiovascular events that occurred among 20,656 participants who could be evaluated for this outcome. In the analysis of 115 fatal cardiovascular events that occurred in a subgroup of 13,401 participants (31.0±5.6 years of age at the adult measurement) who had data on adult risk factors, the adjusted hazard ratio with respect to the childhood combined-risk z score was 3.54 (95% CI, 2.57 to 4.87) per unit increase, and the mutually adjusted hazard ratio with respect to the change in the combined-risk z score from childhood to adulthood was 2.88 (95% CI, 2.06 to 4.05) per unit increase. The results were similar in the analysis of 524 fatal or nonfatal cardiovascular events.

CONCLUSIONS

In this prospective cohort study, childhood risk factors and the change in the combined-risk z score between childhood and adulthood were associated with cardiovascular events in midlife. (Funded by the National Institutes of Health.).

When Hypertension Grows Up: Implications for Transitioning Care of Adolescents and Young Adults With Hypertension From Pediatric to Adult Health Care Providers

Hypertension (HTN) is an important cause of morbidity and mortality in children as well as adults. HTN and related adverse cardiovascular health develop and progress on a continuum across an individual's life course. Pediatric HTN, or even isolated elevated blood pressure as a child, increases the risk of sustained HTN and cardiovascular disease in later adulthood. Transitioning the care of adolescents and young adults who have HTN is an important but unmet health care need that could potentially have a dramatic effect on mitigating the risk of cardiovascular disease in adulthood. However, very little has been published about the transition process in this population, and considerable gaps in the field remain. We discuss the epidemiology, etiology, and management approach in youth with HTN and how they differ from adults. We contextualize HTN and cardiovascular health on a continuum across the life course. We discuss key considerations for the transition process for adolescents and young adults with HTN including the major barriers that exist. Finally, we review key immediate health care needs that are particularly important around the time of the transfer of care.

Nanocarrier-Based Targeted Therapies for Myocardial Infarction

Myocardial infarction is a major cause of morbidity and mortality worldwide. Due to poor inherent regeneration of the adult mammalian myocardium and challenges with effective drug delivery, there has been little progress in regenerative therapies. Nanocarriers, including liposomes, nanoparticles, and exosomes, offer many potential advantages for the therapy of myocardial infarction, including improved delivery, retention, and prolonged activity of therapeutics. However, there are many challenges that have prevented the widespread clinical use of these technologies. This review aims to summarize significant principles and developments in the field, with a focus on nanocarriers using ligand-based or cell mimicry-based targeting. Lastly, a discussion of limitations and potential future direction is provided.

Is carotid artery atherosclerosis associated with poor cognitive function assessed using the Mini-Mental State Examination? A systematic review and meta-analysis

OBJECTIVES

To determine associations between carotid atherosclerosis assessed by ultrasound and the Mini-Mental State Examination (MMSE), a measure of global cognitive function.

DESIGN

Systematic review and meta-analysis.

METHODS

MEDLINE and EMBASE databases were searched up to 1 May 2020 to identify studies assessed the associations between asymptomatic carotid atherosclerosis and the MMSE. Studies reporting OR for associations between carotid plaque or intima-media thickness (cIMT) and dichotomised MMSE were meta-analysed. Publication bias of included studies was assessed.

RESULTS

A total of 31 of 378 reviewed articles met the inclusion criteria; together they included 27 738 participants (age 35-95 years). Fifteen studies reported some evidence of a positive association between measures of atherosclerosis and poorer cognitive performance in either cross-sectional or longitudinal studies. The remaining 16 studies found no evidence of an association. Seven cross-sectional studies provided data suitable for meta-analysis. Meta-analysis of three studies that assessed carotid plaque (n=3549) showed an association between the presence of plaque and impaired MMSE with pooled estimate for the OR (95% CI) being 2.72 (0.85 to 4.59). An association between cIMT and impaired MMSE was reported in six studies (n=4443) with a pooled estimate for the OR (95% CI) being 1.13 (1.04 to 1.22). Heterogeneity across studies was moderate to small (carotid plaque with MMSE, I2=40.9%; cIMT with MMSE, I2=4.9%). There was evidence of publication bias for carotid plaque studies (p=0.02), but not cIMT studies (p=0.2).

CONCLUSIONS

There is some, limited cross-sectional evidence indicating an association between cIMT and poorer global cognitive function assessed with MMSE. Estimates of the association between plaques and poor cognition are too imprecise to draw firm conclusions and evidence from studies of longitudinal associations between carotid atherosclerosis and MMSE is limited.

PROSPERO REGISTRATION NUMBER

CRD42021240077.

Prevention of atherosclerosis from childhood

Cardiovascular diseases caused by atherosclerosis do not typically manifest before middle age; however, the disease process begins early in life. Preclinical atherosclerosis can be quantified with imaging methods in healthy populations long before clinical manifestations present. Cohort studies have shown that childhood exposure to risk factors, such as dyslipidaemia, elevated blood pressure and tobacco smoking, are associated with adult preclinical atherosclerotic phenotypes. Importantly, these long-term effects are substantially reduced if the individual becomes free from the risk factor by adulthood. As participants in the cohorts continue to age and clinical end points accrue, the strongest evidence linking exposure to risk factors in early life with cardiovascular outcomes has begun to emerge. Although science has deciphered the natural course of atherosclerosis, discovered its causal risk factors and developed effective means to intervene, we are still faced with an ongoing global pandemic of atherosclerotic diseases. In general, atherosclerosis goes undetected for too long, and preventive measures, if initiated at all, are inadequate and/or come too late. In this Review, we give an overview of the available literature suggesting the importance of initiating the prevention of atherosclerosis in early life and provide a summary of the major paediatric programmes for the prevention of atherosclerotic disease. We also highlight the limitations of current knowledge and indicate areas for future research.

In vivo identification and validation of novel potential predictors for human cardiovascular diseases

Genetics crucially contributes to cardiovascular diseases (CVDs), the global leading cause of death. Since the majority of CVDs can be prevented by early intervention there is a high demand for the identification of predictive causative genes. While genome wide association studies (GWAS) correlate genes and CVDs after diagnosis and provide a valuable resource for such causative candidate genes, often preferentially those with previously known or suspected function are addressed further. To tackle the unaddressed blind spot of understudied genes, we particularly focused on the validation of human heart phenotype-associated GWAS candidates with little or no apparent connection to cardiac function. Building on the conservation of basic heart function and underlying genetics from fish to human we combined CRISPR/Cas9 genome editing of the orthologs of human GWAS candidates in isogenic medaka with automated high-throughput heart rate analysis. Our functional analyses of understudied human candidates uncovered a prominent fraction of heart rate associated genes from adult human patients impacting on the heart rate in embryonic medaka already in the injected generation. Following this pipeline, we identified 16 GWAS candidates with potential diagnostic and predictive power for human CVDs.

The effectiveness of a high-intensity interval games intervention in schoolchildren: A cluster-randomized trial

The aim of this study was to assess the effectiveness of a high-intensity interval training (HIIT) intervention based on playground games (MOVI-daFit!) on improvements in adiposity, physical fitness, and cardiometabolic risk factors in schoolchildren. A cluster-randomized controlled trial (RCT) was performed that included 562 schoolchildren (9-11 years) from 10 schools in Cuenca, Spain. The intervention consisted of four 60-min sessions per week in the school setting. Analyses were conducted on the intention-to-treat basis. Changes in physical fitness parameters (cardiorespiratory fitness: main outcome), body composition, blood pressure, and biochemical cardiometabolic risk parameters were analyzed using both mixed linear and logistic regression models, controlling for baseline covariates, Tanner stages, health dietary score index, body mass index, and cluster factor school. In boys, no significant differences in any outcome measure were noted except for the standing long jump test (10.13 cm; 95% CI 2.94 to 17.32; p = 0.006) between the intervention group (IG) and the control group (CG). Improvements in mean arterial pressure (-1.68 mmHg; 95% CI -3.28 to -0.08; p = 0.039), the triglyceride/HDL-c ratio (-0.36 mg/dl; 95% CI -0.59 to -0.13; p = 0.002), C-reactive protein (-0.23 mg/L; 95% CI -0.43 to -0.03), VO₂ max (1.44 ml/kg/min; 95% CI 0.52 to 2.36, p = 0.002), 20-m shuttle run test (3.64 laps; 95% CI 0.51 to 6.78), and standing long jump test (7.04 cm; 95% CI 1.21 to 12.87; p = 0.018) were observed in girls in the IG compared with those in the CG. Body composition parameters did not change significantly in either boys or girls. Additionally, children with lower fitness levels obtained greater improvements than children with higher fitness levels. In conclusion, MOVI-daFit! may represent a good strategy for incorporating HIIT into playground games, although its implementation may need to be improved to extend the benefits to children and enhance its adherence.

Analysis of Coronary Artery Lesion Degree and Related Risk Factors in Patients with Coronary Heart Disease Based on Computer-Aided Diagnosis of Coronary Angiography

A combination of various risk factors results in the development of coronary heart disease. The earlier that one identifies and deals with reversible risk factors for coronary heart disease, the greater the chance of recovery. The main goal of this research is to learn whether risk variables are associated with greater extent of coronary artery disease in people with coronary heart disease. This article selects 290 patients who had had coronary angiography in our hospital from September 2018 to March 2019 using a retrospective research and analytic methodology. Coronary angiography split the patients into two groups: those with coronary heart disease and those without. To determine the correlation between risk factors and a score related to heart disease, computer-aided statistical analysis of data about the differences in those risk factors was performed. The results were analyzed using the Spearman correlation and partial correlation, and the relationship between risk factors and Gensini score was analyzed by multiple linear regression. For the analysis, binary logistic regression was used to calculate the correlation between the risk factors of coronary heart disease and the probability of developing coronary heart disease. The findings concluded that increased age, smoking, elevated hs-CRP, HbA1c, hypertension, diabetes, and hyperuricemia are all contributors to coronary heart disease. Coronary heart disease is an independent risk factor for this condition. Many of the factors that play a role in the long-term development of the severity of coronary artery disease, such as hypertension, diabetes, smoking, elevated hs-CRP, decreased HDL-C, raised LDL-C, and TG, are commonly found in men. hs-CRP is the primary risk factor for the degree of coronary artery stenosis and could contribute to the progression of the condition by playing a major role in creating more stenosis.