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Montone RA, Camilli M, Calvieri C, Magnani G, Bonanni A, Bhatt DL, Rajagopalan S, Crea F, Niccoli G. Exposome in ischaemic heart disease: beyond traditional risk factors. Eur Heart J 2024; 45:419-438. [PMID: 38238478 PMCID: PMC10849374 DOI: 10.1093/eurheartj/ehae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 12/22/2023] [Accepted: 01/03/2024] [Indexed: 02/09/2024] Open
Abstract
Ischaemic heart disease represents the leading cause of morbidity and mortality, typically induced by the detrimental effects of risk factors on the cardiovascular system. Although preventive interventions tackling conventional risk factors have helped to reduce the incidence of ischaemic heart disease, it remains a major cause of death worldwide. Thus, attention is now shifting to non-traditional risk factors in the built, natural, and social environments that collectively contribute substantially to the disease burden and perpetuate residual risk. Of importance, these complex factors interact non-linearly and in unpredictable ways to often enhance the detrimental effects attributable to a single or collection of these factors. For this reason, a new paradigm called the 'exposome' has recently been introduced by epidemiologists in order to define the totality of exposure to these new risk factors. The purpose of this review is to outline how these emerging risk factors may interact and contribute to the occurrence of ischaemic heart disease, with a particular attention on the impact of long-term exposure to different environmental pollutants, socioeconomic and psychological factors, along with infectious diseases such as influenza and COVID-19. Moreover, potential mitigation strategies for both individuals and communities will be discussed.
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Affiliation(s)
- Rocco A Montone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli, 1, 00168 Rome, Italy
| | - Massimiliano Camilli
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli, 1, 00168 Rome, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | | | - Giulia Magnani
- Department of Medicine, University of Parma, Parma, Italy
| | - Alice Bonanni
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli, 1, 00168 Rome, Italy
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sanjay Rajagopalan
- Cardiovascular Research Institute, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli, 1, 00168 Rome, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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Candel FJ, Salavert M, Basaras M, Borges M, Cantón R, Cercenado E, Cilloniz C, Estella Á, García-Lechuz JM, Garnacho Montero J, Gordo F, Julián-Jiménez A, Martín-Sánchez FJ, Maseda E, Matesanz M, Menéndez R, Mirón-Rubio M, Ortiz de Lejarazu R, Polverino E, Retamar-Gentil P, Ruiz-Iturriaga LA, Sancho S, Serrano L. Ten Issues for Updating in Community-Acquired Pneumonia: An Expert Review. J Clin Med 2023; 12:6864. [PMID: 37959328 PMCID: PMC10649000 DOI: 10.3390/jcm12216864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 10/18/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
Community-acquired pneumonia represents the third-highest cause of mortality in industrialized countries and the first due to infection. Although guidelines for the approach to this infection model are widely implemented in international health schemes, information continually emerges that generates controversy or requires updating its management. This paper reviews the most important issues in the approach to this process, such as an aetiologic update using new molecular platforms or imaging techniques, including the diagnostic stewardship in different clinical settings. It also reviews both the Intensive Care Unit admission criteria and those of clinical stability to discharge. An update in antibiotic, in oxygen, or steroidal therapy is presented. It also analyzes the management out-of-hospital in CAP requiring hospitalization, the main factors for readmission, and an approach to therapeutic failure or rescue. Finally, the main strategies for prevention and vaccination in both immunocompetent and immunocompromised hosts are reviewed.
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Affiliation(s)
- Francisco Javier Candel
- Clinical Microbiology & Infectious Diseases, Transplant Coordination, IdISSC & IML Health Research Institutes, Hospital Clínico Universitario San Carlos, 28040 Madrid, Spain
| | - Miguel Salavert
- Infectious Diseases Unit, La Fe (IIS) Health Research Institute, University Hospital La Fe, 46015 Valencia, Spain
| | - Miren Basaras
- Immunology, Microbiology and Parasitology Department, Faculty of Medicine and Nursing, University of País Vasco, 48940 Bizkaia, Spain;
| | - Marcio Borges
- Multidisciplinary Sepsis Unit, Intensive Medicine Department, University Hospital Son Llàtzer, 07198 Palma de Mallorca, Spain;
- Instituto de Investigación Sanitaria Islas Baleares (IDISBA), 07198 Mallorca, Spain
| | - Rafael Cantón
- Clinical Microbiology Service, University Hospital Ramón y Cajal, Institute Ramón y Cajal for Health Research (IRYCIS), 28034 Madrid, Spain;
- CIBER of Infectious Diseases (CIBERINFEC), National Institute of Health San Carlos III, 28034 Madrid, Spain;
| | - Emilia Cercenado
- Clinical Microbiology & Infectious Diseases Service, University Hospital Gregorio Marañón, 28009 Madrid, Spain;
| | - Catian Cilloniz
- IDIBAPS, CIBERES, 08007 Barcelona, Spain;
- Faculty of Health Sciences, Continental University, Huancayo 15304, Peru
| | - Ángel Estella
- Intensive Care Unit, INIBiCA, University Hospital of Jerez, Medicine Department, University of Cádiz, 11404 Jerez, Spain
| | | | - José Garnacho Montero
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, 41013 Sevilla, Spain;
| | - Federico Gordo
- Intensive Medicine Department, University Hospital of Henares, 28802 Madrid, Spain;
| | - Agustín Julián-Jiménez
- Emergency Department, University Hospital Toledo, University of Castilla La Mancha, 45007 Toledo, Spain;
| | | | - Emilio Maseda
- Anesthesiology Department, Hospital Quirón Salud Valle del Henares, 28850 Madrid, Spain;
| | - Mayra Matesanz
- Hospital at Home Unit, Clinic University Hospital San Carlos, 28040 Madrid, Spain;
| | - Rosario Menéndez
- Pneumology Service, La Fe (IIS) Health Research Institute, University Hospital La Fe, 46015 Valencia, Spain;
| | - Manuel Mirón-Rubio
- Hospital at Home Service, University of Torrejón, Torrejón de Ardoz, 28006 Madrid, Spain;
| | - Raúl Ortiz de Lejarazu
- National Influenza Center, Clinic University Hospital of Valladolid, University of Valladolid, 47003 Valladolid, Spain;
| | - Eva Polverino
- Pneumology Service, Hospital Vall d’Hebron, 08035 Barcelona, Spain;
- Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- CIBER of Respiratory Diseases (CIBERES), Institute of Health San Carlos III, 28029 Madrid, Spain
| | - Pilar Retamar-Gentil
- CIBER of Infectious Diseases (CIBERINFEC), National Institute of Health San Carlos III, 28034 Madrid, Spain;
- Infectious Diseases & Microbiology Clinical Management Unit, University Hospital Virgen Macarena, IBIS, University of Seville, 41013 Sevilla, Spain
| | - Luis Alberto Ruiz-Iturriaga
- Pneumology Service, University Hospital Cruces, 48903 Barakaldo, Spain; (L.A.R.-I.); (L.S.)
- Faculty of Medicine and Nursing, University of País Vasco, 48940 Bizkaia, Spain
| | - Susana Sancho
- Intensive Medicine Department, University Hospital La Fe, 46015 Valencia, Spain;
| | - Leyre Serrano
- Pneumology Service, University Hospital Cruces, 48903 Barakaldo, Spain; (L.A.R.-I.); (L.S.)
- Faculty of Medicine and Nursing, University of País Vasco, 48940 Bizkaia, Spain
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Anderson R, Feldman C. The Global Burden of Community-Acquired Pneumonia in Adults, Encompassing Invasive Pneumococcal Disease and the Prevalence of Its Associated Cardiovascular Events, with a Focus on Pneumolysin and Macrolide Antibiotics in Pathogenesis and Therapy. Int J Mol Sci 2023; 24:11038. [PMID: 37446214 DOI: 10.3390/ijms241311038] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/26/2023] [Accepted: 06/30/2023] [Indexed: 07/15/2023] Open
Abstract
Despite innovative advances in anti-infective therapies and vaccine development technologies, community-acquired pneumonia (CAP) remains the most persistent cause of infection-related mortality globally. Confronting the ongoing threat posed by Streptococcus pneumoniae (the pneumococcus), the most common bacterial cause of CAP, particularly to the non-immune elderly, remains challenging due to the propensity of the elderly to develop invasive pneumococcal disease (IPD), together with the predilection of the pathogen for the heart. The resultant development of often fatal cardiovascular events (CVEs), particularly during the first seven days of acute infection, is now recognized as a relatively common complication of IPD. The current review represents an update on the prevalence and types of CVEs associated with acute bacterial CAP, particularly IPD. In addition, it is focused on recent insights into the involvement of the pneumococcal pore-forming toxin, pneumolysin (Ply), in subverting host immune defenses, particularly the protective functions of the alveolar macrophage during early-stage disease. This, in turn, enables extra-pulmonary dissemination of the pathogen, leading to cardiac invasion, cardiotoxicity and myocardial dysfunction. The review concludes with an overview of the current status of macrolide antibiotics in the treatment of bacterial CAP in general, as well as severe pneumococcal CAP, including a consideration of the mechanisms by which these agents inhibit the production of Ply by macrolide-resistant strains of the pathogen.
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Affiliation(s)
- Ronald Anderson
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria 0001, South Africa
| | - Charles Feldman
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand Medical School, 7 York Road, Johannesburg 2193, South Africa
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Meregildo-Rodriguez ED, Asmat-Rubio MG, Rojas-Benites MJ, Vásquez-Tirado GA. Acute Coronary Syndrome, Stroke, and Mortality after Community-Acquired Pneumonia: Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12072577. [PMID: 37048661 PMCID: PMC10095577 DOI: 10.3390/jcm12072577] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 02/28/2023] [Accepted: 03/02/2023] [Indexed: 03/31/2023] Open
Abstract
One-third of adult inpatients with community-acquired pneumonia (CAP) develop acute coronary syndrome (ACS), stroke, heart failure (HF), arrhythmias, or die. The evidence linking CAP to cardiovascular disease (CVD) events is contradictory. We aimed to systematically review the role of CAP as a CVD risk factor. We registered the protocol (CRD42022352910) and searched for six databases from inception to 31 December 2022. We included 13 observational studies, 276,109 participants, 18,298 first ACS events, 12,421 first stroke events, 119 arrhythmic events, 75 episodes of new onset or worsening HF, 3379 deaths, and 218 incident CVD events. CAP increased the odds of ACS (OR 3.02; 95% CI 1.88–4.86), stroke (OR 2.88; 95% CI 2.09–3.96), mortality (OR 3.22; 95% CI 2.42–4.27), and all CVD events (OR 3.37; 95% CI 2.51–4.53). Heterogeneity was significant (I2 = 97%, p < 0.001). Subgroup analysis found differences according to the continent of origin of the study, the follow-up length, and the sample size (I2 > 40.0%, p < 0.10). CAP is a significant risk factor for all major CVD events including ACS, stroke, and mortality. However, these findings should be taken with caution due to the substantial heterogeneity and the possible publication bias.
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Surgical Treatment for Empyema Thoracis: Prognostic Role of Preoperative Transthoracic Echocardiography and Serum Calcium. J Pers Med 2022; 12:jpm12061014. [PMID: 35743797 PMCID: PMC9225271 DOI: 10.3390/jpm12061014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/16/2022] [Accepted: 06/19/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Empyema is a major cause of mortality and hospitalization. Symptoms include difficulty breathing and chest pain. Calcium plays an essential role in the physiology of the cardiovascular system. However, there is little evidence on the role of echocardiography and the serum calcium levels of patients undergoing video-assisted thoracoscopic surgery (VATS) for empyema. This study aimed to investigate the risk factors for postoperative mortality in patients with empyema who required surgery. Methods: This single-institution retrospective study compared the outcomes of VATS for thoracic empyema (in terms of survival and mortality) in 122 patients enrolled between July 2015 and June 2019. Results: This study examined patients with thoracic empyema. The majority of the patients were males (100/122, 81.9%). The in-hospital/30-day mortality rate was 10.6% (13 patients). The calcium levels were 7.82 ± 1.17 mg/dL in the survival group and 6.88 ± 1.88 mg/dL in the mortality group (p = 0.032). In the mortality group, the utilization of echocardiography and serum calcium levels independently contributed to the risk prediction more than clinical variables. Patients in our cohort exhibited elevated pulmonary artery systolic pressure (PASP) and hypocalcemia, which were associated with increased postoperative mortality. Conclusion: Elevated PASP and calcium levels at the low end of the normal range demonstrated significant prognostic value in predicting mortality in patients with thoracic empyema who required surgical intervention. Recognizing this potential is critical in order to obtain better outcomes.
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