Aspirin for primary prevention of cardiovascular disease: a meta-analysis with a particular focus on subgroups

The impact of aspirin use on outcomes in patients with inflammatory bowel disease: Insights from a national database

BACKGROUND

Inflammatory bowel disease (IBD) is an inflammatory disorder that can increase the risk of mortality. Aspirin is an anti-inflammatory drug used for primary prevention of cardiovascular events. A single center analysis previously reported that aspirin use did not impact major outcomes in IBD. In this study, we aim to assess the impact of aspirin use on mortality and other outcomes in patients with IBD using national data.

METHODS

National inpatient sample (NIS) 2016-2020 was used to identify adult patients with IBD. Data were collected on patient demographics, hospital characteristics, and comorbidities. The outcomes studied were in-hospital mortality, sepsis, shock, Intensive Care Unit (ICU) admission, and need for surgery. Multivariate logistic regression analysis was performed.

RESULTS

A total of 1,524,820 IBD hospitalizations were included. Of these, 137,430 (9%) were long-term aspirin users. The majority of the patients in the aspirin group were aged > 65 years (34.11%), female (56.37%), White (78.83%) and had Medicare insurance (36.77%). Aspirin users had a lower incidence of in-hospital mortality (1.6% vs 1.4%, P = 0.06), sepsis (2.5% vs 2.9%, P < 0.001), shock (2.9% vs 3.4%, P < 0.001), ICU admission (2.6% vs 2.9%, P < 0.001), need for surgery (2.1% vs 4.2%, P < 0.001). After adjusting for confounders, aspirin was associated with a reduction in mortality (adjusted odds ratio: 0.49, 95%CI 0.45-0.55, P < 0.001).

CONCLUSION

Our study reports that aspirin use among patients with IBD was associated with a lower risk of death, sepsis, and shock. Aspirin use may have a protective effect in patients with IBD. Further studies are needed to confirm these results.

Compliance-Adjusted Estimates of Aspirin Effects Among Older Persons in the ASPREE Randomized Trial

The Aspirin in Reducing Events in the Elderly (ASPREE) Trial recruited 19,114 participants across Australia and the United States during 2010-2014. Participants were randomized to receive either 100 mg of aspirin daily or matching placebo, with disability-free survival as the primary outcome. During a median 4.7 years of follow-up, 37% of participants in the aspirin group permanently ceased taking their study medication and 10% commenced open-label aspirin use. In the placebo group, 35% and 11% ceased using study medication and commenced open-label aspirin use, respectively. In order to estimate compliance-adjusted effects of aspirin, we applied rank-preserving structural failure time models. The results for disability-free survival and most secondary endpoints were similar in intention-to-treat and compliance-adjusted analyses. For major hemorrhage, cancer mortality, and all-cause mortality, compliance-adjusted effects of aspirin indicated greater risks than were seen in intention-to-treat analyses. These findings were robust in a range of sensitivity analyses. In accordance with the original trial analyses, compliance-adjusted results showed an absence of benefit with aspirin for primary prevention in older people, along with an elevated risk of clinically significant bleeding.

Anti-inflammatory therapies were associated with reduced risk of myocardial infarction in patients with established cardiovascular disease or high cardiovascular risks: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND AIMS

We aimed to evaluate the association between anti-inflammatory therapies and the incidence of cardiovascular events in patients with established cardiovascular disease (CVD) or high cardiovascular risks.

METHODS

Literature retrieval was conducted in PubMed, Medline, Embase, the Cochrane Central Register of Controlled Trials and Clinicaltrial.gov website from the inception to December 2022. Randomized controlled trials comparing anti-inflammatory therapies with placebo in patients with established CVD or high cardiovascular risks were included. The results of the meta-analysis were computed as the risk ratio (RR) with 95% confidence interval (CI).

RESULTS

Compared with placebo, anti-inflammatory therapies were associated with decreased incidence of myocardial infarction (MI) (RR = 0.93, 95% CI, 0.88 to 0.98), which was mainly driven by therapies targeting central IL-6 signaling pathway (RR = 0.83, 95% CI, 0.74 to 0.93). IL-1 inhibitors treatment was associated with reduced risks of heart failure (RR = 0.38, 95% CI, 0.18 to 0.80) while lower incidence of stroke was observed in patients with colchicine treatment (RR = 0.47, 95% CI, 0.28 to 0.77). MI events were less frequent in patients over 65 years of age (RR = 0.90, 95% CI, 0.83 to 0.98) or with follow-up duration over 1 year (RR = 0.90, 95% CI, 0.85 to 0.96) when comparing anti-inflammatory therapies with placebo.

CONCLUSIONS

Anti-inflammatory therapies, especially those targeting the central IL-6 signaling pathway, may serve as promising treating strategies to ameliorate the risk of MI. IL-1 inhibitor and colchicine were associated with decreased risks of heart failure and stroke, respectively. MI risk reduction by anti-inflammatory therapies seemed to be more prominent in older patients with long follow-up duration.

A Mild Dose of Aspirin Promotes Hippocampal Neurogenesis and Working Memory in Experimental Ageing Mice

Aspirin has been reported to prevent memory decline in the elderly population. Adult neurogenesis in the hippocampus has been recognized as an underlying basis of learning and memory. This study investigated the effect of aspirin on spatial memory in correlation with the regulation of hippocampal neurogenesis and microglia in the brains of ageing experimental mice. Results from the novel object recognition (NOR) test, Morris water maze (MWM), and cued radial arm maze (cued RAM) revealed that aspirin treatment enhances working memory in experimental mice. Further, the co-immunohistochemical assessments on the brain sections indicated an increased number of doublecortin (DCX)-positive immature neurons and bromodeoxyuridine (BrdU)/neuronal nuclei (NeuN) double-positive newly generated neurons in the hippocampi of mice in the aspirin-treated group compared to the control group. Moreover, a reduced number of ionized calcium-binding adaptor molecule (Iba)-1-positive microglial cells was evident in the hippocampus of aspirin-treated animals. Recently, enhanced activity of acetylcholinesterase (AChE) in circulation has been identified as an indicative biomarker of dementia. The biochemical assessment in the blood of aspirin-treated mice showed decreased activity of AChE in comparison with that of the control group. Results from this study revealed that aspirin facilitates hippocampal neurogenesis which might be linked to enhanced working memory.

Sex differences in type 2 diabetes

The prevalence of type 2 diabetes mellitus is increasing in both sexes, but men are usually diagnosed at a younger age and lower body fat mass than women. Worldwide, an estimated 17.7 million more men than women have diabetes mellitus. Women appear to bear a greater risk factor burden at the time of their type 2 diabetes diagnosis, especially obesity. Moreover, psychosocial stress might play a more prominent role in diabetes risk in women. Across their lifespan, women experience greater hormone fluctuations and body changes due to reproductive factors than men. Pregnancies can unmask pre-existing metabolic abnormalities, resulting in the diagnosis of gestational diabetes, which appears to be the most prominent risk factor for progression to type 2 diabetes in women. Additionally, menopause increases women's cardiometabolic risk profile. Due to the progressive rise in obesity, there is a global increase in women with pregestational type 2 diabetes, often with inadequate preconceptual care. There are differences between men and women regarding type 2 diabetes and other cardiovascular risk factors with respect to comorbidities, the manifestation of complications and the initiation of and adherence to therapy. Women with type 2 diabetes show greater relative risk of CVD and mortality than men. Moreover, young women with type 2 diabetes are currently less likely than men to receive the treatment and CVD risk reduction recommended by guidelines. Current medical recommendations do not provide information on sex-specific or gender-sensitive prevention strategies and management. Thus, more research on sex differences, including the underlying mechanisms, is necessary to increase the evidence in the future. Nonetheless, intensified efforts to screen for glucose metabolism disorders and other cardiovascular risk factors, as well as the early establishment of prophylactic measures and aggressive risk management strategies, are still required for both men and women at increased risk of type 2 diabetes. In this narrative review we aim to summarise sex-specific clinical features and differences between women and men with type 2 diabetes into risk factors, screening, diagnosis, complications and treatment.

Growth Differentiation Factor 15 Is Associated with Platelet Reactivity in Patients with Acute Coronary Syndrome

Bleeding events in patients with acute coronary syndrome (ACS) are a risk factor for adverse outcomes, including mortality. We investigated the association of growth differentiation factor (GDF)-15, an established predictor of bleeding complications, with on-treatment platelet reactivity in ACS patients undergoing coronary stenting receiving prasugrel or ticagrelor. Platelet aggregation was measured by multiple electrode aggregometry (MEA) in response to adenosine diphosphate (ADP), arachidonic acid (AA), thrombin receptor-activating peptide (TRAP, a protease-activated receptor-1 (PAR-1) agonist), AYPGKF (a PAR-4 agonist) and collagen (COL). GDF-15 levels were measured using a commercially available assay. GDF-15 correlated inversely with MEA ADP (r = -0.202, p = 0.004), MEA AA (r = -0.139, p = 0.048) and MEA TRAP (r = -0.190, p = 0.007). After adjustment, GDF-15 was significantly associated with MEA TRAP (β = -0.150, p = 0.044), whereas no significant associations were detectable for the other agonists. Patients with low platelet reactivity in response to ADP had significantly higher GDF-15 levels (p = 0.005). In conclusion, GDF-15 is inversely associated with TRAP-inducible platelet aggregation in ACS patients treated with state-of-the-art antiplatelet therapy and significantly elevated in patients with low platelet reactivity in response to ADP.

Adherence to European guidelines for the use of aspirin in primary health care

INTRODUCTION AND OBJECTIVES

Cardiovascular disease remains a leading cause of global morbidity and mortality. The administration of low doses of aspirin in secondary prevention of atherosclerotic cardiovascular disease (ASCVD) has been clearly established. However, the most recent guidelines do not recommend aspirin in primary prevention, reserving it for high-risk patients and after a risk/benefit assessment. The aim of this study was to assess adherence to European guidelines for the use of aspirin in primary and secondary prevention of ASCVD in primary health care.

METHODS

The study population consisted of individuals aged >50 years registered at two primary health care units without (primary prevention) and with (secondary prevention) previous ASCVD events.

RESULTS

We studied a total of 1262 individuals, 720 in primary prevention and 542 in secondary prevention. A total of 61 individuals (8.5%) were under aspirin therapy in primary prevention, most of them taking 150 mg/day (57%). In secondary prevention, 195 patients (27%) were receiving aspirin only, most taking 150 mg/day (52%), and 166 patients (31%) were not under any antithrombotic or anticoagulant therapy. The 100 mg dosage was predominant in patients with ischemic heart disease with (64%) and without (64%) angina, as well as those with myocardial infarction (61.5%) and peripheral vascular disease (62%).

CONCLUSIONS

In this study, the prevalence of aspirin use in primary prevention was 8.5%. We found that 30% of patients were not taking either antithrombotic or anticoagulation therapy in secondary prevention. In both primary and secondary prevention, the 150 mg dosage was predominant.

The resolution of the Expert Council on current issues of the use of acetylsalicylic acid for the purpose of primary prevention of cardiovascular diseases in the light of new scientific data and updated clinical guidelines

Expert Council: Drapkina O. M., Vavilova T. V., Karpov Yu. A., Kobalava Zh. D., Lomakin N. V., Martynov A. I., Roitman E. V., Sychev D. A.Scientific communities: the Russian Society for the Prevention of Non-Communicable Diseases (ROPNIZ), the Russian Scientific Medical Society of Therapists (RNMOT), the Russian Antithrombotic Forum (RAF), the National Association for Thrombosis and Hemostasis (NATH).

Adherence to European guidelines for the use of acetylsalicylic acid in primary health care

INTRODUCTION AND OBJECTIVES

Cardiovascular disease remains a leading cause of global morbidity and mortality. The administration of low doses of acetylsalicylic acid (ASA) in secondary prevention of atherosclerotic cardiovascular disease (ASCVD) has been clearly established. However, the most recent guidelines do not recommend aspirin in primary prevention, reserving it for high-risk patients and after a risk/benefit assessment. The aim of this study was to assess the adherence to European guidelines for the use of ASA in primary and secondary prevention of ASCVD in primary health care.

METHODS

The study population corresponded to individuals >50 years registered at two primary health care units without (primary prevention) and with previous ASCVD events (secondary prevention).

RESULTS

Reporting the population size: e.g. "we studied a total of 1262 individuals, 720 in primary prevention and 542 in secondary prevention". A total of 61 individuals (8.5%) were under aspirin therapy in primary prevention, most of them taking 150 mg/day (57%). In secondary prevention, 195 patients (27%) were receiving ASA only, most taking 150 mg/day (52%), and 166 patients (31%) were not under any antithrombotic or anticoagulant therapy. The 100 mg dosage was predominant in patients with ischemic heart disease with (64%) and without (64%) angina, as well as those with myocardial infarction (61.5%) and peripheral vascular disease (62%).

CONCLUSIONS

In this study, the prevalence of aspirin use in primary prevention was 8.5%. We found that 30% of patients were not taking either antithrombotic or anticoagulation therapy in secondary prevention. In both primary and secondary prevention, the 150 mg dosage was predominant.

Effectiveness and safety of Shexiang Baoxin Pill (MUSKARDIA) in patients with stable coronary artery disease and concomitant diabetes mellitus: a subgroup analysis of a randomized clinical trial

BACKGROUND

Preliminary studies have indicated that Shexiang Baoxin Pill (MUSKARDIA) has a coronary artery dilation effect and increases the coronary blood flow, relieving the symptoms of angina. This study aimed to evaluate the benefit of MUSKARDIA on patients with stable coronary artery disease (CAD) and diabetes mellitus (DM).

METHODS

This was a subgroup analysis of a multicenter, randomized, placebo-controlled phase IV trial. CAD patients with a medical history of DM or baseline fasting blood glucose (FBG) ≥7.0 mmol/L were grouped according to the treatment (standard therapy plus MUSKARDIA or placebo). The primary outcome was major adverse cardiovascular events (MACEs), which was the composite outcome of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke. The secondary outcome was the composite outcome of all-cause death, non-fatal myocardial infarction, non-fatal stroke, hospitalization for unstable angina or heart failure, and coronary angioplasty.

RESULTS

MACEs occurred in 2.6% (9/340) and 4.8% (18/376) of patients in the MUSKARDIA and placebo groups, respectively ( P  = 0.192). Secondary composite outcome was significantly less frequent with MUSKARDIA than with placebo (15.3% [52/340] vs . 22.6% [85/376], P  = 0.017). Risk of MACEs (hazard ratio [HR] = 0.69, 95% confidence interval [CI]: 0.31-1.57) was comparable between two groups. In patients with uncontrolled DM (≥4 measurements of FBG ≥7 mmol/L in five times of follow-up), the risk of secondary outcome was significantly lower with MUSKARDIA (5/83, 6.0%) than with placebo (15/91, 16.5%) (HR = 0.35, 95%CI: 0.13-0.95).

CONCLUSION

As an add-on to standard therapy, MUSKARDIA shows a trend of reduced MACEs in patients with stable CAD and DM. Furthermore, MUSKARDIA may reduce the frequency of all-cause death, hospitalization, and coronary angioplasty in this population, especially in those with uncontrolled DM.

TRIAL REGISTRATION

ChiCTR.org.cn, ChiCTR-TRC-12003513.

Hypertensive disorders of pregnancy and long-term cardiovascular health: FIGO Best Practice Advice

Hypertensive disorders of pregnancy (HDP) are the most common causes of maternal and perinatal morbidity and mortality. They are responsible for 16% of maternal deaths in high-income countries and approximately 25% in low- and middle-income countries. The impact of HDP can be lifelong as they are a recognized risk factor for future cardiovascular disease. During pregnancy, the cardiovascular system undergoes significant adaptive changes that ensure adequate uteroplacental blood flow and exchange of oxygen and nutrients to nurture and accommodate the developing fetus. Failure to achieve normal cardiovascular adaptation is associated with the development of HDP. Hemodynamic alterations in women with a history of HDP can persist for years and predispose to long-term cardiovascular morbidity and mortality. Therefore, pregnancy and the postpartum period are an opportunity to identify women with underlying, often unrecognized, cardiovascular risk factors. It is important to develop strategies with lifestyle and therapeutic interventions to reduce the risk of future cardiovascular disease in those who have a history of HDP.

[Sex and gender-specific aspects in prediabetes and diabetes mellitus-clinical recommendations (Update 2023)]

Metabolic diseases dramatically affect the life of men and women from infancy up to old age in different and manifold ways and are a major challenge for the healthcare system. The treating physicians are confronted with the different needs of women and men in the clinical routine. Gender-specific differences affect pathophysiology, screening, diagnostic and treatment strategies of diseases as well as the development of complications and mortality rates. Impairments in glucose and lipid metabolism, regulation of energy balance and body fat distribution and therefore the associated cardiovascular diseases, are greatly influenced by steroidal and sex hormones. Furthermore, education, income and psychosocial factors play an important role in the development of obesity and diabetes differently in men and women. Males appear to be at greater risk of diabetes at a younger age and at a lower body mass index (BMI) compared to women but women feature a dramatic increase in the risk of diabetes-associated cardiovascular diseases after the menopause. The estimated future years of life lost owing to diabetes is somewhat higher in women than men, with a higher increase in vascular complications in women but a higher increase of cancer deaths in men. In women prediabetes or diabetes are more distinctly associated with a higher number of vascular risk factors, such as inflammatory parameters, unfavourable changes in coagulation and higher blood pressure. Women with prediabetes and diabetes have a much higher relative risk for vascular diseases. Women are more often morbidly obese and less physically active but may have an even greater benefit in health and life expectation from increased physical activity than men. In weight loss studies men often showed a higher weight loss than women; however, diabetes prevention is similarly effective in men and women with prediabetes with a risk reduction of nearly 40%. Nevertheless, a long-term reduction in all cause and cardiovascular mortality was so far only observed in women. Men predominantly feature increased fasting blood glucose levels, women often show impaired glucose tolerance. A history of gestational diabetes or polycystic ovary syndrome (PCOS) as well as increased androgen levels and decreased estrogen levels in women and the presence of erectile dysfunction or decreased testosterone levels in men are important sex-specific risk factors for the development of diabetes. Many studies showed that women with diabetes reach their target values for HbA_1c, blood pressure and low-density lipoprotein (LDL)-cholesterol less often than their male counterparts, although the reasons are unclear. Furthermore, sex differences in the effects, pharmacokinetics and side effects of pharmacological treatment should be taken more into consideration.

A Cross-Sectional Study on the Prevalence of Self-Prescribed Aspirin Use for Prevention of Adverse Ischemic Vascular Events Among Moderate-Risk Individuals: A Single Center Study

Introduction Despite the overwhelming amount of evidence against the use of aspirin for primary prophylaxis of cardiovascular disease (CVD), the arguably unwarranted use of aspirin has increased over the years, which may or may not be based on any specific medical advice, and merely self-prescribed. Aim This study aimed to determine the prevalence of unwarranted aspirin use among moderate-risk individuals for the primary prevention of adverse vascular events in Saudi Arabia. Patient and method A cross-sectional study was conducted among 100 patients who presented to the emergency room (ER) due to suspected cardiac diseases. The data were collected from the patients who visited ER in King Fahad Hospital, Al-Hofuf, Saudi Arabia. Participants were asked about their socio-demographic characteristics, aspirin use habits, and their comorbidities. Results Of the 100 patients, 35% were aged more than 60 years old. The overall use of aspirin was 78%. The prevalence of aspirin use was significantly more common among the older age group (53.8%), those with associated chronic diseases, such as diabetes (59%) and hypertension (75.6%) and those with a previous history of hospitalization due to stroke or a cardiac event (66.7%). Conclusion The use of aspirin among patients who are at moderate risk of cardiovascular events was widely prevalent, but their unwarranted use was low. Older patients with chronic diseases who believed in its great benefit and tended to ignore its complications are the most common users of aspirin. More research is recommended to determine the prevalence and the factors associated with unwarranted use of aspirin in patients with CVD in our region.

Safety and efficacy of a cardiovascular polypill in people at high and very high risk without a previous cardiovascular event: the international VULCANO randomised clinical trial

BACKGROUND

Cardiovascular (CV) polypills are a useful baseline treatment to prevent CV diseases by combining different drug classes in a single pill to simultaneously target more than one risk factor. The aim of the present trial was to determine whether the treatment with the CNIC-polypill was at least non-inferior to usual care in terms of low-density lipoprotein cholesterol (LDL-c) and systolic BP (SBP) values in subjects at high or very high risk without a previous CV event.

METHODS

The VULCANO was an international, multicentre open-label trial involving 492 participants recruited from hospital clinics or primary care centres. Patients were randomised to the CNIC-polypill -containing aspirin, atorvastatin, and ramipril- or usual care. The primary outcome was the comparison of the mean change in LDL-c and SBP values after 16 weeks of treatment between treatment groups.

RESULTS

The upper confidence limit of the mean change in LDL-c between treatments was below the prespecified margin (10 mg/dL) and above zero, and non-inferiority and superiority of the CNIC-polypill (p = 0.0001) was reached. There were no significant differences in SBP between groups. However, the upper confidence limit crossed the prespecified non-inferiority margin of 3 mm Hg. Significant differences favoured the CNIC-polypill in reducing total cholesterol (p = 0.0004) and non-high-density lipoprotein cholesterol levels (p = 0.0017). There were no reports of major bleeding episodes. The frequency of non-serious gastrointestinal disorders was more frequent in the CNIC-polypill arm.

CONCLUSION

The switch from conventional treatment to the CNIC-polypill approach was safe and appears a reasonable strategy to control risk factors and prevent CVD. Trial registration This trial was registered in the EU Clinical Trials Register (EudraCT) the 20th February 2017 (register number 2016-004015-13; https://www.clinicaltrialsregister.eu/ctr-search/search?query=2016-004015-13 ).

Need for a Paradigm Shift in the Treatment of Ischemic Stroke: The Blood-Brain Barrier

Blood-brain barrier (BBB) integrity is essential to maintaining brain health. Aging-related alterations could lead to chronic progressive leakiness of the BBB, which is directly correlated with cerebrovascular diseases. Indeed, the BBB breakdown during acute ischemic stroke is critical. It remains unclear, however, whether BBB dysfunction is one of the first events that leads to brain disease or a down-stream consequence. This review will focus on the BBB dysfunction associated with cerebrovascular disease. An added difficulty is its association with the deleterious or reparative effect, which depends on the stroke phase. We will first outline the BBB structure and function. Then, we will focus on the spatiotemporal chronic, slow, and progressive BBB alteration related to ischemic stroke. Finally, we will propose a new perspective on preventive therapeutic strategies associated with brain aging based on targeting specific components of the BBB. Understanding BBB age-evolutions will be beneficial for new drug development and the identification of the best performance window times. This could have a direct impact on clinical translation and personalised medicine.

Aspirin for Primary Prevention of Cardiovascular Diseases: "WALTZ" with the Evidence

PURPOSE OF REVIEW

In this review article, a detailed analysis of the current literature is provided, along with a "glimpse" into what the future holds for aspirin in the context of primary prevention.

RECENT FINDINGS

The role of aspirin in primary prevention of cardiovascular diseases (CVD) has been extensively evaluated; however, the results provided over the years have been controversial. Identification of individual subgroups who may benefit from aspirin administration at an acceptable risk of bleeding complications is of paramount importance. Additionally, questions emerge at everyday clinical practice regarding the optimal use of aspirin in different phenotypes of patients due to age, sex, obesity status, frailty and diabetes mellitus. Until further data become available, the effective management of the well-established CV risk factors constitutes the milestone in the primary prevention of CVD. Moreover, based on the available evidence, the beneficial addition of aspirin in the modern era of lifestyle and pharmacological interventions for primary CVD prevention remains largely undetermined and further research is needed.

Clinical relevance of potentially inappropriate medications and potential prescribing omissions according to explicit criteria-a validation study

PURPOSE

To investigate the clinical relevance of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs), and to evaluate the association between PIMs/PPOs and inadequate drug treatment.

METHODS

PIMs/PPOs, concordantly identified by two physicians applying the STOPP/START criteria, the EU(7)-PIM list, and a Swedish set in 302 consecutive older primary care patients, were assessed regarding clinical relevance for the specific patient. The physicians determined, in consensus, whether an action related to the medication was medically justified prior to the next regular consultation. If so, the drug treatment was categorised as inadequate, and if not, the treatment was considered adequate.

RESULTS

In all, 259 (86%) patients had 1010 PIMs/PPOs, 150 (15%) of which, in 81 (27%) patients, were assessed as clinically relevant (kappa: 0.26). A total of 75 (50%) clinically relevant PIMs and PPOs were prioritised for medical action before the next regular consultation. Action-requiring clinically relevant PIMs most often concerned acetylsalicylic acid (ASA) for primary prevention (four out of 68 patients on ASA). The corresponding PPOs concerned beta-blockers in ischaemic heart disease (four out of 61 patients with this condition). When an overall medical perspective was applied, 164 (63%) out of 259 patients with PIMs/PPOs were assessed as having adequate treatment. In adjusted logistic regression, number of PIMs and/or PPOs and number of drugs were associated with inadequate drug treatment.

CONCLUSION

One in seven PIMs/PPOs may be clinically relevant, half of these not of priority for medical action. Cautious interpretation is warranted when PIMs/PPOs are used as outcome measures.

Both G protein-coupled and immunoreceptor tyrosine-based activation motif receptors mediate venous thrombosis in mice

Platelets are critical in hemostasis and a major contributor to arterial thrombosis (AT). (Pre)clinical studies suggest platelets also contribute to venous thrombosis (VT), but the mechanisms are largely unknown. We hypothesized that in VT, platelets use signaling machinery distinct from AT. Here we aimed to characterize the contributions of platelet G protein-coupled (GPCR) and immunoreceptor tyrosine-based activation motif (ITAM) receptor signaling to VT. Wild-type (WT) and transgenic mice were treated with inhibitors to selectively inhibit platelet-signaling pathways: ITAM-CLEC2 (Clec2mKO), glycoprotein VI (JAQ1 antibody), and Bruton's tyrosine kinase (ibrutinib); GPCR-cyclooxygenase 1 (aspirin); and P2Y12 (clopidogrel). VT was induced by inferior vena cava stenosis. Thrombin generation in platelet-rich plasma and whole-blood clot formation were studied ex vivo. Intravital microscopy was used to study platelet-leukocyte interactions after flow restriction. Thrombus weights were reduced in WT mice treated with high-dose aspirin + clopidogrel (dual antiplatelet therapy [DAPT]) but not in mice treated with either inhibitor alone or low-dose DAPT. Similarly, thrombus weights were reduced in mice with impaired ITAM signaling (Clec2mKO + JAQ1; WT + ibrutinib) but not in Clec2mKO or WT + JAQ1 mice. Both aspirin and clopidogrel, but not ibrutinib, protected mice from FeCl3-induced AT. Thrombin generation and clot formation were normal in blood from high-dose DAPT- or ibrutinib-treated mice; however, platelet adhesion and platelet-neutrophil aggregate formation at the vein wall were reduced in mice treated with high-dose DAPT or ibrutinib. In summary, VT initiation requires platelet activation via GPCRs and ITAM receptors. Strong inhibition of either signaling pathway reduces VT in mice.

Benefits and Risks Associated with Low-Dose Aspirin Use for the Primary Prevention of Cardiovascular Disease: A Systematic Review and Meta-Analysis of Randomized Control Trials and Trial Sequential Analysis

BACKGROUND

The role of aspirin in cardiovascular primary prevention remains controversial. Moreover, evidence for the potential benefits of aspirin in patients with high cardiovascular risk remains limited.

OBJECTIVE

The aim of this study was to explore the role of low-dose aspirin in primary prevention.

METHODS

The PubMed, EMBASE, Cochrane Library, and ClinicalTrials.gov databases were searched for randomized clinical trials (RCTs) from the date of inception to August 2021. The efficacy outcomes were major adverse cardiovascular events (MACE), myocardial infarction (MI), ischemic stroke (IS), all-cause mortality, and cardiovascular mortality, whereas safety outcomes were major bleeding, intracranial hemorrhage, and gastrointestinal (GI) bleeding. Subgroup analyses were based on different cardiovascular risks and diabetes statuses. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using the fixed- and random-effects models, and trial sequential analysis (TSA) was conducted to determine the robustness of the results.

RESULTS

A total of 10 RCTs fulfilled the inclusion criteria. The use of aspirin was associated with a significant reduction in the risk of MACE (RR 0.89, 95% CI 0.84-0.93), MI (RR 0.86, 95% CI 0.78-0.95), and IS (RR 0.84, 95% CI 0.76-0.93); however, aspirin also increased the risk of safety outcomes, i.e. major bleeding (RR 1.42, 95% CI 1.26-1.60), intracranial hemorrhage (RR 1.33, 95% CI 1.11-1.59), and GI bleeding (RR 1.91, 95% CI 1.44-2.54). Subgroup analyses revealed that in the absence of a statistically significant interaction, a trend toward a net benefit of lower incidence of cardiovascular events (number needed to treat of MACE: high risk: 682 vs. low risk: 2191) and lesser risk of bleeding events (number needed to harm of major bleeding: high risk: 983 vs. low risk: 819) was seen in the subgroup of high cardiovascular risk. Meanwhile, the greater MACE reduction was also detected in the high-risk group of diabetes or nondiabetes patients. Furthermore, a post hoc subgroup analysis indicated a significant rate reduction in patients aged ≤ 70 years but not in patients aged > 70 years. TSA confirmed the benefit of aspirin for MACE up to a relative risk reduction of 10%.

CONCLUSION

The current study demonstrated that the cardiovascular benefits of low-dose aspirin were equally balanced by major bleeding events. In addition, the potential beneficial effects might be seen in the population ≤ 70 years of age with high cardiovascular risk and no increased risk of bleeding.

Dietary Intervention Effectiveness, Clinical Outcomes and Nutrient and Salicylate Intakes in Older Adults Living in Long-Term Care Homes: The Results from the Senior’s Plate Project

Optimal nutrition is an important part of the therapeutic process offered to patients in long-term care, as it can significantly influence their nutritional and health status. The aim of this study was to assess the impacts of a dietary intervention on the nutritional status, clinical outcomes and selected nutrient and salicylate intakes among older adults living in a long-term care nursing home. To achieve the research goal, a prospective, non-randomized, baseline-controlled intervention study was conducted. The study was conducted within the framework of the “Senior’s Plate Project”, a project established in 2018 by the Polish Society of Dietetics. Methods: A 3 month dietary intervention, which included one serving of supplementary food, served as a second breakfast (Nestle Sinlac). Energy, nutrients and salicylates intakes were estimated on the basis of the menus. Food and beverage intakes among residents were verified by health care personnel. Anthropometric measurements and clinical examinations were conducted according to standard procedures at baseline and after intervention. Results: Of the 38 residents qualified for the study, 29 completed the program. Residents’ body mass index (BMI) values ranged from 13.3 kg/m2 to 34 kg/m2. A BMI <22 kg/m2, indicating underweight, was found in 19 subjects. The dietary intervention resulted in increased body weight (57.8 ± 12.3 vs. 59.4 ± 12.6 kg), BMI (22.4 ± 4.0 vs. 23.0 ± 4.1 kg/m2) and body fat (19.2 ± 8.7 vs. 20.6 ± 8.9 kg). Significant changes in the levels of biochemical parameters, including serum calcium (8.7 vs. 9.5 mg/dL), potassium (4.1 ± 0.6 vs. 4.5 ± 0.5 mmol/L) and zinc (74.1 ± 10.9 vs. 109.0 ± 20.4 µg/dL), were observed. Energy, protein, fat and carbohydrate intakes were significantly higher in the third month of the intervention as compared to the baseline. The estimated medial daily intake of salicylates was low and ranged from 0.34 mg to 0.39 mg. Conclusions: The dietary intervention resulted in beneficial and significant changes in the nutritional status, biochemical parameters and nutrition of residents of the long-term care home. These results suggest that practical and individualized approaches are required to improve the nutritional status and clinical outcomes of nursing homes residents.

Role of diabetes in stroke: Recent advances in pathophysiology and clinical management

The increasing prevalence of diabetes and stroke is a major global public health concern. Specifically, acute stroke patients, with pre-existing diabetes, pose a clinical challenge. It is established that diabetes is associated with a worse prognosis after acute stroke and the various biological factors that mediate poor recovery profiles in diabetic patients is unknown. The level of association and impact of diabetes, in the setting of reperfusion therapy, is yet to be determined. This article presents a comprehensive overview of the current knowledge of the role of diabetes in stroke, therapeutic strategies for primary and secondary prevention of cardiovascular disease and/or stroke in diabetes, and various therapeutic considerations that may apply during pre-stroke, acute, sub-acute and post-stroke stages. The early diagnosis of diabetes as a comorbidity for stroke, as well as tailored post-stroke management of diabetes, is pivotal to our efforts to limit the burden. Increasing awareness and involvement of neurologists in the management of diabetes and other cardiovascular risk factors is desirable towards improving stroke prevention and efficacy of reperfusion therapy in acute stroke patients with diabetes.

Low-doses aspirin in the primary prevention of cardiovascular disease in patients with diabetes: Meta-analysis stratified by baseline cardiovascular risk

BACKGROUND AND AIM

The aim of this meta-analysis was to analyze the risks and benefits of low-dose aspirin in patients with T2D without cardiovascular conditions according to the baseline cardiovascular risk.

METHODS

We performed a meta-analysis including randomized clinical trials that evaluated the use of low-dose aspirin (75-100 mg/day) versus placebo/usual care in patients with T2D. Studies were classified as low, moderate and high risk based on the number of events in the placebo/control arms or by cardiovascular risk score when reported. The incidence of MACE, cardiovascular mortality and bleeding were evaluated.

RESULTS

Ten eligible trials (34069 patients) were considered eligible for the analyses. According to the stratified analysis, low-dose aspirin use was associated with reduced risk for MACE in the moderate/high-risk group (OR: 0.88; 95% CI, 0.80-0.97; I² = 0%) but not in the low-risk group (OR: 0.89; 95% CI, 0.77-1.01; I² = 0%). Likewise, low-dose aspirin use was associated with more bleeding in the low-risk group, showing a non-significant trend in the moderate/high-risk group. There was no reduction in cardiovascular mortality in either group. Beyond the different findings in each stratum, the differences between the subgroups were not statistically significant.

CONCLUSION

This study showed that low-dose aspirin in patients with T2D reduces MACE and increases bleeding. Based on the within-subgroups results, the baseline cardiovascular risk does not modify the effect of aspirin therapy. However, few studies were included and the comparison between subgroups showed a trend in favor to the highest risk group, these results should be confirmed in future studies.

Subclinical Leaflet Thrombosis After Transcatheter Aortic Valve Replacement: A Meta-Analysis

This meta-analysis and systematic review was performed to evaluate the clinical relevance of subclinical leaflet thrombosis (SLT) following transcatheter aortic valve replacement. PubMed, Web of Science, and CENTRAL were searched for eligible randomized and nonrandomized studies until November 2020. Risk ratios (RRs) or odds ratios and 95% CIs were calculated, using a random-effects model. Overall, 25 studies were eligible for the analysis and comprised a total of 11,098 patients. The median incidence of SLT was 6% at a median follow-up of 30 days. Use of intra-annular valves was associated with 2-fold greater risk for the development of SLT compared with use of supra-annular valves. There was no difference in the risk for SLT (RR: 0.97; 95% CI: 0.72-1.29; P = 0.83) between single-antiplatelet therapy (SAPT) and dual-antiplatelet therapy (DAPT), whereas oral anticoagulation (OAC) was associated with a 58% relative risk reduction for SLT (RR: 0.42; 95% CI: 0.29-0.61; P < 0.00001) compared with SAPT and DAPT. In patients with diagnosed leaflet thrombosis at follow-up, the risk for stroke or transient ischemic attack was increased by 2.6-fold (RR: 2.56; 95% CI: 1.60-4.09; P < 0.00001) compared with patients without leaflet thrombosis. In patients diagnosed with SLT, the odds of SLT resolution increased by 99% after switch from antiplatelet agents to OAC (odds ratio: 0.01; 95% CI: 0.00-0.06; P < 0.00001). To summarize, indication-based use of OAC after transcatheter aortic valve replacement is associated with a lower risk for SLT compared with SAPT and DAPT. Switching to OAC seems to be effective for SLT resolution. As SLT increased the odds of stroke or transient ischemic attack in the included population, further studies are needed to investigate whether screening tests for SLT and appropriate antithrombotic therapy improve long-term valve functionality and clinical prognosis.

An observational study of T2-weighted white matter hyperintensities on magnetic resonance imaging of the internal auditory meatus and brain: ignore or not?

BACKGROUND

Magnetic resonance imaging of the internal auditory meatus frequently detects incidental white matter hyperintensities. This study investigated the association between these and the risk of stroke and transient ischaemic attack, or myocardial infarction.

METHODS

The records of patients with incidental white matter hyperintensities were reviewed, and data were collected on: age, sex, cardiovascular risk factors, and incidence of stroke and transient ischaemic attack, or myocardial infarction, five years later. The risk factors associated with vascular events were explored.

RESULTS

Of 6978 patients, 309 (4.4 per cent) had incidental white matter hyperintensities. Of these, 20 (6.5 per cent) had a stroke or transient ischaemic attack within five years, and 5 (1.7 per cent) had a myocardial infarction. The number of cardiovascular risk factors was significantly associated with the incidence of stroke and transient ischaemic attack (p = 0.004), and myocardial infarction (p = 0.023).

CONCLUSION

The number of cardiovascular risk factors predicts the likelihood of vascular events; appropriate risk factor management is recommended for patients with incidental white matter hyperintensities of presumed vascular origin.

Current Studies of Aspirin as an Anticancer Agent and Strategies to Strengthen its Therapeutic Application in Cancer

Aspirin has emerged as a promising intervention in cancer in the past decade. However, there are existing controversies regarding the anticancer properties of aspirin as its mechanism of action has not been clearly defined. In addition, the risk of bleeding in the gastrointestinal tract from aspirin is another consideration that requires medical and pharmaceutical scientists to work together to develop more potent and safe aspirin therapy in cancer. This review presents the most recent studies of aspirin with regard to its role in cancer prevention and treatment demonstrated by highlighted clinical trials, mechanisms of action as well as approaches to develop aspirin therapy best beneficial to cancer patients. Hence, this review provides readers with an overview of aspirin research in cancer that covers not only the unique features of aspirin, which differentiate aspirin from other non-steroidal anti-inflammatory drugs (NSAIDs), but also strategies that can be used in the development of drug delivery systems carrying aspirin for cancer management. These studies convey optimistic messages on the continuing efforts of the scientist on the way of developing an effective therapy for patients with a low response to current cancer treatments.

Cardiovascular Outcome in Patients Treated With SGLT2 Inhibitors for Heart Failure: A Meta-Analysis

Background: Sodium–glucose co-transporter 2 (SGLT2) inhibitors are an emerging class of glucose-lowering drugs that have become increasingly relevant for the treatment and prevention of heart failure (HF). Therefore, we aimed to investigate various SGLT2 inhibitors in patients with established HF at baseline and focused on the different types of HF.

Methods: An extensive search of PubMed and Web of Science until January 2021 was done. Two reviewers, independently and in duplicate, applied the selection criteria. This meta-analysis was conducted according to the PRISMA guidelines. Data were pooled using a random-effects model. Randomized controlled trials (RCTs) of SGLT2 inhibitors vs. a comparator in patients with HF reporting clinical outcomes were included. The primary efficacy outcome was the composite of hospitalization for HF (HHF) or cardiovascular (CV) mortality. All-cause mortality, CV mortality, and HHF were considered as secondary endpoints. Subgroup analyses involving the status of diabetes, type of HF, administered type of SGLT2 inhibitor, sex, age, body mass index (BMI), estimated glomerular filtration rate (eGFR), cause of HF, and concomitant medication were performed.

Results: Seventeen RCTs, comprising a total of 20,749 participants, were included (n = 10,848 treated with SGLT2 inhibitors and n = 9,901 treated with a comparator). Treatment with SGLT2 inhibitors in a HF population was associated with a 27% relative risk reduction (RRR) of HHF or CV mortality [risk ratio (RR) = 0.73, 95% CI = 0.68–0.78], 32% RRR of HHF (RR = 0.68, 95% CI = 0.62–074), 18% RRR of CV mortality (RR = 0.82, 95% CI = 0.73–0.91), and 17% RRR of all-cause mortality (RR = 0.83, 95% CI = 0.75–0.91). The effect of SGLT2 inhibitors on the primary endpoint was consistent among the different gliflozines. The effect of SGLT2 inhibitors on the primary endpoint was independent of underlying diabetes mellitus, age, sex, BMI, renal function, and HF type.

Conclusions: SGLT2 inhibitors are associated with improved CV outcomes in patients with HF.

Differences in the prevention and control of cardiovascular and cerebrovascular diseases

At present, the prevention and control of cardiovascular diseases (CAVDs) has made initial advancements, although the prevention and control of cerebrovascular diseases (CEVDs) has not yet achieved the desired progress. In this paper, we review the prevention and control of CEVDs and CAVDs, and analyze the differences in prevention effects, and the pathological and physiological structures pertaining to CEVDs and CAVDs. Combined with the different effects of low-dose aspirin in the primary prevention of CEVDs and CAVDs by meta-analysis, aspirin plays a more important role in the primary prevention of CAVDs than CEVDs. We recognize the misunderstandings and blind spots concerning prevention and control of CEVDs, which can be summarized as follows: (1) CEVDs and CAVDs can be controlled by the same methods and drugs; (2) considering the same pathological factors for cardiovascular diseases; (3) a lack of understanding of the particularity of CEVDs; (4) a focus on platelets and neglect of cerebrovascular protection. In summary, our research clarifies the differences in the prevention measures and drugs used for CEVDs and CAVDs. Of particular concern is the serious lack of preventive drugs for CEVDs in clinical use. An ideal drug for the prevention of CEVDs should have protective effects on the blood, the vascular endothelium, the blood-brain barrier (BBB), and other related factors. Our review aims to highlight several issues in the current prevention of CEVDs and CAVDs, and to provide an optimized plan for preventive drug discovery.

Contemporary Clinical Use of Aspirin: Mechanisms of Action, Current Concepts, Unresolved Questions, and Future Perspectives

The ability of aspirin to inhibit platelet aggregation has positioned this agent within the most frequently used drugs worldwide. The aim of this article is to review the contemporary clinical use of aspirin and also to discuss unresolved issues not yet translated into clinical practice. Results from several clinical trials have led to strong guideline recommendations for aspirin use in the acute management and secondary prevention of cardiovascular disease. On the contrary, guidelines regarding aspirin use as primary prevention of cardiovascular disease are almost conservative, supported by recent trials reporting that the bleeding risk outweighs the potential benefits in most patients. In pregnancy, aspirin has proved efficient in preventing preeclampsia and small-for-gestational-age births in women at high risk, and is hence widely recommended in clinical guidelines. Despite the vast amount of clinical data on aspirin, several unresolved questions remain. Randomized trials have reported that aspirin reduces the risk of recurrent venous thromboembolism, but the clinical relevance remains limited, because direct oral anticoagulants are more effective. Laboratory studies suggest that a twice-daily dosing regimen or evening intake may lead to more efficient platelet inhibition, and the potential clinical benefit of such strategies is currently being explored in ongoing clinical trials. Enteric-coated formulations of aspirin are frequently used, but it remains unclear if they are safer and as efficient as plain aspirin. In the future, aspirin use after percutaneous coronary interventions might not be mandatory in patients who also need anticoagulant therapy, as several trials support shorter aspirin duration strategies. On the other hand, new treatment indications for aspirin will likely arise, as there is growing evidence that aspirin may reduce the risk of colorectal cancer and other types of cancer.

The functions of fluoxetine and identification of fluoxetine-mediated circular RNAs and messenger RNAs in cerebral ischemic stroke

Fluoxetine is used to improve cognition, exercise ability, depression, and neurological functions in patients with cerebral ischemic stroke. Circular RNAs (circRNAs) play important regulatory roles in multiple diseases. However, studies regarding the fluoxetine-mediated circRNA-microRNA-messenger RNA (mRNA) axis have not been conducted. This study is aim to investigate the functions of fluoxetine and identification of fluoxetine-mediated circRNAs and mRNAs in cerebral ischemic stroke. The middle cerebral artery occlusion (MCAO) rat models were successfully established at fisrt, and then rats were intraperitoneally injected with 10-mg/kg fluoxetine hydrochloride for 14 d. Afterward, the cerebral infarction area was evaluated using triphenyltetrazolium chloride staining. High-throughput sequencing was adopted to screen the differential circRNAs and mRNAs. The candidate circRNAs, mRNAs, and potential microRNAs were verified using quantitative reverse transcriptase polymerase chain reaction (qRT-PCR). In addtion, microRNA and circRNA binding was verified using the dual-luciferase reporter assay. Results revealed that fluoxetine markedly diminished the cerebral infarction area in rats after MCAO. The circRNAs and mRNAs were differentially expressed, which includes 879 circRNAs and 815 mRNAs between sham and MCAO groups, respectively, and 958 circRNAs and 838 mRNAs between MCAO and fluoxetine groups, respectively. In which, circMap2k1 and Pidd1 expression was significantly increased in the MCAO group but suppressed after fluoxetine treatment. Moreover, circMap2k1 directly binds with miR-135b-5p. Taken together, we verified that fluoxetine could improve brain injury after cerebral ischemic stroke. Moreover, the circMap2k1/miR-135b-5p/Pidd1 axis is potentially involved in cerebral ischemic stroke.

PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews

The methods and results of systematic reviews should be reported in sufficient detail to allow users to assess the trustworthiness and applicability of the review findings. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement was developed to facilitate transparent and complete reporting of systematic reviews and has been updated (to PRISMA 2020) to reflect recent advances in systematic review methodology and terminology. Here, we present the explanation and elaboration paper for PRISMA 2020, where we explain why reporting of each item is recommended, present bullet points that detail the reporting recommendations, and present examples from published reviews. We hope that changes to the content and structure of PRISMA 2020 will facilitate uptake of the guideline and lead to more transparent, complete, and accurate reporting of systematic reviews.

Efficacy and Safety of Ticagrelor Monotherapy in Patients Undergoing Percutaneous Coronary Intervention: A Meta-Analysis

Dual antiplatelet therapy (DAPT) and subsequent P2Y₁₂ inhibitor monotherapy, particularly ticagrelor, is an emerging treatment strategy in patients undergoing percutaneous coronary intervention (PCI). This meta‐analysis was designed to investigate whether short‐term DAPT followed by ticagrelor monotherapy is associated with a favorable outcome as compared with standard DAPT (1–3 months of DAPT was termed “short‐term” DAPT, 6–12 months DAPT was termed “standard” DAPT). The primary outcome was the composite of major adverse cardiovascular events (MACE) comprising myocardial infarction, stroke, and cardiovascular death. Secondary outcomes included all‐cause mortality and net adverse clinical events (NACE; myocardial infarction, stroke, all‐cause death, stent thrombosis, and major bleeding). The primary safety outcome was major bleeding. Three studies comprising 26,143 patients were included. The risk of MACE was similar between the two treatment groups (risk ratio (RR) 0.86, 95% confidence interval (CI), 0.72–1.02, P = 0.08, I² = 22%). Short‐term DAPT followed by ticagrelor monotherapy resulted in a 20% relative risk reduction of all‐cause mortality (RR 0.80, 95% CI, 0.65–0.98, P = 0.03, I² = 0%) and an 18% relative risk reduction of NACE (RR 0.82, 95% CI, 0.71–0.94, P = 0.005, I² = 33%) as compared with standard DAPT. Short‐term DAPT followed by ticagrelor monotherapy significantly decreased the risk of major bleeding (RR 0.67, 95% CI, 0.49–0.92, P = 0.01, I² = 65%). In patients with acute coronary syndrome, short‐term DAPT followed by ticagrelor monotherapy resulted in an unchanged ischemic risk but a significantly lower bleeding risk compared with standard DAPT. Short‐term DAPT followed by ticagrelor monotherapy compared with standard DAPT resulted in a favorable safety and efficacy profile. Direct comparisons of aspirin vs. ticagrelor monotherapy following PCI are needed.

Atrial high‑rate episodes and risk of major adverse cardiovascular events in patients with dual chamber permanent pacemakers: a retrospective study

Patients with atrial high-rate episodes (AHRE) are at higher risk of major adverse cardiovascular events (MACE). The cutoff threshold for AHRE duration for MACE, with/without history of atrial fibrillation (AF) or myocardial infarction (MI), is unknown. A total of 481 consecutive patients with/without history of AF or MI receiving dual-chamber pacemaker implantation were included. The primary outcome was a composite endpoint of MACE after AHRE ≥ 5 min, ≥ 6 h, and ≥ 24 h. AHRE was defined as > 175 bpm (MEDTRONIC) or > 200 bpm (BIOTRONIK) lasting ≥ 5 min. Cox regression analysis with time-dependent covariates was conducted. Patients' mean age was 75.3 ± 10.7 years and 188 (39.1%) developed AHRE ≥ 5 min, 115 (23.9%) ≥ 6 h, and 83 (17.3%) ≥ 24 h. During follow-up (median 39.9 ± 29.8 months), 92 MACE occurred (IR 5.749%/year, 95% CI 3.88-5.85). AHRE ≥ 5 min (HR 5.252, 95% CI 2.575-10.715, P < 0.001) and ≥ 6 h (HR 2.548, 95% CI 1.284-5.058, P = 0.007) was independently associated with MACE, but not AHRE ≥ 24 h. Patients with history of MI (IR 17.80%/year) had higher MACE incidence than those without (IR 3.77%/year, p = 0.001). Significant differences were found between MACE patients with/without history of AF in AHRE ≥ 5 min but not AHRE ≥ 6 h or ≥ 24 h. Patients with dual-chamber pacemakers who develop AHRE have increased risk of MACE, particularly after history of AF or MI.

The Use of Aspirin in Contemporary Primary Prevention of Atherosclerotic Cardiovascular Diseases Revisited: The Increasing Need and Call for a Personalized Therapeutic Approach

The use of aspirin has been widely accepted for the secondary prevention of atherosclerotic cardiovascular disease (ASCVD) in all patient populations, as the benefits linked to the reduction of clinical events outweigh the risk of major bleeding. However, despite the undisputable, though modest, potential of aspirin to reduce atherothrombotic events, its overall efficacy and safety in primary ASCVD prevention remains debatable, despite being used for this purpose for decades. The net clinical benefit of aspirin was brought into question by three recent large contemporary randomized controlled trials evaluating its role in various primary prevention populations (individuals with diabetes [ASCEND], an elderly population [ASPREE], and middle-aged adults at high estimated cardiovascular risk [ARRIVE]) and numerous large meta-analyses published during the past year. As a result, the usual generalized recommendations for the use of aspirin in patients with estimated intermediate to high ASCVD risk but without overt ASCVD have already been removed from most international guidelines. Since the primary prevention framework encompasses heterogenous groups of subjects with variable absolute ASCVD risk, a more individualized approach based on the best possible estimated ratio between the potential health benefits from fewer atherothrombotic events and harms because of potential increases in major bleeding is warranted in clinical practice. With this compromise, clinicians can better decide on the personalized use of aspirin in patients at high risk of major adverse cardiovascular events.

An unusual presentation of acute myocardial infarction in physiotherapy direct access: findings from a case report

BACKGROUND

Shoulder pain (SP) may originate from both musculoskeletal and visceral conditions. Physiotherapists (PT) may encounter patients with life-threatening pathologies that mimic musculoskeletal pain such as Acute Myocardial Infarction (AMI). A trained PT should be able to distinguish between signs and symptoms of musculoskeletal or visceral origin aimed at performing proper medical referral.

CASE PRESENTATION

A 46-y-old male with acute SP lasting from a week was diagnosed with right painful musculoskeletal shoulder syndrome, in two successive examinations by the emergency department physicians. However, after having experienced a shift of the pain on the left side, the patient presented to a PT. The PT recognized the signs and symptoms of visceral pain and referred him to the general practitioner, which identified a cardiac disease. The final diagnosis was acute myocardial infarction.

CONCLUSION

This case report highlights the importance of a thorough patient screening examination, especially for patients treated in an outpatient setting, which allow distinguishing between signs and symptoms of musculoskeletal from visceral diseases.

Cerebrovascular disease in women

Cerebrovascular disease is a major cause of morbidity, mortality, and disability in women. The spectrum of disease differs between men and women, with women being particularly vulnerable to certain conditions, especially during specific periods of life such as pregnancy. There are several unique risk factors for cerebrovascular disease in women, and the influence of some traditional risk factors for stroke is stronger in women. Moreover, disparities persist in representation of women in clinical trials, acute intervention, and stroke outcomes. In this review, we aimed to explore the epidemiology, etiologies, and management of cerebrovascular disease in women, highlighting some of these differences and the growing need for sex-specific management guidelines and health policies.

Pros and Cons of Aspirin for the Primary Prevention of Cardiovascular Events: A Secondary Study of Trial Sequential Analysis

Background and Aims: Aspirin leads to substantial benefits for the secondary prevention of cardiovascular disease (CVD). We aimed to cast more light on aspirin's role for the primary prevention of CVD. Methods: Databases were searched for clinical trials comparing aspirin vs. no aspirin use in this meta-analysis. Efficacy and safety profiles were rigorously investigated. Trial sequential analysis (TSA) was used to determine the robustness of the results. Results: Fourteen studies with 163,840 participants were eligible (mean follow-up 6.2 y). Aspirin intake was found to be associated with 9, 13, and 12% reductions in the risk of cardiovascular events (CV events) (relative risk [RR]: 0.91, 95% confidence intervals [CI]: 0.87-0.96; risk difference (RD): 0.29%; absolute risk percentage (AR%): 7.61%; number needed to treat (NNT): 345), myocardial infarction (RR: 0.87, 95% CI: 0.77-0.97; RD: 0.21%; AR%: 11.11%; NNT: 488) and ischemic stroke (RR: 0.88, 95% CI: 0.80-0.96; RD: 0.21%; AR%: 16.14%; NNT: 476), respectively; aspirin intake was also associated with 40%, 30%, and 57% increases in the risk of major bleeding (RR: 1.40, 95% CI: 1.29-1.53; RD: 0.47%; AR%: 27.85; NNT: 214), intracranial bleeding (RR: 1.30, 95% CI: 1.11-1.52; RD: 0.10%; AR%: 22.99%; NNT: 1,000) and major gastrointestinal bleeding (RR: 1.57, 95% CI: 1.38-1.78; RD: 0.32%; AR%: 36.70%; NNT: 315), respectively. Further, populations with low doses of aspirin intake (≤100 mg), populations <65 y old or populations with body mass index (BMI) ≧ 25 experienced more advantages; high-risk (10-y cardiovascular risk ≧10%) and full diabetic individuals reported hardly clinical benefits. Conclusion: Aspirin intake was associated with a reduced risk of CV events and an increased incidence of bleeding profiles in primary prevention. It is necessary to identify individual's CVD risk using clear examinations or assessments before aspirin intake, and truly realize individualized prescription.

The associations of plasma phospholipid arachidonic acid with cardiovascular diseases: A Mendelian randomization study

Background

Arachidonic acid (AA), a major long-chain n-6 polyunsaturated fatty acid in animal foods, has been linked to inflammation, coagulation, and testosterone, which might relate to atherosclerotic cardiovascular diseases (ASCVD). We assessed the associations of genetically predicted plasma phospholipid AA with ASCVD and other CVD overall and by sex using Mendelian randomization (MR).

Methods

We conducted two-sample MR, applying eight genetic variants, independent of a highly pleiotropic variant (rs174547), strongly (p < 5 × 10⁻⁸) predicting AA, primarily to summary statistics of genetic associations with ASCVD, including ischaemic heart disease (IHD), ischaemic stroke, and peripheral artery disease (PAD) from CARDIoGRAMplusC4D 1000 Genomes (60,801 IHD cases, 123,504 controls), MEGASTROKE (34,217 ischaemic stroke cases, 406,111 controls), and Pan-UK Biobank (n=~420,531), and secondarily to genetic associations with other CVD from Pan-UK Biobank, Atrial Fibrillation Consortium, HERMES consortium, and FinnGen. We also assessed sex differences.

Findings

Genetically predicted AA was associated with ASCVD (odds ratio (OR) per % of total fatty acids increase 1.03, 95% confidence interval (CI) 1.01 to 1.05) and its subtypes IHD (OR 1.03, 95% CI 1.004 to 1.05), ischaemic stroke (OR 1.03, 95% CI 1.004 to 1.06) and possibly PAD (OR 1.08, 95% CI 1.00 to 1.17), possibly more strongly in men than women. AA was also associated with venous thromboembolism (OR 1.12, 95% CI 1.05 to 1.19). A similar pattern was observed when using rs174547 to genetically predict AA.

Interpretation

Our study suggests positive associations of AA with ASCVD and venous thromboembolism, with possibly stronger associations in men than women.

Funding

No funding.

The Discovery of Druggable Anti-aging Agents

Caloric restriction (CR) has been shown to extend the lifespan of many species. Research to identify compounds that imitate the results of CR has shown extensions of both lifespan and healthspan via different mechanisms. For example, mechanistic target of rapamycin (mTOR) inhibitors such as rapamycin, phenols, and flavonoids show antioxidant characteristics, while spermidine induces autophagy. Herein, we summarize research progress and proposed mechanisms for the most well-known compounds showing lifespan-extending potential for anti-aging characteristics.

Benefits and Risks Associated With Aspirin Use in Patients With Diabetes for the Primary Prevention of Cardiovascular Events and Mortality: A Meta-Analysis

PURPOSE

A meta-analysis was conducted to assess the benefits and risks of aspirin for the primary prevention of cardiovascular disease and all-cause mortality events in adults with diabetes.

METHODS

An extensive and systematic search was conducted in MEDLINE (via PubMed), Cinahl (via Ebsco), Scopus, and Web of Sciences from 1988 to December 2020. A detailed literature search was conducted using aspirin, cardiovascular disease (CVD), diabetes, and efficacy to identify trials of patients with diabetes who received aspirin for primary prevention of CVD. Demographic details with the primary outcome of events and bleeding outcomes were analyzed. The Cochrane Collaboration's risk of bias tool was used to assess the methodological quality of the included studies. Random-effects meta-analysis was used to calculate the pooled odds ratio for outcomes of cardiovascular events, death, and adverse events.

FINDINGS

A total of 8 studies were included with 32,024 patients with diabetes; 16,001 allocated to aspirin, and 16,023 allocated to the control group. There was no difference between aspirin and control groups with respect to all-cause mortality, cardiovascular mortality, or bleeding events. However, MACE was significantly lower in the aspirin group.

IMPLICATIONS

Although aspirin has no significant risk on primary endpoints of cardiovascular events and bleeding outcomes in patients with diabetes compared to control, major adverse cardiovascular events (MACE) were significantly lower in the aspirin group. Further research on the use of aspirin alone or in combination with other antiplatelet drugs is required in patients with diabetes to supplement currently available research.

SYSTEMATIC REVIEW REGISTRATION

identifier [XU#/IRB/2020/1005].

Plasma Trimethylamine-N-Oxide Is an Independent Predictor of Long-Term Cardiovascular Mortality in Patients Undergoing Percutaneous Coronary Intervention for Acute Coronary Syndrome

To investigate the association of liver metabolite trimethylamine N-oxide (TMAO) with cardiovascular disease (CV)-related and all-cause mortality in patients with acute coronary syndrome (ACS) who underwent percutaneous coronary intervention. Our prospective observational study enrolled 292 patients with ACS. Plasma concentrations of TMAO were measured during the hospitalization for ACS. Observation period lasted seven yr in median. Adjusted Cox-regression analysis was used for prediction of mortality. ROC curve analysis revealed that increasing concentrations of TMAO levels assessed at the time point of ACS significantly predicted the risk of CV mortality (c-index=0.78, p < 0.001). The cut-off value of >4 μmol/L, labeled as high TMAO level (23% of study population), provided the greatest sum of sensitivity (85%) and specificity (80%) for the prediction of CV mortality and was associated with a positive predictive value of 16% and a negative predictive value of 99%. A multivariate Cox regression model revealed that high TMAO level was a strong and independent predictor of CV death (HR = 11.62, 95% CI: 2.26-59.67; p = 0.003). High TMAO levels as compared with low TMAO levels were associated with the highest risk of CV death in a subpopulation of patients with diabetes mellitus (27.3 vs. 2.6%; p = 0.004). Although increasing TMAO levels were also significantly associated with all-cause mortality, their estimates for diagnostic accuracy were low. High TMAO level is a strong and independent predictor of long-term CV mortality among patients presenting with ACS.

Repurposing drugs to fight aging: The difficult path from bench to bedside

The steady rise in life expectancy occurred across all developed countries during the last century. This demographic trend is, however, not accompanied by the same healthspan extension. This is since aging is the main risk factor for all age-associated pathological conditions. Therefore, slowing the rate of aging is suggested to be more efficient in preventing or delaying age-related diseases than treat them one by one, which is the common approach in a current pharmacological disease-oriented paradigm. To date, a variety of medications designed to treat particular pathological conditions have been shown to exhibit pro-longevity effects in different experimental models. Among them, there are many commonly used prescription and over-the-counter pharmaceuticals such as metformin, rapamycin, aspirin, statins, melatonin, vitamin antioxidants, etc. All of them are being increasingly investigated in preclinical and clinical trials with the aim of determine whether they have potential for extension of human healthspan. The results from these trials are frequently inconclusive and fall short of initial expectations, suggesting that innovative research ideas and additional translational steps are required to overcome obstacles for implementation of such approaches in clinical practice. In this review, recent advances and challenges in the field of repurposing widely used conventional pharmaceuticals to target the aging process are summarized and discussed.

The Connotation of Variances in the Risk Predictors, Medications, Homocysteine, and Homocysteine Pathway Gene Polymorphisms with CVA/Stroke

Cerebrovascular accidents (CVAs) are vascular multifactorial, multigenic ailments with intricate genetic, environmental risk influences. The present study aimed to establish affiliation of CVAs/stroke with blood parameters, differences in prescribed drugs consumption, and with differences in homocysteine pathway genes polymorphisms. The participants in study included controls n  = 251, transient ischemic attack (TIA) patients n  = 16, and stroke cases n  = 122, respectively, (total participants, n  = 389). The analyzed single nucleotide polymorphisms (SNPs) included C677T(rs1801133), A1298C(rs1801131) of methylene tetrahydrofolate reductase ( MTHFR ), A2756G(rs1805087) of methyl tetrahydrofolate homocysteine methyltransferase/methionine synthase ( MS ), and the A192G(rs662) of paraoxonase 1( PON1 ) genes, all validated by tetra-primer allele refractory mutation system polymerase chain reaction (T-ARMS-PCR). The insertion deletion (I/D; rs4646994) polymorphism in angiotensin converting enzyme ( ACE ) gene was analyzed using routine PCR. All studied traits were scrutinized through analysis of variance (ANOVA), and later through regression analysis. Through ANOVA and multiple comparison, there was association of CVA with serum homocysteine, cholesterol, and with diastolic blood pressure readings. When data was subjected to regression, serum homocysteine and diastolic blood pressure (significant through ANOVA), as well as two additional traits, high-density lipoproteins (HDL), and rs1801133 MTHFR SNP sustained statistical significance and noteworthy odds in relation to CVA and stroke. The ailments affecting cerebral vasculature are mutifactorial, whereby genes, proteins, and environmental cues all exert cumulative effects enhancing CVA risk. The current study emphasizes that SNPs and variation in circulating biomarkers can be used for screening purposes and for reviewing their effects in stroke/CVA-linked risk progression.