Association of smartphone-recorded steps over years and change in cardiovascular risk factors among working aged adults

Backgrounds

Evidence indicates a causal role of physical activity (PA), including steps, in decreasing cardiovascular disease (CVD) risk. However, few data exist on long-term steps and their relation to changes in CVD risk factors.

Objectives

To examine the associations of long-term smartphone-recorded steps and changes in CVD-related biomarkers in a large cohort of working aged adults.

Methods

The present analysis made use of data two national database and a commercial app database. Participants who underwent an annual health check-up between April 2015 and November 2020 and a second health check-up 24 to 35 months thereafter, and whose daily step data were available, were included. We evaluated the associations between smartphone-recorded daily steps over two years following the initial health check-up and two-year changes in the following CVD risk factors: weight, waist, blood pressure (BP), lipid and glucose metabolism biomarkers. Generalized additive models were used to investigate the non-linear relationships of steps and changes in CVD risks. Models were adjusted for baseline steps and other confounders. The present study design is summarized in Figure 1.

Results

A total of 15,708 participants with mean (SD) age of 44.1 (9.5) and 23.5% women were included. Differences in weight were almost linearly associated with two-year steps in men (estimate [SE] per 1000 steps/day: −0.33 [0.029] kg), and inversely related only above 5,000 steps/day in women (−0.18 [0.054] kg) (Figure 2). Similar trends were observed in waist. An inverse linear association with systolic BP was observed in men (−0.34 [0.097] mmHg) but not in women. Greater steps were associated with favorable change in HDL cholesterol and triglycerides (0.61 [0.068] and −3.4 [0.61] mg/dL in men; 0.64 [0.17] and −2.3 [0.67] mg/dL in women), while negative changes in LDL cholesterol was evident in men only (−0.59 [0.17] mg/dL). A significant negative association with HbA1c was observed only in women (−0.012 [0.0043] %). In the secondary analyses of the associations between one-year steps and one-year (i.e., 12 to 23 months) changes in CVD related biomarkers (N=26,884), the relationships were weaker and less robust compared with those in two-year analyses.

Conclusions

In a large cohort of Japanese adults, smartphone-recorded steps over years were associated with beneficial changes in CVD risk factors, with some differences between men and women in the associational patterns. The sex differences might highlight the undercount of steps among women who may be less likely to always carry their phone [1], or true sex differences in the effects of steps. The findings support the benefit of long-term PA for CVD health and suggest a useful role of smartphone-recorded steps for monitoring CVD risk over the long term.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): DeSC Healthcare Inc., Tokyo, Japan

Differential impact of coronary revascularization on long-term clinical outcome according to coronary flow characteristics: analysis of the international ILIAS registry

Backgrounds

Coronary pressure indices such as fractional flow reserve (FFR) are standard in guiding elective revascularization. However, considering additional coronary flow parameters could further individualize and optimize the decision on revascularization, especially in terms of the impact on prognosis. We aimed to investigate the potentially differential prognostic associations of elective PCI according to coronary flow properties represented by coronary flow reserve (CFR), coronary flow capacity (CFC) and baseline CFC (bCFC).

Methods

From the Inclusive invasive physiological assessment in angina syndromes (ILIAS) registry composed of 16 hospitals globally from 7 countries, patients with obstructive coronary artery disease who underwent invasive coronary physiological assessment were included (N=2370 vessels). We assessed effect measure modifications of the association of PCI and 5-year target vessel failure (TVF) according to CFR, CFC and bCFC either assessed by Doppler-technique or thermodilution-method in three models: conditional logistic regression, marginal structural model, and COX proportional hazard model. Reduced CFR, CFC and bCFC were defined as CFR<2.1, CFR<2.1 with hyperemic average peak flow velocity (APV)<33.8 cm/s, and CFR<2.1 with baseline APV>17.0 cm/s in Doppler-technique, respectively (Figure 1), and the corresponding percentiles in thermodilution-methods. All models were adjusted for FFR, the interaction between PCI and FFR, and other confounders.

Results

The mean age of the population was 63.3 years and there were 1322 (73.6%) males. Median FFR was 0.85 and PCI was performed in 600 (25.3%) vessels. Reduced CFR, CFC, and abnormal bCFC were defined in 988 (41.7%), 542 (22.9%), and 600 (25.3%) vessels, respectively. There were little overlaps in vessels with reduced CFC and abnormal bCFC. In univariate analyses, vessels with reduced CFC had worse outcomes compared with those with normal CFC if deferred (13.4% vs. 6.6%), whereas reduced CFC was associated with better prognosis if treated by PCI (9.5% vs. 11.3%). Significant effect measure modifications were observed by CFC either in odds ratio (P=0.0018), additive (P=0.029), and hazard ratio scale (P=0.0002) (Figure 2). Vessels with reduced CFC had, compared with those with normal CFC, higher adjusted absolute risk of 5-year TVF by 5.9 [0.1, 12] percent if deferred, but lower risk by 1.8 [−1.7, 5.3] percent if treated by PCI. CFR and bCFC were not significant effect modifiers in any scales. Similar associations were observed in per-patient analyses, whereas the findings were less robust.

Conclusions

We observed a beneficial impact of PCI on absolute risk of 5-year clinical outcomes in vessels with reduced CFC, and a detrimental effect in those with normal CFC. CFR and bCFC were not robust effect modifiers of PCI. Therefore, CFC, combined with FFR, could be potentially used to optimize the patient selection for elective PCI treatment.

Funding Acknowledgement

Type of funding sources: None.

Contribution of dental health in cardiovascular secondary prevention

Backgrounds

Previous studies have suggested that periodontitis is associated with cardiovascular disease (CVD), partly through exaggerated systematic inflammation through pathogens breaking into the bloodstream and their metabolic products. However, the clinical evidence in the cardiovascular secondary prevention is limited. In addition, there is a paucity of data about the contribution of comprehensively assessed dental health, including dental caries or teeth loss, to CVD incidence. Consequently, current ESC guideline for CVD prevention just briefly refers the contribution of dental health [1].

Objective

To investigate the associations between teeth loss, periodontitis, and dental caries and incident major adverse cardiovascular events (MACE) in patients with existing CVD.

Methods

Patients with known CVD who were admitted to the Department of Cardiology between May 2012 and August 2015 were prospectively, consecutively enrolled. Patients underwent comprehensive dental examinations, including counts of lost teeth, dental caries, and periodontal measurements of clinical attachment loss (CAL), periodontal probing pocket depth (PPD), and bleeding on probing (BOP) by trained periodontists during the hospital stay. We assessed the associations between these dental measures and MACE, defined as a composite of cardiac death, acute myocardial infarction, stroke, and hospital re-admission for worsened congestive heart failure, using multivariate COX proportional hazard models and restricted mean survival time (RMST) analyses. P-values were adjusted by Bonferroni methods.

Results

Among 888 patients included for the present analyses, the mean age was 63.9 (SD: 13.1) years and there were 242 (27.3%) women. During a median follow-up of 4.6 (IQR: 1.4, 6.7) years, incident MACE was confirmed in 142 patients. In multivariate COX proportional hazard models, one more tooth loss was associated with 3 (95% CI: 1, 5) % higher hazard of MACE (adjusted p=0.020). Kaplan-Meier curves showing survival from MACE according to the quartiles of teeth loss were described in Figure 1. Compared with patients with 0 to ≤4 lost teeth, periods free from MACE (95% CI) by 5-years of follow-up were on average shorter by 0.17 (−0.04, 0.37) years, 0.26 (0.04, 0.49) years, and 0.59 (0.34, 0.85) years in patients with 5 to ≤7, 8 to ≤13, and >13 lost teeth, respectively. The RMST differences with varied cutoff years were shown in Figure 2. There were no significant associations between the number of dental caries, CAL, PPD, and BOP and MACE incidence.

Conclusion

In hospitalized patients due to existing cardiovascular diseases, total number of lost teeth was associated with incident MACE. Given that teeth loss is an ultimate consequence of periodontitis or dental caries, the present findings imply that efforts to prevent losing teeth by maintaining dental health would be effective measures for cardiovascular secondary prevention.

Funding Acknowledgement

Type of funding sources: None.

Robust association between changes in coronary flow capacity following PCI and vessel-oriented outcomes

Backgrounds

While trials show a comparative effectiveness of percutaneous coronary intervention (PCI) against medical therapy with respect to patient outcomes, deferring all elective PCI might be too simplistic, given the prognostic benefit differential according to several factors. Coronary flow capacity (CFC) is a potentially useful coronary flow (CF)-related physiologic marker of ischemia for guiding PCI indication [1,2]. However, the physiological/prognostic mechanics of the CFC guidance, which could be assessed by CFC changes following PCI, have not been investigated.

Objectives

To assess the determinants and prognostic implication of the change in the CFC status following PCI.

Methods

From a single center registry, 450 patients with chronic coronary syndrome (CCS) who underwent fractional flow reserve (FFR)-guided PCI with pre-/post-PCI coronary physiological assessments by thermodilution-method were included. CFC status was defined as follows [1]; normal CFC as CFR ≥2.80 with hyperemic CF (hCF) ≥3.70; mildly reduced CFC as CFR <2.80 and ≥2.10, combined with hCF <3.70 and ≥2.56; moderately reduced CFC as CFR <2.10 and ≥1.70, and 1/Tmn <2.56 and ≤2.00; and severely reduced CFC otherwise (CFR <1.70 and hCF <2.00). Associations between PCI-related changes in thermodilution method-derived CFC categories and incident target vessel failure (TVF) during a median follow-up of 4.3 (IQR: 2.5, 6.9) years were assessed by multivariate COX proportional hazard models.

Results

The mean (SD) age was 67.1 (10.0) years and there were 75 (16.7%) women. There were no differences in survival according to pre-PCI CFC status (P for linear trends = 0.22). Compared with patients showing no change in CFC categories after PCI, patients with category worsened, +1, +2, and +3 category improved had the hazard ratio (95% CI) for incident TVF of 2.27 (0.95, 5.43), 0.85 (0.33, 2.22), 0.45 (0.12, 1.63), and 0.14 (0.016, 1.30), respectively (P for linear trends = 0.0017). The relevant Kaplan-Meier curves were illustrated in the Figure, which highlights a best survival in those with +3 categories improvement (severely reduced to normal CFC) and worst in worsened CFC. After adjustment for confounders, one additional improvement in CFC status was associated with 0.61 (0.45, 0.83) times the hazard of TVF. CFC changes ≥3 categories were largely predicted by pre-PCI CFC with area under the curve of 0.94 (95% CI: 0.93, 0.96), and 48.6% of the variability of continuous CFC changes in ranks was explained solely by pre-PCI CFC, while only 12.4% by FFR.

Conclusion

CFC improvement following PCI, which was largely determined by the pre-PCI CFC status, was associated with lower risk of incident TVF in patients with CCS who underwent PCI. Therefore, CFC changes provide a mechanistic explanation on a potential favorable effect of PCI on reducing vessel-oriented outcome in lesions with reduced CFC and low FFR.

Funding Acknowledgement

Type of funding sources: None.

Transfemoral versus transapical approach for transcatheter aortic valve implantation: a systematic review and meta-analysis of adjusted studies

Background

In selected patients with severe aortic stenosis, transcatheter aortic valve implantation (TAVI), via either transfemoral (TF) or transapical (TA) access, offers a less invasive alternative to standard surgical replacement. Comparison of TF- vs. TA-TAVI is usually confounded by the higher comorbidities of patients undergoing TA-TAVI, rendering the observed comparison of the TF- vs. TA-approach unclear. The present meta-analysis provides updated evidence of this comparison by focusing on studies reporting adjusted outcomes.

Methods

A systematic review of the literature was performed in MEDLINE, EMBASE, Web of Science, clinicaltrials.gov, and Cochrane database. We only included studies in which the comparison between TF- and TA-TAVI was adjusted for potential confounders. Primary outcomes were early and mid-term mortality. Secondary outcomes included cardiovascular events, bleeding, pacemaker, and acute kidney injury. Survival data was either obtained directly from reported outcomes or estimated from Kaplan-Meier curves. Meta-regression was used to adjust for follow-up duration. Meta-analyses were performed using random effects models on odds ratios (OR) and hazard ratios (HR). The protocol was registered on PROSPERO (ID: CRD42020218163).

Results

A total of 24 studies with 36,158 patients were included in the present analyses. Of these studies, 7 used propensity score adjustment techniques and 17 used multivariable regression. TA-TAVI was associated with significantly higher postoperative mortality at 30 days (OR=1.67; 95% CI, 1.34 to 2.09; p<0.001) and 1 year (HR, 1.36; 95% CI, 1.21 to 1.53; p<0.001). However, meta-analysis of studies censoring patients who died in the first 30 days showed no significant difference in 1 year mortality by access route (HR, 1.20; 95% CI, 0.95 to 1.52; p=0.13). TA-approach was associated with increased perioperative surgical complications, such as bleeding (OR, 1.46, 95% CI, 1.09 to 1.96; p=0.012), acute kidney injury (OR, 2.31, 95% CI 1.60 to 3.33; p=0.001), and myocardial infarction (OR, 1.83, 95% CI 1.06 to 3.16; p=0.029). TA-TAVI was associated with reduced vascular complications (OR, 0.32, 95% CI 0.18–0.56; p<0.001), late postoperative aortic regurgitation (OR, 0.48, 95% CI 0.30 to 0.75; p=0.001), and a trend towards less pacemaker requirement (OR, 0.80, 95% CI 0.60–1.08, p=0.15).

Conclusions

Based on this meta-analysis of adjusted studies, a TA approach is associated with higher early and mid-term mortality compared to TF-TAVI. Excess mortality is likely driven by higher perioperative bleeding, renal complications and myocardial infarction. TA-TAVI did confer some benefits, such as reduced vascular complications, late postoperative aortic regurgitation, and a trend towards less pacemaker requirement. The optimal TAVI route should be based on individualized assessment by a multidisciplinary team. Longer follow-up and randomized studies are needed to ascertain long-term outcomes.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Prognostic value of pre-revascularization fractional flow reserve mediated by the post-revascularization level: a causal mediation analysis

Background

The prognostic value of pre-percutaneous coronary intervention (PCI) fractional flow reserve (FFR) can depend on that of the post-PCI FFR and their interaction. To correctly interpret the prognostic value of pre-PCI FFR, it is essential to understand to what extent the relationship between pre-PCI FFR and clinical outcome is explained by pre-PCI FFR-related post-PCI FFR.

Purpose

The aim of this study is to investigate the extent to which post-PCI FFR mediates the relationship between pre-PCI FFR and vessel-related outcomes using a global, multicenter collaboration registry.

Methods

Patient data from 4 global FFR registries were pooled and 1488 patients with pre-PCI FFR ≤0.80 were analyzed. The primary outcome was target vessel failure (TVF) during 2-years of follow-up. We evaluated the extent to which post-PCI FFR <0.90 mediated the association between pre-PCI FFR <0.75 and TVF employing a causal mediation analysis in a counterfactual framework.

Results

Among 1488 patients, the mean (standard deviation) age was 63.5 (9.9) years and 78% (1161 patients) were male. The median (IQR) pre-PCI and post-PCI FFR were 0.71 (0.62–0.76) and 0.88 (0.83–0.92), respectively. The direct effect of low pre-PCI FFR (<0.75) on TVF was significantly elevated (OR: 1.81, 95% CI: 1.03–3.18, p=0.038), and was not mediated by post-PCI FFR<0.90 (indirect effect, OR: 1.01, 95% CI: 0.98–1.05, p=0.39). In the model, post-PCI FFR explained only 2.2% of the association between pre-PCI FFR and TVF. The subgroup analysis implicated that the prognostic information of pre-PCI FFR was mainly for diffuse lesions.

Conclusions

The prognostic information of pre-PCI FFR did not greatly depend on the results of PCI assessed by post-PCI FFR. Pre-PCI FFR, as a prognostic marker, may mainly reflect the global atherosclerotic burden of the artery, not the extent of the modifiable epicardial stenosis, thus providing independent information from post-PCI FFR.

Interpretation

Funding Acknowledgement

Type of funding source: None

P3578Determinants of visual-functional mismatches as assessed by coronary angiography and 3-D angiography-based quantitative flow ratio

Background

Quantitative flow ratio (QFR) is a novel three-dimensional quantitative coronary angiography (QCA)-based computational index that can estimate fractional flow reserve (FFR) without pharmacologically induced hyperemia or the use of a pressure wire.

Purpose

We aimed to evaluate the determinants of visual-functional mismatches between conventional two-dimensional QCA and QFR.

Methods

A total of 504 de novo intermediate-to-severe lesions from 504 patients with stable angina who underwent angiographical and physiological assessments were analyzed. All lesions were divided into four groups based on the significance of visual (QCA-diameter stenosis [DS] >50% and ≤50%) and functional (QFR <0.80 and ≥0.80) stenosis severity. Patient characteristics, angiographic findings, QFR computations, and physiological indices were compared among the four groups.

Results

Among 504 lesions, 153 lesions (30.4%) showed concordantly negative (DS ≤50% and QFR >0.80) and 170 lesions (33.7%) showed concordantly positive (DS >50% and QFR ≤0.80) visual and functional assessments. Among 181 lesions (35.9%) with discordant results, 75 lesions (14.9%) showed a mismatch (DS >50% and QFR >0.80) and 106 lesions (21.0%) showed a reverse mismatch (DS ≤50% and QFR ≤0.80), respectively. Reverse mismatch was associated with smaller reference diameter (odds ratio [OR] 0.561; P=0.036), greater DS (OR 1.039, P=0.013), lower coronary flow reserve (CFR) (OR 0.571, P<0.001, non-diabetes mellitus (OR 2.141, P=0.013) and lower ejection fraction (OR 0.961, P=0.011). Mismatch was associated with smaller DS (OR 0.914, P<0.001), shorter lesion length (OR 0.894, P=0.001), higher CFR (OR 1,633, P<0.001), and lower estimated glomerular filtration rate (OR, 0.968, P=0.001). Lesion location and the index of microcirculatory resistance was not associated with the prevalence of reverse mismatch or mismatch.

Conclusions

There was a high prevalence of visual-functional mismatches between QCA-DS and QFR, and CFR was an important functional factor of mismatches. Our results suggested the difference between predictors of reported visual-functional mismatches of QCA/FFR and those of QCA/QFR.