Posttraumatic Stress Disorder After Spontaneous Coronary Artery Dissection: A Report of the International Spontaneous Coronary Artery Dissection Registry

BACKGROUND

Myocardial infarction secondary to spontaneous coronary artery dissection (SCAD) can be traumatic and potentially trigger posttraumatic stress disorder (PTSD). In a large, multicenter, registry-based cohort, we documented prevalence of lifetime and past-month SCAD-induced PTSD, as well as related treatment seeking, and examined a range of health-relevant correlates of SCAD-induced PTSD.

METHODS AND RESULTS

Patients with SCAD were enrolled in the iSCAD (International SCAD) Registry. At baseline, site investigators completed medical report forms, and patients reported demographics, medical/SCAD history, psychosocial factors (including SCAD-induced PTSD symptoms), health behaviors, and health status via online questionnaires. Of 1156 registry patients, 859 patients (93.9% women; mean age, 52.3 years) completed questionnaires querying SCAD-induced PTSD. Nearly 35% (n=298) of patients met diagnostic criteria for probable SCAD-induced PTSD in their lifetime, and 6.4% (n=55) met criteria for probable past-month PTSD. Of 811 patients ever reporting any SCAD-induced PTSD symptoms, 34.8% indicated seeking treatment for this distress. However, 46.0% of the 298 patients with lifetime probable SCAD-induced PTSD diagnoses reported never receiving trauma-related treatment. Younger age at first SCAD, fewer years since SCAD, being single, unemployed status, more lifetime trauma, and history of anxiety were associated with greater past-month PTSD symptom severity in multivariable regression models. Greater past-month SCAD-induced PTSD symptoms were associated with greater past-week sleep disturbance and worse past-month disease-specific health status when adjusting for various risk factors.

CONCLUSIONS

Given the high prevalence of SCAD-induced PTSD symptoms, efforts to support screening for these symptoms and connecting patients experiencing distress with empirically supported treatments are critical next steps.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04496687.

Twenty-five-year trends in incidence, angiographic appearance, and management of spontaneous coronary artery dissection

BACKGROUND

Spontaneous coronary artery dissection (SCAD) has been described as an infrequent cause of acute coronary syndrome (ACS). Knowledge about the disease is still limited and SCAD might still be underdiagnosed.

OBJECTIVES

Trends in incidence, presentation, angiographic appearance, management, and outcomes of SCAD over 25 years were analyzed.

METHODS

Patients with SCAD between 1997 and 2021 at the University Hospital Zurich, Switzerland, were included. Incidences were assessed as total numbers and proportions of ACS cases. Clinical data were collected from medical records and angiographic findings were reviewed. Major adverse cardiac events (MACE) were defined as the composite of all-cause death, cardiac arrest, SCAD recurrence or progression, other myocardial infarction, and stroke.

RESULTS

One hundred fifty-six SCAD cases were included in this study. The incidence increased significantly in total (p < 0.001) and relative to ACS cases (p < 0.001). This was based on an increase of shorter lesions (p = 0.004), SCAD type 2 (p < 0.001), and lesions in side branches (p = 0.014), whereas lesions in the left main coronary artery and proximal segments were decreasing (p-values 0.029 and < 0.001, respectively). There was an increase in conservative therapy (p < 0.001). The rate of MACE (24%) was stable, however, there was a reduced proportion of patients with a need for intensive care treatment (p = 0.017).

CONCLUSIONS

SCAD represents an important entity of ACS that still might be underappreciated. The increasing incidence of SCAD is likely based on better awareness and familiarity with the disease. A lower need for intensive care treatment suggests positive effects of the increasing implementation of conservative management.

Non-atherosclerotic acute cardiac syndromes: spontaneous coronary artery dissection and Takotsubo syndrome. Comparison of long-term clinical outcomes

BACKGROUND

Spontaneous coronary artery dissection (SCAD) and Takotsubo syndrome (TTS) constitute two common causes of nonatherosclerotic acute cardiac syndrome particularly frequent in women. Currently, there is no information comparing long-term clinical outcomes in unselected patients with these conditions.

METHODS

We compared the baseline characteristics, in-hospital outcomes, and the 12-month and long-term clinical outcomes of two large prospective registries on SCAD and TTS.

RESULTS

A total of 289 SCAD and 150 TTS patients were included; 89% were women. TTS patients were older with a higher prevalence of cardiovascular risk factors. Precipitating triggers were more frequent in TTS patients, while emotional triggers and depressive disorders were more common in the SCAD group. Left ventricular ejection fraction was lower in TTS patients, but SCAD patients showed higher cardiac biomarkers. In-hospital events (43.3% vs. 5.2%, P <0.01) occurred more frequently in TTS patients. TTS patients also presented more frequent major adverse events at 12-month (14.7% vs. 7.1%, HR 5.3, 95% CI: 2.4-11.7, P <0.01) and long-term (median 36 vs. 31 months, P =0.41) follow-up (25.8% vs. 9.6%, HR 4.5, 95% CI: 2.5-8.2, P <0.01). Atrial fibrillation was also more frequent in TTS patients. Moreover, TTS patients presented a higher 12-month and long-term mortality (5.6% vs. 0.7%, P =0.01; and 12.6% vs. 0.7%, P <0.01) mainly driven by noncardiovascular deaths.

CONCLUSION

Compared to SCAD, TTS patients are older and present more cardiovascular risk factors but less frequent depressive disorder or emotional triggers. TTS patients have a worse in-hospital, mid-term, and long-term prognosis with higher noncardiac mortality than SCAD patients.

Spontaneous Coronary Artery Dissection Across the Health Care Pathway: A National, Multicenter, Patient-Informed Investigation

BACKGROUND

Clinical practice guidelines for the management and convalescence of patients with spontaneous coronary artery dissection (SCAD) have yet to be developed. The targeted content, delivery, and outcomes of interventions that benefit this population remain unclear. Patient-informed data are required to substantiate observational research and provide evidence to inform and standardize clinical activities.

METHODS AND RESULTS

Patients diagnosed with SCAD (N=89; 86.5% women; mean age, 53.2 years) were purposively selected from 5 large tertiary care hospitals. Patients completed sociodemographic and medical questionnaires and participated in an interview using a patient-piloted semistructured interview guide. Interviews were transcribed and subjected to framework analysis using inductive and then deductive coding techniques. Approximately 1500 standard transcribed pages of interview data were collected. Emotional distress was the most commonly cited precipitating factor (56%), with an emphasis on anxiety symptoms. The awareness and detection of SCAD as a cardiac event was low among patients (35%) and perceived to be moderate among health care providers (55%). Health care providers' communication of the prognosis and self-management of SCAD were perceived to be poor (79%). Postevent psychological disorders among patients were evident (30%), and 73% feared recurrence. Short- and longer-term follow-up that was tailored to patients' needs was desired (72%). Secondary prevention programming was recommended, but there were low completion rates of conventional cardiac rehabilitation (48%), and current programming was deemed inadequate.

CONCLUSIONS

This early-stage, pretrial research has important implications for the acute and long-term management of patients with SCAD. Additional work is required to validate the hypotheses generated from this patient-oriented research.

Venous compression syndromes in females: A descriptive review

Venous compression syndromes have been described, yet the role of sex is poorly understood. Although iliac vein compression has been discussed more often with the advent of newer technologies, research has fallen short on defining epidemiology, best practices for evaluation and treatment, and differences in responses to treatment between men and females. The authors report on iliac vein compression, nonthrombotic renal vein compression, and other venous compression syndromes in females. Literature searches of PubMed were performed using the following keywords: females/females and May Thurner, venous stenting, venous outcomes, deep venous disease, deep venous compression, venous stenting, renal vein compression, renal vein surgery/stent, popliteal vein entrapment, venous thoracic vein entrapment, and popliteal vein entrapment. The articles prompted the authors to research further as the referenced articles were reviewed. Sex representation has not been addressed adequately in the research of venous compression syndromes, making the discussion of best treatment options and long-term outcomes difficult. More specific understanding of epidemiology and response to interventions will only come from research that addresses these issues directly, understanding that some of these syndromes occur rarely.

[French National registry of spontaneous coronary artery dissections : ''DISCO registry'']

AIM

Spontaneous coronary artery dissection (SCAD) is a form of acute coronary syndrome (ACS). The aim of this registry is to assess the clinical and angiographic features of SCAD, to describe the therapeutic management and prognosis, and to identify links with other vascular diseases.

METHOD

From 2016 to 2018, 424 patients with a diagnosis of SCAD were included prospectively and retrospectively in 51 French cardiology centres.

RESULTS

373 patients with confirmed SCAD were included. The mean age was 51.5±10.3 years with 90.6% women. 54.7% of patients had <2 cardiovascular risk factors. ACS occurred in 96.2% of patients. 84.2% of patients were managed conservatively, 15.5% interventionally and 0.3% surgically. At 1-year follow-up, recurrence of SCAD occurred in 3.3%. No deaths occurred. The association with fibro-muscular dysplasia was found in 45% of cases and genetic analysis confirmed a strong relationship between the occurrence of SCAD and gene variations at the PHACTR1 locus.

CONCLUSION

The DISCO registry is the largest European cohort of SCAD. It confirms that this disease mainly affects young women with few cardiovascular risk factors, and that there is a strong association with the presence of fibromuscular dysplasia (45%). Conservative management should be preferred, with a favourable prognosis (no deaths at 1 year; recurrence rate of 3.3%).

The Patient Experience After Spontaneous Coronary Artery Dissection

OBJECTIVE

There is considerable burden of anxiety, depression, and post-traumatic stress disorder in patients with spontaneous coronary artery dissection (SCAD), yet research is limited on the experience and impact of SCAD from the patient perspective. This literature review sought to describe the current state of the literature on the patient experience of SCAD and consequences for patients following a SCAD event from the patient perspective. To better understand how people's experiences of SCAD affect their wellbeing, quality of life, lifestyles, and identity, and what would be useful from the patient perspective, an integrative review was performed.

METHODS

An integrative literature review was conducted to understand the experience of SCAD and the post-event implications. Five databases were searched. Search terms included 'spontaneous coronary artery dissection', 'SCAD', 'patient', 'experience', 'perspective', and 'opinion'. English-language, peer-reviewed primary research in people with a diagnosis of SCAD that reflected the patient experience was included. Data indicating the SCAD experience including distress prevalence were extracted into an Excel spreadsheet, and narrative synthesis of included studies followed.

FINDINGS

From 325 identified studies, five were included for review, yielding a combined sample of 447 participants. Patients with SCAD reported a lack of information about SCAD and the recovery process, and use of the internet for obtaining information. Patients with SCAD reported challenges in recovery including anxiety associated with fear of recurrence and uncertainty, and a need for greater support. A wide range of negative emotions was reported during and after the SCAD event. Participants reported participating in support groups, with mixed reviews of their appropriateness and effectiveness.

[Knowledge of chronic venous disease among healthcare professionals in Spain]

INTRODUCTION

Chronic venous disease (CVD) is classified as the most prevalent vascular disease in humans. It has been associated with an increased incidence of cardiovascular diseases and is a strong predictor of all-cause mortality, representing a public health problem of the first magnitude. The objective of this study was to analyze the actions in the management of CVD in the daily clinical practice of health professionals in Spain.

MATERIAL AND METHODS

Observational, descriptive and cross-sectional study with data collection through an opinion survey of 22 questions completed electronically through a Google® form for professionals involved in chronic venous disease care. Three hundred surveys were analyzed. The quantitative variables were represented with means and standard deviation and the qualitative ones with percentages and confidence intervals.

RESULTS

Three hundred surveys analyzed. 65.3% were women. The most participatory age group was over 55 years of age. 85% of those surveyed considered that CVD is an underdiagnosed and undertreated disease, with an added negative impact in terms of follow-up during the Covid-19 pandemic, since 91.7% considered that it had not been adequate. 47% of the participants did not know the CEAP classification and 56.3% did not know the venous clinical severity scale (VCSS). 92.7% of physicians prescribed compression stockings and 74.7% phlebotonic drugs. Hidrosmine was the best known and most prescribed venoactive drug (51.7%). 73% of the doctors recognized that they did not use any algorithm or protocol for the diagnosis, treatment and monitoring of CVD in their usual clinical practice and 91% stated that they were not trained in their workplaces. 54.3% of the physicians believed that one of the main limitations that made follow-up of the disease difficult was the lack of coordination with the vascular surgeons.

CONCLUSIONS

Updating and responding to the training needs of professionals regarding CVD is essential to guarantee quality care continuity in the care of our patients.

Characteristics and treatment of nonagenarian patients with vascular disease admitted to internal medicine services. NONAVASC-2 registry

INTRODUCTION

Vascular disease (VD) is the most frequent cause of morbidity and mortality and its prevalence increases with age. Old patients are not included in studies on VD, their characteristics and treatments being unknown.

OBJECTIVE

Know the clinical characteristics of nonagenarian patients hospitalized in Internal Medicine services with a diagnosis of established VD and the adequacy of their pharmacological management.

MATERIAL AND METHODS

The NONAVASC-2 registry is an observational, prospective, multicentre study. Hospitalized patients for any cause were included. Data collection was carried out through an anonymous online database with sociodemographic, clinical, analytical, therapeutic and evolutionary parameters.

RESULTS

One thousand forty-nine patients with a mean age of 93.14 years (57.8% women) were included. The prevalence of risk factors and VD was high: hypertension (84.9%), dyslipidemia (50.9%) and diabetes mellitus (29.4%). 33.4% presented severe-total dependency. 82.9% received antithrombotic treatment (53.7% antiplatelets, 25.4% anticoagulation and 3.8% double therapy). Only 38.2% received statins. The percentage of severe dependence (39.2% vs 24.1%; p = 0.00) and severe cognitive impairment (30.8% vs 13.8%; p = 0.00) was significantly higher among patients who did not receive them. 19% died during admission.

CONCLUSIONS

Nonagenarian patients with VD present high comorbidity, dependence and mortality. Despite being in secondary prevention, 17% did not receive antithrombotics and only 38% received statins. The underprescription is conditioned, among other factors, by the functional status. More studies are necessary to determine the impact of this issue on their prognosis.

Precipitating factors in patients with spontaneous coronary artery dissection: Clinical, laboratoristic and prognostic implications

BACKGROUND

Spontaneous coronary artery dissection (SCAD) often presents with acute coronary syndrome and underlying pathophysiology involves the interplay between predisposing factors and precipitating stressors, such as emotional and physical triggers. In our study we sought to compare clinical, angiographic and prognostic features in a cohort of patients with SCAD according to the presence and type of precipitating stressors.

METHODS

Consecutive patients with angiographic evidence of SCAD were divided into three groups: patients with emotional stressors, patients with physical stressors and those without any stressor. Clinical, laboratoristic and angiographic features were collected for each patient. The incidence of major adverse cardiovascular events, recurrent SCAD and recurrent angina was assessed at follow-up.

RESULTS

Among the total population (64 subjects), 41 [64.0%] patients presented with precipitating stressors, including emotional triggers (31 [48.4%] subjects) and physical efforts (10 [15.6%] subjects). As compared with the other groups, patients with emotional triggers were more frequently female (p = 0.009), had a lower prevalence of hypertension (p = 0.039] and dyslipidemia (p = 0.039), were more likely to suffer from chronic stress (p = 0.022) and presented with higher levels of C-reactive protein (p = 0.037) and circulating eosinophils cells (p = 0.012). At a median follow-up of 21 [7; 44] months, patients with emotional stressors experienced higher prevalence of recurrent angina (p = 0.025), as compared to the other groups.

CONCLUSIONS

Our study shows that emotional stressors leading to SCAD may identify a SCAD subtype with specific features and a trend towards a worse clinical outcome.

Spontaneous coronary artery dissection in Spain: a study using the minimum data set of the Spanish National Health System

INTRODUCTION AND OBJECTIVES

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction (AMI). We sought to compare the results on in-hospital mortality and 30-day readmission rates among patients with AMI-SCAD vs AMI due to other causes (AMI-non-SCAD).

METHODS

Risk-standardized in-hospital mortality (rIMR) and risk-standardized 30-day readmission ratios (rRAR) were calculated using the minimum dataset of the Spanish National Health System (2016-2019).

RESULTS

A total of 806 episodes of AMI-SCAD were compared with 119 425 episodes of AMI-non-SCAD. Patients with AMI-SCAD were younger and more frequently female than those with AMI-non-SCAD. Crude in-hospital mortality was lower (3% vs 7.6%; P<.001) and rIMR higher (7.6±1.7% vs 7.4±1.7%; P=.019) in AMI-SCAD. However, after propensity score adjustment (806 pairs), the mortality rate was similar in the 2 groups (AdjOR, 1.15; 95%CI, 0.61-2,2; P=.653). Crude 30-day readmission rates were also similar in the 2 groups (4.6% vs 5%, P=.67) whereas rRAR were lower (4.7±1% vs 4.8%±1%; P=.015) in patients with AMI-SCAD. Again, after propensity score adjustment (715 pairs) readmission rates were similar in the 2 groups (AdjOR, 1.14; 95%CI, 0.67-1.98; P=.603).

CONCLUSIONS

In-hospital mortality and readmission rates are similar in patients with AMI-SCAD and AMI-non-SCAD when adjusted for the differences in baseline characteristics. These findings underscore the need to optimize the management, treatment, and clinical follow-up of patients with SCAD.

Cardiovascular disease in women: A review of spontaneous coronary artery dissection

Research has demonstrated the disproportionate quality of care for women with cardiovascular disease. These findings have prompted a renewed focus on cardiovascular disease awareness and disease prevention in women. Spontaneous coronary artery dissection (SCAD) is a significant cause of myocardial infarction (MI) and sudden death that primarily affects women. ongoing research has led to improved diagnostic capabilities and changes in approaches to initial and long-term management most importantly this research has provided evidence that SCAD is more common than previously thought and must be evaluated and treated differently from atherosclerotic MI. The difference between SCAD and atherosclerotic MI is highlighted in high rates of recurrent disease, gender distribution, association with exogenous hormones, pregnancy, migraine, physical and emotional stress triggers, concurrent systemic arteriopathies, and connective tissue disease. In this review, we provide updated insights and a summary of the epidemiology, risk factors, clinical presentation, diagnosis, treatment options, prognosis, and recurrence prevention of SCAD. We aim to provide a review of SCAD as a focus on cardiovascular disease awareness and disease prevention in women.

Association of Younger vs Older Ages With Changes in Incidence of Stroke and Other Vascular Events, 2002-2018

Importance

Some studies have reported increasing stroke incidence at younger ages (<55 years) but have often relied only on administrative data, and more population-based studies of adjudicated stroke are required. An understanding of the drivers of any increase in incidence of young stroke also requires comparisons with stroke trends at older ages and with trends in incidence of other vascular events at younger ages.

Objective

To determine temporal changes in incidence of stroke and other major vascular events at younger vs older ages.

Design, Setting, and Participants

Prospective population-based incidence study conducted from April 2002 to March 2018 with a mean catchment population of 94 567 in Oxfordshire, England.

Exposures

Calendar time, premorbid vascular risk factors, and occupation.

Main Outcomes and Measures

Changes in incidence of stroke, transient ischemic attack (TIA), and other major vascular events (myocardial infarction, sudden cardiac death, and peripheral vascular events) stratified by age, sex, diagnostic workup, etiology, and severity.

Results

A total of 2429 incident strokes were ascertained (mean age, 73.6 [SD, 14.4] years; 51.3% female). From 2002-2010 to 2010-2018, stroke incidence increased significantly among participants younger than 55 years (incidence rate ratio [IRR], 1.67; 95% CI, 1.31-2.14) but fell significantly among participants aged 55 years or older (IRR, 0.85; 95% CI, 0.78-0.92; P < .001 for difference). The significant increase in incidence at younger than 55 years was independent of sex, stroke severity, pathological subtype, and changes in investigation and was also seen for TIA (IRR, 1.87; 95% CI, 1.36-2.57) but not for myocardial infarction and other major vascular events (IRR, 0.73; 95% CI, 0.58-0.93). Although TIA and stroke at younger than 55 years were significantly associated with diabetes (risk ratio [RR], 3.47; 95% CI, 2.54-4.74), hypertension (RR, 2.52; 95% CI, 2.04-3.12), current smoking (RR, 2.38; 95% CI, 1.92-2.94), and obesity (RR, 1.36; 95% CI, 1.07-1.72), the significant increase in incidence from 2002-2010 to 2010-2018 was still seen in individuals without these risk factors. The increase was greatest in professional/managerial occupations (IRR, 2.52; 95% CI, 1.75-3.62) and least in partially skilled/unskilled occupations (IRR, 1.17; 95% CI, 0.79-1.74). The proportion of TIAs and strokes among those younger than 55 years without known vascular risk factors increased significantly over time (45 [30.4%] vs 115 [42.4%]; absolute difference, 12.0%; 95% CI, 2.6-21.5), especially in patients with cryptogenic events (10 [18.5%] vs 63 [49.2%]; absolute difference, 30.7%; 95% CI, 17.2-44.2; P < .001; P = .002 for heterogeneity).

Conclusions and Relevance

Comparing persons living in Oxfordshire, England, in 2002-2010 vs 2010-2018, there was a significant increase in stroke incidence in those younger than 55 years, but a decrease in those aged 55 years or older. Given the absence of this divergence for other vascular events, further research is needed to understand the causes of this difference.

Risk Factors for and Treatment of Chronic Venous Disease in Thai Patients

Introduction

The prevalence of chronic venous disease (CVD), a common health care problem, is still underestimated. A few previous epidemiologic studies have report Asian patients with this condition in western countries, but not in Asian countries. The aim of this study was to determine risk factors for CVD and its treatment in Thai individuals.

Methods

In this cross-sectional study, we collected data of patients with CVD visiting Chulabhorn Hospital Vascular Clinic from 1 December 2018–1 October 2021. We reviewed medical records for patient characteristics, comorbidities, Clinical, Etiology, Anatomy, Pathophysiology (CEAP) categories, Venous Clinical Severity Score (VCSS), ultrasound findings and treatment.

Results

The study cohort comprised 260 CVD patients with CVD of mean age 61.92 ± 12.82 years. Almost 80% of participants were female. A history of deep vein thrombosis (DVT) was the strongest risk factor for severe CVD. Other identified risk factors comprised body–mass index (BMI) >30 kg/m², and older age. The most common CEAP categories were C2 (39%) and C1 (33.8%). Superficial venous reflux was the most common location of venous reflux in this study, 67.32% of participants having great saphenous vein reflux and 16.99% small saphenous vein reflux. Only 4.76% of our cohort had both reflux and obstruction. Most of the participants had undergone compression therapy, approximately half of them complying well with wearing of stockings. Nineteen percent of our cohort had undergone sclerotherapy and 14% surgery, which comprised radiofrequency ablation in 97% of them.

Conclusion

The major risk factors for severe CVD identified in this study were deep vein thrombosis, body mass index>30 kg/m² and older age. The most common CEAP category was C2 (39%). GSV was the most commonly involved venous system. Involvement of numerous venous systems was a risk factor for severe CVD.

Clinical implications of arterial hypertension in patients with spontaneous coronary artery dissection

BACKGROUND

Spontaneous coronary artery dissection (SCAD) is a rare but increasingly recognized cause of acute coronary syndrome. Many patients with SCAD have associated coronary risk factors. However, the implications of arterial hypertension in SCAD patients remain unknown.

OBJECTIVE

This study sought to assess the clinical implications of arterial hypertension in a nationwide cohort of patients with SCAD.

METHODS

The Spanish SCAD registry (NCT03607981) prospectively enrolled 318 consecutive patients. All coronary angiograms were centrally analyzed to confirm the diagnosis of SCAD. Patients were classified according to the presence of arterial hypertension.

RESULTS

One-hundred eighteen patients (37%) had a diagnosis of arterial hypertension. Hypertensive SCAD patients were older (60 ± 12 vs. 51 ± 9 years old) and had more frequently dyslipidemia (56 vs. 23%) and diabetes (9 vs. 3%) but were less frequently smokers (15 vs. 35%) than normotensive SCAD patients (all P < 0.05). Most patients in both groups were female (90 vs. 87%, NS) and female patients with hypertension were more frequently postmenopausal (70 vs. 47%, P < 0.05). Hypertensive SCAD patients had more severe lesions and more frequently multivessel involvement (15 vs. 7%, P < 0.05) and coronary ectasia (19 vs. 7%, P < 0.05) but showed a similar prevalence of coronary tortuosity (34 vs. 26%, NS). Revascularization requirement was similar in both groups (17 vs. 26%, NS) but procedural success was significantly lower (65 vs. 88%, P < 0.05) and procedural-related complications more frequent (65 vs. 41%, P < 0.05) in SCAD patients with hypertension.

CONCLUSION

Patients with SCAD and hypertension are older, more frequently postmenopausal and have more coronary risk factors than normotensive SCAD patients. During revascularization SCAD patients with hypertension obtain poorer results and have a higher risk of procedural-related complications (NCT03607981).

Deep phenotyping of Alzheimer's disease leveraging electronic medical records identifies sex-specific clinical associations

Alzheimer's Disease (AD) is a neurodegenerative disorder that is still not fully understood. Sex modifies AD vulnerability, but the reasons for this are largely unknown. We utilize two independent electronic medical record (EMR) systems across 44,288 patients to perform deep clinical phenotyping and network analysis to gain insight into clinical characteristics and sex-specific clinical associations in AD. Embeddings and network representation of patient diagnoses demonstrate greater comorbidity interactions in AD in comparison to matched controls. Enrichment analysis identifies multiple known and new diagnostic, medication, and lab result associations across the whole cohort and in a sex-stratified analysis. With this data-driven method of phenotyping, we can represent AD complexity and generate hypotheses of clinical factors that can be followed-up for further diagnostic and predictive analyses, mechanistic understanding, or drug repurposing and therapeutic approaches.

Procedural Results of Patients Undergoing Transcatheter Aortic Valve Implantation With Aortic Annuli Diameter ≥26 mm: insights from the German Aortic Valve Registry

Patients presenting with severe aortic stenosis and large aortic annuli are challenging to treat because of the size limitations of available transcatheter heart valves. In this study, we aimed to determine clinical and hemodynamic outcomes in patients presenting with large aortic annuli who underwent transcatheter aortic valve implantation (TAVI). Patients from the German Aortic Valve Registry who underwent TAVI either with the Edwards Sapien (ES) or Medtronic CoreValve (MCV) systems from 2011 to 2017 were included. They were further stratified into a large (aortic annulus diameter 26 to 29 mm for ES; 26 to 30 mm for MCV) and extra-large (aortic annulus diameter >29 mm for ES; >30 mm for MCV) group and analyzed using propensity score adjustment. Extra-large was set beyond the sizing limitations according to the manufacturer's instructions for use. Patients in the large (n = 5,628) and extra-large (n = 509) groups were predominantly male (large: 92.6% vs extra-large: 91.9%). The 30-day mortality was comparable (large: 3.9% vs extra-large: 5.0%, p = 0.458). Procedure duration (large: 78.9 minutes ± 0.82 vs extra-large: 86.4 minutes ± 1.9, p <0.001) was longer in the extra-large group. Likewise, vascular complications (large: 6.2% vs extra-large: 12%, p = 0.002) and the need for a permanent pacemaker implantation (large: 18.8% vs extra-large: 26.0%, p = 0.027) were more often present in the extra-large group. Aortic regurgitation ≥II after valve implantation was numerically higher (large: 3.0% vs extra-large: 5.3%, p = 0.082) in patients with extra-large anatomy. In conclusion, patients with large and extra-large aortic annulus diameters who underwent TAVI have comparable 30-day mortality. Beyond the recommended annulus range, there is a higher risk for vascular complications and permanent pacemaker implantation.

Association between the Neutrophil-to-lymphocyte Ratio and New-onset Subclinical Macrovascular and Microvascular Diseases in the Chinese Population

OBJECTIVE

The association between neutrophil-to-lymphocyte ratio (NLR) with subclinical macrovascular and microvascular diseases has been less investigated. We sought to examine the association between NLR and new-onset subclinical macrovascular and microvascular abnormalities in the Chinese population.

METHODS

From a community cohort, we included 6,430 adults aged ≥ 40 years without subclinical macrovascular and microvascular diseases at baseline. We measured subclinical macrovascular and microvascular abnormalities separately using the ankle-brachial index (ABI), brachial-ankle pulse wave velocity (baPWV), and albuminuria.

RESULTS

During a mean follow-up of 4.3 years, 110 participants developed incident abnormal ABI, 746 participants developed incident elevated baPWV, and 503 participants developed incident albuminuria. Poisson regression analysis indicated that NLR was significantly associated with an increased risk of new-onset abnormal ABI, elevated baPWV, and albuminuria. Compared to overweight/obese participants, we found a much stronger association between NLR and subclinical vascular abnormalities in participants with normal weight. Furthermore, we found an interaction between the NLR and body mass index (BMI) on the risk of new-onset abnormal ABI ( P for interaction: 0.01).

CONCLUSION

NLR was associated with subclinical macrovascular and microvascular diseases in the Chinese population. Furthermore, in participants with normal weight, the association between NLR and subclinical vascular abnormalities was much stronger.

The Influence of Different Types of Diabetes on Vascular Complications

The final outcome of diabetes is chronic complications, of which vascular complications are the most serious, which is the main cause of death for diabetic patients and the direct cause of the increase in the cost of diabetes. Type 1 and type 2 diabetes are the main types of diabetes, and their pathogenesis is completely different. Type 1 diabetes is caused by genetics and immunity to destroy a large number of β cells, and insulin secretion is absolutely insufficient, which is more prone to microvascular complications. Type 2 diabetes is dominated by insulin resistance, leading to atherosclerosis, which is more likely to progress to macrovascular complications. This article explores the pathogenesis of two types of diabetes, analyzes the pathogenesis of different vascular complications, and tries to explain the different trends in the progression of different types of diabetes to vascular complications, in order to better prevent diabetes and its vascular complications.

Methylenetetrahydrofolate (MTHFR), the One-Carbon Cycle, and Cardiovascular Risks

The 5-10-methylenetetrahydrofolate reductase (MTHFR) enzyme is vital for cellular homeostasis due to its key functions in the one-carbon cycle, which include methionine and folate metabolism and protein, DNA, and RNA synthesis. The enzyme is responsible for maintaining methionine and homocysteine (Hcy) balance to prevent cellular dysfunction. Polymorphisms in the MTHFR gene, especially C677T, have been associated with various diseases, including cardiovascular diseases (CVDs), cancer, inflammatory conditions, diabetes, and vascular disorders. The C677T MTHFR polymorphism is thought to be the most common cause of elevated Hcy levels, which is considered an independent risk factor for CVD. This polymorphism results in an amino acid change from alanine to valine, which prevents optimal functioning of the enzyme at temperatures above 37 °C. Many studies have been conducted to determine whether there is an association between the C677T polymorphism and increased risk for CVD. There is much evidence in favour of this association, while several studies have concluded that the polymorphism cannot be used to predict CVD development or progression. This review discusses current research regarding the C677T polymorphism and its relationship with CVD, inflammation, diabetes, and epigenetic regulation and compares the evidence provided for and against the association with CVD.

Postprandial endothelial dysfunction and CIMT after oral fat challenge in patients with type 2 diabetes mellitus with and without macrovascular disease - A preliminary study

BACKGROUND

Very few studies have reported on association of postprandial lipids and endothelial dysfunction among patients with diabetes. Whether endothelial dysfunction particularly postprandial FMD is worse in patients with T2DM with macrovascular disease compared to those without and whether this difference is related to postprandial hypertriglyceridemia (PPHTg) is unclear. Therefore, present study was aimed to assess the relationship between PPHTg and endothelial function in patients with T2DM with and without macrovascular disease.

METHOD

Endothelial dysfunction by FMD and CIMT were compared in patients with T2DM with and without macrovascular disease (n = 13 each group) and 13 age, sex and BMI matched healthy individuals after an oral fat challenge.

RESULTS

There was significant postprandial deterioration of FMD 4-hr after fat challenge in patients with diabetes (P < 0.001) as well as healthy individuals (P = 0.004). Patients with diabetes with macrovascular disease had significantly lower fasting (5.7 ± 6.1% vs. 22.7 ± 10.0% and vs. 24.7 ± 5.3%) as well as postprandial (4-hr) (3.1 ± 5.0% vs. 15.3 ± 8.1% and vs. 15.4 ± 5.7%) FMD compared to other two groups. Fasting, postprandial as well as change in FMD and CIMT in patients with diabetes correlated significantly with fasting as well as postprandial triglycerides with stronger correlation in those with macrovascular disease.

CONCLUSION

Study found significant endothelial dysfunction by FMD that shows substantial further deterioration postprandially following high fat meal in patients with diabetes with macrovascular disease compared to patients with diabetes without macrovascular disease and healthy individuals. Study also indicates that PPHTg is a contributor to endothelial dysfunction. However, more studies are required to corroborate these findings.

Spontaneous coronary artery dissection in old patients: clinical features, angiographic findings, management and outcome

AIMS

Spontaneous coronary artery dissection (SCAD) is a relatively rare but well-known cause of acute coronary syndrome. Clinical features, angiographic findings, management and outcomes of SCAD in old patients (>65 years of age) remain unknown.

METHODS AND RESULTS

The Spanish multicentre prospective SCAD registry (NCT03607981), included 318 consecutive patients with SCAD. Data were collected between June 2015 and April 2019. All angiograms were analysed in a centralized corelab. For the purposes of this study, patients were classified according to age in two groups <65 and ≥65 years old and in-hospital outcomes were analysed. Fifty-five patients (17%) were ≥65 years old (95% women). Older patients had more often hypertension (76% vs. 29%, P < 0.01) and dyslipidaemia (56% vs. 30%, P < 0.01), and less previous (4% vs. 18%, P < 0.001) or current smoking habit (4% vs. 33%, P < 0.001). An identifiable trigger was less often present in old patients (27% vs. 43%, P = 0.028). They also had more often severe coronary tortuosity (36% vs. 11%, P = 0.036) and showed more frequently coronary ectasia (24% vs. 9%, P < 0.01). Older patients were more often managed conservatively (89% vs. 75%, P = 0.025), with no significant differences in major adverse cardiac events during index admission (7% vs. 8%, P = 0.858). There were no differences between groups in terms of in-hospital stay, new acute myocardial infarction, unplanned coronary angiography or heart failure.

CONCLUSION

Older patients with SCAD show different clinical and angiographic characteristics compared with younger patients. Initial treatment strategy was different between groups, though in-hospital outcomes do not significantly differ (NCT03607981).

Associations of Serum Uric Acid Levels With Macrovascular and Renal Microvascular Dysfunction Among Individuals From Sub-Saharan Africa

IMPORTANCE

Serum uric acid (SUA) level is associated with vascular dysfunction in Eurasian populations, but little is known about this association in individuals from sub-Saharan Africa, who have a high prevalence of both relatively high SUA levels and vascular dysfunction.

OBJECTIVES

To assess the associations of SUA levels with macrovascular and kidney microvascular dysfunction in individuals of sub-Saharan African ancestry and evaluate potential factors that could mediate these associations.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional analyses of baseline data from the multicenter Research on Obesity and Diabetes Among African Migrants study, conducted from 2012 to 2015, were performed from January to March 2021. The population included Ghanaian individuals living in Ghana and Europe.

EXPOSURE

Abnormal SUA levels.

MAIN OUTCOMES AND MEASURES

Logistic regression was used to examine the associations of SUA level quartiles with microvascular (albuminuria) and macrovascular (peripheral artery disease and coronary artery disease) dysfunction, with adjustments for age, sex, estimated glomerular filtration rate, site of residence, socioeconomic status, alcohol, smoking, diabetes, hypertension, waist-hip ratio, and total cholesterol level. Mediation analysis was performed to assess whether the association was via elevated blood pressure, hemoglobin A1c, and high-sensitivity C-reactive protein levels or via weight-hip ratio. The research questions were formulated after data collection.

RESULTS

A total of 4919 Ghanaian individuals (3047 [61.9%] women) aged 25-75 years (mean [SD], 46.26 [11.08] years) were included. There was a significant positive association between SUA quartiles and albuminuria, but not coronary artery disease or peripheral artery disease, after adjustment for covariates. After full adjustment, individuals in the fourth SUA quartile had higher odds of albuminuria (adjusted odds ratio [aOR], 1.54; 95% CI, 1.07-2.21), but not peripheral artery disease (aOR, 1.35; 95% CI, 0.87-2.08) or coronary artery disease (aOR, 1.09; 95% CI, 0.77-1.55), compared with individuals in the first quartile. After full adjustment, systolic and diastolic blood pressure significantly mediated the association between SUA concentrations and albuminuria, accounting for 19.4% of the total association for systolic and 17.2% for diastolic blood pressure; hemoglobin A1c, high-sensitivity C-reactive protein, and waist-hip ratio did not mediate this association.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study among a sub-Saharan African population, elevated SUA levels were significantly associated with kidney microvascular dysfunction and mediated partly through elevated blood pressure. These findings suggest that individuals from sub-Saharan Africa with elevated SUA levels may benefit from periodic screening for kidney microvascular dysfunction to aid early detection or treatment.

Impact of High Body Mass Index on Vascular and Bleeding Complications After Transcatheter Aortic Valve Implantation

Increased body mass index (BMI) is an established cardiovascular risk factor. The impact of high BMI on vascular and bleeding complications in patients undergoing transcatheter aortic valve implantation (TAVI) is not clarified. RISPEVA, a multicenter prospective database of patients undergoing TAVI stratified by BMI was used for this analysis. Patients were classified as normal or high BMI (obese and overweight) according to the World Health Organization criteria. A comparison of 30-day vascular and bleeding outcomes between groups was performed using propensity scores methods. A total of 3776 matched subjects for their baseline characteristics were included. Compared with normal BMI, high BMI patients had significantly 30-day greater risk of the composite of vascular or bleeding complications (11.1% vs 8.8%, OR: 1.28, 95% CI [1.02 to 1.61]; p = 0.03). Complications rates were higher in both obese (11.3%) and overweight (10.5%), as compared with normal weight patients (8.8%). By a landmark event analysis, the effect of high versus normal BMI on these complications appeared more pronounced within 7 days after the TAVI procedure. A significant linear association between increased BMI and vascular complications was observed at this time frame (p = 0.03). In conclusion, compared with normal BMI, both obese and overweight patients undergoing TAVI, experience increased rates of 30-day vascular and bleeding complications. These findings indicate that high BMI is an independent risk predictor of vascular and bleeding complications after TAVI.

Cardiac and vascular disorders as para-occupational diseases - a Polish perspective

INTRODUCTION

The study presents the difference between occupational and para-occupational diseases in terms of Polish law, and indicates the fact that cardiovascular diseases (CVDs) are considered to be work-related, and describes the latest reports on the prevalence of cardiovascular risk factors in workplaces.

OBJECTIVE

The aim of this study is to present the difference between occupational and para-occupational diseases in terms of Polish law. Also indicated is the fact that cardiovascular diseases (CVDs) are considered to be work-related and the latest reports on the prevalence of cardiovascular risk factors in workplaces are described.

BRIEF DESCRIPTION OF THE STATE OF KNOWLEDGE

Polish law distinguishes two groups of diseases that may arise in connection with work: occupational diseases and work-related diseases (so-called para-occupational diseases). Despite the fact that both groups are connected with the work environment they are not equivalent in legal terms. CVDs are one of the greatest threat to human life. The pathogenesis of these diseases is highly dependent on the compilation of adverse risk factors, which are typically divided into modifiable and non-modifiable. To-date, modifiable factors, i.a. excess weight and high blood pressure, were mainly associated with an unhealthy lifestyle. However, a shift in perspective has taken place and currently researchers focus more on the work environment as a possible factor affecting people's health. It is emphasized that an unhealthy work environment increases the risk of CVD. Research shows that workplaces are rich in risk factors specifically related to work, including psychosocial, physical and chemical factors.

CONCLUSIONS

Legal principles covering para-occupational diseases in Poland seem incomplete. It is suggested that providing detailed legal authorization and defining the bodies that will objectively and reliably engage in the diagnostic process of para-occupational diseases may be beneficial to employees.

Pregnancy-Associated Spontaneous Coronary Artery Dissection: Clinical Characteristics, Outcomes, and Risk During Subsequent Pregnancy

OBJECTIVES

Spontaneous coronary artery dissection (SCAD) is a common cause of pregnancy-associated myocardial infarction.

METHODS

This study compares the clinical course and longitudinal follow-up of 22 cases of pregnancy-associated SCAD (P-SCAD) with 285 cases of non-pregnancy SCAD (NP-SCAD) from Kaiser Permanente Northern California between September 2002 through June 2017.

RESULTS

Age in the P-SCAD group was significantly lower than in the NP-SCAD group (37.1 ± 5.7 years vs 50.9 ± 9.9 years, respectively; P<.001). Both cohorts were racially diverse, but the P-SCAD group had fewer whites (27.3% vs 50.7%; P=.03). The P-SCAD group had higher multigravidity (54.6% vs 31.4%; P=.03) and 68.2% were of advanced maternal age. The rates of ST-elevation myocardial infarction, ventricular tachycardia/fibrillation, and left main coronary dissection were similar. Proximal vessel dissection (31.8% vs 7.7%; P<.01), multiple vessel dissection (31.8% vs 9.5%; P<.01), and reduced ejection fraction at presentation (49.6 ± 10.5% vs 55.7 ± 10.4%; P=.01) were more common in the P-SCAD group vs the NP-SCAD group, respectively. More P-SCAD patients had cardiogenic shock and/or required intra-aortic balloon pump support (9.1% vs 1.1%; P=.04). Medical management was the principal coronary treatment strategy in both groups. P-SCAD patients experienced more major adverse cardiovascular events (50.0% vs 26.0%; P=.02), driven by persistent reduced ejection fraction ≤45% at follow-up (18.2% vs 5.3%; P=.04). Recurrent SCAD (18.2% vs 11.2%; P=.31) and cardiovascular death (0% vs 0.4%; P>.99) were similar in the P-SCAD group vs the NP-SCAD group, respectively. Seven patients had successful subsequent pregnancies without cardiac complications.

CONCLUSION

P-SCAD has a higher-risk presentation, but similar long-term prognosis compared with NP-SCAD. In addition, subsequent pregnancy after SCAD may present acceptable risk.

Spontaneous Coronary Artery Dissection and Menopause

Spontaneous coronary artery dissection (SCAD) is a relatively rare but well-known cause of acute coronary syndrome in women. The role of sexual hormones has been related to the pathophysiology of SCAD. However, clinical features, angiographic findings, management and outcomes of SCAD women in relation to menopause status remain unknown. The Spanish multicenter prospective SCAD registry (NCT03607981), included 318 consecutive patients with SCAD. All coronary angiograms were analyzed in a centralized Corelab. In this substudy, 245 women were classified according to their menopause state (pre-menopausal and post-menopausal). In-hospital outcomes were analyzed: 148 patients (60.4%) were post-menopausal. These patients were older (57 [52 to 66] vs 49 [44 to 54] years, p <0.01) and had more often hypertension (49% vs 27%, p <0.01) and dyslipidemia (46% vs 25%, p <0.01). Post-menopausal women showed more often previous history of acute coronary syndrome, including previous SCAD (9% vs 3%, p = 0.046), and presented less frequently as ST-segment elevation myocardial infarction on admission, compared with premenopausal women (34% vs 49%, p = 0.014). On the other hand, premenopausal women showed more often proximal and multisegment involvement (24% vs 7%, and 32% vs 18%, respectively, both p <0.01). Post-menopausal women were more often managed conservatively (85% vs 71%, p <0.01) and presented less frequently left ventricular dysfunction (both, p <0.01). There were no differences between groups in terms of in-hospital stay or mortality, new acute myocardial infarction, unplanned coronary angiography or heart failure. In conclusion, post-menopausal women with SCAD show different clinical and angiographic characteristics compared with pre-menopausal SCAD patients. Initial treatment strategy was different between groups, though in-hospital outcomes did not significantly differ (NCT03607981).

High-Sensitivity Cardiac Troponin T and Recurrent Vascular Events After First Ischemic Stroke

Background Recent evidence suggests cardiac troponin levels to be a marker of increased vascular risk. We aimed to assess whether levels of high-sensitivity cardiac troponin T (hs-cTnT) are associated with recurrent vascular events and death in patients with first-ever, mild to moderate ischemic stroke. Methods and Results We used data from the PROSCIS-B (Prospective Cohort With Incident Stroke Berlin) study. We computed Cox proportional hazards regression analyses to assess the association between hs-cTnT levels upon study entry (Roche Elecsys, upper reference limit, 14 ng/L) and the primary outcome (composite of recurrent stroke, myocardial infarction, and all-cause death). A total of 562 patients were analyzed (mean age, 67 years [SD 13]; 38.6% women; median National Institutes of Health Stroke Scale=2; hs-cTnT above upper reference limit, 39.2%). During a mean follow-up of 3 years, the primary outcome occurred in 89 patients (15.8%), including 40 (7.1%) recurrent strokes, 4 (0.7%) myocardial infarctions, and 51 (9.1%) events of all-cause death. The primary outcome occurred more often in patients with hs-cTnT above the upper reference limit (27.3% versus 10.2%; adjusted hazard ratio, 2.0; 95% CI, 1.3-3.3), with a dose-response relationship when the highest and lowest hs-cTnT quartiles were compared (15.2 versus 1.8 events per 100 person-years; adjusted hazard ratio, 4.8; 95% CI, 1.9-11.8). This association remained consistent in sensitivity analyses, which included age matching and stratification for sex. Conclusions Hs-cTnT is dose-dependently associated with an increased risk of recurrent vascular events and death within 3 years after first-ever, mild to moderate ischemic stroke. These findings support further studies of the utility of hs-cTnT for individualized risk stratification after stroke. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01363856.

NHLBI-CMREF Workshop Report on Pulmonary Vascular Disease Classification: JACC State-of-the-Art Review

The National Heart, Lung, and Blood Institute and the Cardiovascular Medical Research and Education Fund held a workshop on the application of pulmonary vascular disease omics data to the understanding, prevention, and treatment of pulmonary vascular disease. Experts in pulmonary vascular disease, omics, and data analytics met to identify knowledge gaps and formulate ideas for future research priorities in pulmonary vascular disease in line with National Heart, Lung, and Blood Institute Strategic Vision goals. The group identified opportunities to develop analytic approaches to multiomic datasets, to identify molecular pathways in pulmonary vascular disease pathobiology, and to link novel phenotypes to meaningful clinical outcomes. The committee suggested support for interdisciplinary research teams to develop and validate analytic methods, a national effort to coordinate biosamples and data, a consortium of preclinical investigators to expedite target evaluation and drug development, longitudinal assessment of molecular biomarkers in clinical trials, and a task force to develop a master clinical trials protocol for pulmonary vascular disease.

Standardized Measurement of Femoral Artery Depth by Computed Tomography to Predict Vascular Complications After Transcatheter Aortic Valve Implantation

Vascular complications (VCs) are difficult to predict and remain an important issue after transfemoral (TF) transcatheter aortic valve implantation (TAVI) although their incidence has decreased with size reduction of introducers. We aimed to evaluate a standardized measurement of femoral artery depth (FAD) using computed tomography (CT) to predict VCs after TAVI. We performed a retrospective study of 679 TF TAVI patients. We evaluated a standardized CT method to measure FAD immediately above the bifurcation. Sheath-to-femoral-artery ratio (SFAR), calcification, and tortuosity were also evaluated. VCs were defined by the Valve Academic Research Consortium (VARC)-2. Receiver operating characteristic (ROC) curves were used to predict major VCs and the need for a stent-graft. The median values of FAD and SFAR were 49.0 (36.2 to 66.7) mm and 0.95 (0.81 to 1.18), respectively. Major VCs occurred in 37 (5.4%) patients and a stent-graft was required in 49 (7.1%) patients. FAD predicted the need for a stent-graft [0.61 (0.51 to 0.70), p = 0.04] but not major VCs [0.52 (0.40 to 0.63), p = 0.76]. In contrast, SFAR did not predict the need for a stent-graft [0.53 (0.43 to 0.62), p = 0.61] but predicted major VCs [0.70 (0.58 to 0.81), p = 0.001]. Calcification and tortuosity predicted neither major VCs nor the need for a stent-graft. In conclusion, the results of our study suggest that CT measurements of FAD and SFAR provide additional information to predict major VCs and the need for a femoral stent-graft after TF TAVI.

Ultrasound arterial anomalies in patients exposed to nilotinib therapy for chronic myeloid leukemia

INTRODUCTION

Patients exposed to nilotinib for chronic myeloid leukemia (CML) appear to be at risk of arterial complication. The prevalence and aspect of ultrasound asymptomatic arterial lesions are unknown.

OBJECTIVE

To describe prevalence and characteristics of ultrasound arterial anomalies in patients treated with nilotinib for CML.

METHODS

Patients treated with nilotinib from 2006 to 2015 in the department of the Paoli-Calmettes Institute, Marseille, were included retrospectively. A vascular ultrasound screening was carried out from 2010. The arterial lesions at the first examination were described: plaque and its echogenicity, stenosis or occlusion. A vascular arterial anomaly (VAA) was defined by the presence of a clinical and/or ultrasound anomaly. Patients with or without VAA at initial vascular examination were compared using bivariate and multivariate analysis.

RESULTS

74 patients were included (51.4% men, mean age 54.5 years); 25 patients had ultrasound arterial anomalies (33.8%). Carotid bulb was the most involved territory (44%). Arterial anomalies were: 88% plaques, 44%>50% stenosis and 12% occlusion. 72.7% plaques were echolucent or hypoechogenic. A VAA was present in 25 patients with initial vascular evaluation (33.8%). Patients with VAA at baseline were significantly older (64.9 vs 49.3, P<0.001), older at nilotinib initiation (60.8 vs 46.5, P<0.001), with more arterial hypertension (40% vs 12.2%, P=0.01), with more cardiovascular risk factors (P=0.03). In patient with no cardiovascular risk factor 12.5% had VAA (n=24).

CONCLUSION

Nilotinib seems to be associated to arterial lesions of unstable lipid-like appearance. The most involved arterial territory was the carotid bulb and the most common lesion was echolucent or hypoechogenic plaque. VAA can occur in patients without cardiovascular risk factors. This result encourages us to systematically screen and follow all patients exposed to nilotinib even those without cardiovascular risk factors.

Urine Albumin/Creatinine Ratio and Microvascular Disease in Elderly Hypertensive Patients without Comorbidities

OBJECTIVES

A high urine albumin/creatinine ratio (UACR) is associated with microvascular disease in hypertensive patients. However, hypertensive patients frequently have other comorbidities. Thus, it is difficult to distinguish the role of UACR from that of comorbidities in microvascular disease. The aim of this study was to evaluate the association between UACR and microvascular disease in elderly hypertension patients without comorbidities.

METHODS

A cross-sectional cohort study of 2252 essential hypertension patients aged 65-94 years without comorbidities between January 1, 2016, and December 31, 2017, was conducted. Microvascular disease was evaluated by hypertension retinopathy (HR). Multivariable adjusted odds of HR by UACR quartiles were determined using logistic regression.

RESULTS

The HR prevalence was 22.1% (n = 472) among the cohort study and was significantly different among UACR quartiles (19.7%, 20.3%, 22.0%, and 26.4% in quartiles 1, 2, 3, and 4, respectively, P = 0.036). After adjustment for covariates, higher UACR (odds ratio (OR) = 1.42, 95% confidence interval (CI) 1.05-1.92, quartile 4 versus 1) were significantly associated with HR. Among male patients, higher UACR (OR = 1.65, 95% CI 1.07-2.55, quartile 4 versus 1) were significantly associated with HR after adjustment for covariates. Among female patients, however, 64% and 40% increased odds of HR were noted in the highest and lowest UACR (quartiles 4 and 1, respectively) compared to UACR quartile 2.

CONCLUSIONS

Microvascular disease was associated with higher UACR in elderly male essential hypertension patients without comorbidities but was associated with lower and higher UACR in female patients without comorbidities.

Childhood Exposure to Low to Moderate Doses of Ionizing Radiation and the Risk of Vascular Diseases

In the Tinea Capitis Study (Israel, 1966-2011), we assessed the association between childhood exposure to low to moderate doses of ionizing radiation (IR) to the head and neck and the development of vascular diseases (ischemic heart disease, carotid artery stenosis, and stroke) in adulthood. The study included 17,734 individuals from the Tinea Capitis cohort (7,408 irradiated in childhood and 10,326 nonirradiated), insured by Israel's largest health provider. Individual dosimetry was estimated based on measurements made on a head phantom and original treatment records. The mean doses were 1.5, 0.09, 0.78, and 0.017 Gy to brain, thyroid, salivary gland, and breast, respectively. Data on vascular diseases was abstracted from computerized medical records. Using Poisson regressions, we examined the association of radiation with morbidity. Any vascular disease was reported for 2,221 individuals. Adjusted for age, sex, socioeconomic status, smoking, hypertension, and diabetes, exposure to IR increased the risk of developing any vascular diseases (relative risk (RR) = 1.19, 95% confidence interval (CI): 1.09, 1.29), stroke (RR = 1.35, 1.20, 1.53), carotid artery stenosis (RR = 1.32, 1.06, 1.64), and ischemic heart disease (RR = 1.12, 1.01, 1.26). The risk of developing vascular diseases was positively associated with dose and inversely associated with age at exposure. In conclusion, the results indicate that early exposure to low to moderate doses of IR increases the risk of cerebro- and cardiovascular impairments.

Lessons Learned from the Impact of the COVID-19 Pandemic in a Vascular Surgery Department and Preparation for Future Outbreaks

Objectives

This study aims to report the changes and adaptations of a vascular tertiary center during a global pandemic and the impact on its activity and patients.

Methods

We conducted a retrospective cohort study within the Vascular Surgery ward in Centro Hospitalar Universitário Lisboa Norte, Portugal. All data from surgical, inpatient and outpatient activity were collected from February to June 2020 and compared to the same 5-month period in 2018 and 2019. We ran a descriptive analysis of all data and performed statistical tests for the variation of procedures and admissions between February and June 2018 and the same time period in 2020.

Results

During the outbreak, our staff had to be readapted. Six nurses were transferred to COVID-19 units (out of a total of 33 nurses) while 1 of the 7 residents was transferred to an intensive care unit and 1 senior surgeon was put on prophylactic leave. In the outpatient clinic, there was an increase in the number of telemedicine consultations with a greater focus on first-time referrals and urgent cases. There was a significant increase in the total number of elective admissions whereas there were significantly less admissions from an emergency setting (+57% and −54%, respectively, P < 0.001). The vascular surgery team performed a total number of 584 procedures between February and June 2020 (−17.8% compared to 2018 and 2019), with a significant increase in the number of endovascular procedures (P < 0.001) and in the use of local and regional anesthesia (P < 0.001), especially in the Angio Suite (+600%, P < 0.001). Comparing with 2018 and 2019, the surgical team performed less outpatient procedures in early 2020. We reported a significant increase in the total number of procedures for patients with a chronic limb-threatening ischemia (CLTI) diagnosis (+21%, P < 0.001). We did not report significant changes in the proportion of other vascular conditions. Regarding mortality, we observed a 16% decrease in the intraoperative mortality (P 0.67).

Conclusions

In this study, we assessed the impact of the COVID-19 outbreak in daily activity during the contingency period. During the outbreak, there was an overall decline in outpatient clinics and inpatient admissions. Nevertheless, and despite the restrictions imposed by the pandemic and health authorities, we managed to maintain most procedures for most vascular diseases, particularly for CLTI urgent cases, without a significant increase in the mortality rate. Stringent protective measures for patient and staff or higher use of endovascular techniques and local anesthesia are some of the successful changes implemented in the department. These learned lessons are to be pursued as the pandemic evolves with future outbreaks of COVID-19, such as the current second outbreak currently spreading through Europe.

Factors associated with vascular and neurological complications of hand-arm vibration syndrome among tire shop workers in Kelantan, Malaysia

OBJECTIVE

Prolonged exposure to hand-arm vibration (HAV) at the workplace is associated with hand-arm vascular syndrome (HAVS). This study aimed to determine the prevalence and the factors associated with the vascular and neurological complications of HAVS among tire shop workers in Kelantan, Malaysia.

METHODS

A cross-sectional study involving 200 tire shop workers from two districts in Kelantan was conducted. Data were collected at the field using Malay Translated HAVS questionnaire, and hand-arm vibration was measured. Multiple logistic regression analysis was used to determine the associated factors.

RESULTS

The prevalence of vascular and neurological complications of HAVS among the tire shop workers was 12.5% (95% CI: 10.16, 14.84) and 37.0% (95% CI: 30.31, 43.69), respectively. From multiple logistic regression analysis, only A(8) of HAV exposure was significantly associated with the development of vascular complications and A(8) of HAV exposure, age. and body mass index were significantly associated with the development of neurological complications of HAVS.

CONCLUSION

This study has identified that HAVS is a significant problem among workers exposed to HAV in a warm environment. A(8) of HAV exposure is significantly associated with the development of both vascular and neurological complications. Therefore, there is a need for better control of vibration exposure in Malaysia.

Prevalence and clinical outcomes of triglyceride deposit cardiomyovasculopathy among haemodialysis patients

OBJECTIVE

To evaluate the effect of triglyceride deposit cardiomyovasculopathy (TGCV) on the cardiovascular outcomes in haemodialysis (HD) patients with suspected coronary artery disease (CAD).

METHODS

This retrospective single-centre observational study included data from the cardiac catheter database of Narita Memorial Hospital between April 2011 and March 2017. Among 654 consecutive patients on HD, the data for 83 patients with suspected CAD who underwent both [123I]-β-methyl-iodophenyl-pentadecanoic acid scintigraphy and coronary angiography were analysed. Patients were divided into three groups: definite TGCV (17 patients), probable TGCV (22 patients) and non-TGCV control group (44 patients). The primary endpoint was a composite of cardiovascular death, non-fatal myocardial infarction and non-fatal stroke assessed for up to 5 years of follow-up.

RESULTS

The prevalence of definite TGCV was approximately 20% and 2.6% among consecutive HD patients with suspected CAD and among all HD patients, respectively. At the end of the median follow-up period of 4.7 years, the primary endpoint was achieved in 52.9% of the definite TGCV patients (HR, 7.45; 95% CI: 2.28 to 24.3; p<0.001) and 27.3% of the probable TGCV patients (HR, 3.28; 95% CI: 0.93 to 11.6; p=0.066), compared with that in 9.1% of the non-TGCV control patients. Definite TGCV was significantly and independently associated with cardiovascular mortality and outcomes among HD patients in all multivariate models.

CONCLUSIONS

TGCV is not uncommon in HD patients and is associated with an increased risk of cardiovascular events including cardiovascular death. Thus, TGCV might be a potential therapeutic target.

Aortic intima-media thickness in neonates exposed to early-onset preeclampsia

Aortic intima-media thickness (aIMT) and its ratio to aortic diameter (aIMT/AoD) were measured on the second and fifth postnatal day in 39 neonates exposed to early-onset preeclampsia and 39 controls. Both aIMT and aIMT/AoD were higher in neonates exposed to preeclampsia (P < 0.001 for all comparisons).

Interactive associations of sex and hyperlipidemia with calcific tendinitis of the shoulder in Taiwanese adults

Calcific tendinitis (CT) of the shoulder is a painful disorder usually identified in individuals aged 40 and 60 years. The estimated global prevalence of CT is 2.7% to 36%. We examined the association of hyperlipidemia and sex with CT of the shoulder using Taiwan Biobank (TWB) and the National Health Insurance Research Database (NHIRD).Data were available for 9903 TWB participants who were recruited between 2008 and 2015. We used multiple logistic regression analysis to estimate the odds ratios (OR) and 95% confidence intervals (CI) for CT of the shoulder.Overall, 1564 women, and 1491 men were identified with hyperlipidemia. Women, compared to men, had higher odds of CT of the shoulder (OR, 1.53; 95% CI, 1.08-2.16). Hyperlipidemia, compared to no hyperlipidemia, was associated with an increased risk of CT (OR, 1.40; 95% CI, 1.02-1.93). The test for interaction was significant for sex and hyperlipidemia (P = .006). After stratification, the odds ratio for CT was 1.95 (95% CI, 1.30-2.92) in women and 0.82 (95% CI, 0.48-1.39) in men, respectively. Compared to men with no hyperlipidemia, the odds ratio was 0.86 (95% CI, 0.53-1.38) for men with hyperlipidemia and 2.00 (95% CI, 1.29-3.10) for women with hyperlipidemia.Importantly, our findings indicated that the risk for CT of the shoulder was higher among Taiwanese women with hyperlipidemia. However, CT risk among their male counterparts with hyperlipidemia was not significant.