Epilepsy and Heart Disease.

Reply from authors: Left main disease and multivessel coronary artery disease should not be thought as two separate manifestations of ischemic heart disease

52 Percutaneous coronary intervention vs. coronary artery bypass graft surgery in left main coronary artery disease – clinical outcomes in the mid-west region

Introduction: The American Heart Association (AHA) promotes ideal cardiovascular health (CVH) to reduce the risk of heart disease and stroke by achieving seven metrics (normal weight, not smoking, ≥5 fruits and vegetables daily, physical activity ≥150 minutes per week, no diabetes, no high blood pressure, and no high cholesterol). Overall, about 5% of the adult population report ideal CVH. Characterizing CVH among women of reproductive age (WRA; 18-44 years of age) offers opportunities to promote overall cardiovascular and preventive health along the life course. Methods: Data from the 2019 Behavioral Risk Factor Surveillance System was used to estimate define CVH categories (poor, intermediate, ideal) among 38,012 WRA from 49 states (New Jersey didn’t meet standards for weighting), District of Columbia, Guam, and Puerto Rico. Per commonly used standards, having > 6 metrics defined ideal CVH, 3-5 metrics defined intermediate, and 0-2 metrics defined poor CVH. A generalized logit model was used to estimate the associations between race/ethnicity and education with CVH (poor vs intermediate CVH, and ideal vs. intermediate CVH), accounting for age and insurance status. Results: Overall, 8.6% (95%CI:8.2-9.1%) of WRA reported poor CVH, 85.4% (95%CI: 84.8-86.1) reported intermediate CVH, and 6.0% (95%CI:5.5-6.5) reported ideal CVH. Non-Hispanic Black (NHB) WRA had higher odds of reporting poor vs. intermediate CVH (AOR=1.34; 95%CI:1.14-1.58) and lower odds of reporting ideal vs. intermediate CVH (AOR=0.47; 95%CI:0.33-0.68) compared to non-Hispanic White WRA. College graduates also had lower odd of reporting poor vs. intermediate CVH (AOR=0.21; 95%CI:0.17-0.27) and higher odds of reporting ideal vs. intermediate CVH (AOR=2.59; 95%CI:1.52-4.43) compared to those with less than a high school education. Conclusion: Most WRA have intermediate CVH, nearly 1 in 10 have poor CVH, and only about 1 in 16 have ideal CVH. The CVH metric used in this study provides evidence of the disproportionate burden of poor CVH among NHB WRA and women with less than a college degree. Understanding the barriers to ideal CVH for WRA, particularly social and structural determinants, may improve cardiovascular health and reduce disparities across the life course.

BackgroundObstructive left main disease (LMD) is a challenging entity of coronary artery disease with variable patterns among different studies. We aimed to evaluate the prevalence, demographic, clinical, and angiographic profiles of LMD. We conducted a single-center retrospective study over a period of 10 years to screen all patients who underwent elective cardiac catheterization for chronic coronary syndrome. Of the 19,336 screened cases, 944 obstructive LMD patients were included as the patients' group. Age and sex-matched control groups included patients with normal coronary angiography and non-LMD.ResultsObstructive LMD had a prevalence of 4.9%, a mean age of around 60 years, and a male to female ratio of approximately 3:1. About 9.8% of LMD patients were < 50 years. Compared to males, females with LMD had significantly older age and increasing prevalence with age from 9.7% in patients < 50 years to 27.4% in patients > 70 years. LMD versus non-LMD patients had a significantly higher prevalence of diabetes mellitus, dyslipidemia, and number of stenotic coronary segments and arteries, and nonsignificant differences regarding smoking, hypertension, previous myocardial infarction, and ejection fraction. Ostial LMD had a prevalence of 2%, a mean age of around 58 years and 21% were females. In LMD patients, the most affected sites were the ostial/proximal left anterior descending artery and distal left main bifurcation. Bypass grafting surgery was the standard angiographic decision in LMD in 75.8% of cases, which was significantly higher than non-LMD. LMD patients revascularized surgically versus percutaneous treatment had significantly lower ejection fraction, significantly higher multivessel disease, and no significant differences regarding age, sex, hypertension, and diabetes mellitus.ConclusionObstructive LMD is a relatively common angiographic finding, with a higher prevalence among males around 60 years. In LMD, bypass grafting was the main revascularization strategy. We recommend integrating clinical characteristics, and noninvasive investigations as a predictive model of LMD.

Presence of Carotid and Peripheral Arterial Disease in Patients With Left Main Disease

The healthy worker effect (HWE) is a bias that is believed to have strongly affected the validity of previous cohort mortality studies on the relationship between firefighting and heart disease. There is a strong healthy hired effect (a component of the HWE) among firefighters, owing particularly to the recruitment of nondiabetic candidates. This is shown in previous studies in which the reported standardized mortality ratios for diabetes are much less than unity, generally around 0.3 to 0.5. Because diabetes is known to increase the risk of heart disease, a deficit of diabetes among firefighters is expected to lead to a deficit of heart injury and disease. This would make the cohort mortality studies incapable of detecting any increase in risk of heart injury and disease among firefighters. There is also a strong healthy worker survivor effect (another component of the HWE) among firefighters. In addition, heart disease is a classic example of the HWE because heart disease is chronic and its risk factors can be identified in the selection process. It is believed that (1) a major problem of previous studies on firefighting and heart disease is their failure to recognize the importance of the HWE when interpreting their results, and (2) a technique to re-assess results in light of the HWE is urgently needed. This article addresses the generally accepted principles relating to the HWE, including its definition and sources, and proposes a technique for re-assessing the literature in light of the HWE. The technique was applied to carefully re-assess 23 studies that provided direct evidence for the relationship between firefighting and heart disease. Before the re-assessment, 7 of the 23 studies showed positive evidence and 16 showed no evidence. After the re-assessment, 11 studies showed positive evidence and 12 showed no evidence. Based on the results of the re-assessment of the 23 studies, we concluded that (1) there is strong evidence of an increased risk of death overall from heart disease among firefighters; (2) there is insufficient evidence, even after considering the HWE, that there is an increased risk of death from aortic aneurysm among firefighters; and (3) there is insufficient evidence, even after considering the HWE, for a relationship between firefighting and any heart disease subtype, such as acute myocardial infarction.

Background: Cardiovascular disease (CVD) is the leading cause of death in the US and primary risk factors for CVD are well known. Promoting the ideal state of cardiovascular (CV) health factors and behaviors has been previously defined as CV health. The objective of this study is to assess CV health among US adults in urban areas. Methods: Data from the Behavior Risk Factor Surveillance System (BRFSS) 2011 were used for analysis and included 307,101 participants from 198 metropolitan and micropolitan statistical areas (MMSA) with an adequate sample size for estimates (range: 493 to 9,241 participants). Seven indicators were used to define ideal levels of CV health using self-reported data: no hypertension, no diabetes, no high cholesterol, no current smoking, no obesity, and meeting physical activity guidelines and fruit and vegetable consumption targets. Each metric was given a score (0=no, 1=yes) and summed. The percentage achieving ideal CV health (all 7 metrics at ideal level), good CV health (6-7 metrics at ideal levels), poor CV health (0-2 metrics at ideal levels), and the mean CV health score were calculated for each MMSA. Estimates and 95% confidence intervals were age-standardized. Results: Overall, 16.7% (16.4-17.1) and 11.5% (11.2-11.8) of participants among the 198 MMSAs had good and poor CV health, respectively. Few respondents in MMSAs met all ideal CV health standards (&lt;1%), likely driven by the limited number of participants meeting fruit and vegetable consumption targets (5.7%) in this sample. The overall mean CV health score was 3.91 (3.90-3.92). The percentage of participants with good CV health varied from 3.0% (1.5-5.8) (Mobile, AL) to 23.8% (17.0-32.3) (Kalispell, MT). The percentage of participants with poor CV health varied from 6.1% (4.2-8.6) (Boulder, CO) to 26.5% (18.2-36.8) (Kingsport-Bristol-Bristol, TN-VA). The mean CV health score ranged from 3.44 (3.2-3.7) (Kingsport-Bristol-Bristol, TN-VA) to 4.7 (4.5-4.9) (Boulder, CO). Conclusions: Across select US MMSAs, few adults met ideal CV health standards, and only 16% had good CV health. CV health varied significantly across MMSAs. Reducing the burden and mitigating the deleterious effects of CVD can be achieved through the promotion of CV health. Local clinical and public health agencies have the unique opportunity to tailor evidenced-based interventions to promote CV health in their populations. The methodology and findings used in this study can be utilized by local jurisdictions to target lagging health indicators with focused interventions.

Task Force structure and summary of clinical evidence of 2022 ESC/EACTS review of the 2018 guideline recommendations on the revascularization of left main coronary artery disease. CABG, coronary artery bypass grafting; PCI, percutaneous coronary intervention; LM, left main; SYNTAX, Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery. a'Event' refers to the composite of death, myocardial infarction (according to Universal Definition of Myocardial Infarction if available, otherwise protocol defined) or stroke. In October 2021, the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) jointly agreed to establish a Task Force (TF) to review recommendations of the 2018 ESC/EACTS Guidelines on myocardial revascularization as they apply to patients with left main (LM) disease with low-to-intermediate SYNTAX score (0-32). This followed the withdrawal of support by the EACTS in 2019 for the recommendations about the management of LM disease of the previous guideline. The TF was asked to review all new relevant data since the 2018 guidelines including updated aggregated data from the four randomized trials comparing percutaneous coronary intervention (PCI) with drug-eluting stents vs. coronary artery bypass grafting (CABG) in patients with LM disease. This document represents a summary of the work of the TF; suggested updated recommendations for the choice of revascularization modality in patients undergoing myocardial revascularization for LM disease are included. In stable patients with an indication for revascularization for LM disease, with coronary anatomy suitable for both procedures and a low predicted surgical mortality, the TF concludes that both treatment options are clinically reasonable based on patient preference, available expertise, and local operator volumes. The suggested recommendations for revascularization with CABG are Class I, Level of Evidence A. The recommendations for PCI are Class IIa, Level of Evidence A. The TF recognized several important gaps in knowledge related to revascularization in patients with LM disease and recognizes that aggregated data from the four randomized trials were still only large enough to exclude large differences in mortality.

Current guideline statements for primary and secondary prevention of cardiovascular disease (CVD) rely on estimates of absolute risk of coronary events. For example, the American Heart Association guidelines on primary prevention state that persons with ≥10% risk over 10 years of myocardial infarction (MI) or coronary death should be considered for antiplatelet therapy with aspirin.1 Similarly, the National Cholesterol Education Program Adult Treatment Panel III (ATP III) guidelines2 state that target low-density lipoprotein level should be based on projected absolute risk of future coronary events rather than on presence or absence of specific risk factors. These guidelines state that patients at high risk of MI and coronary death, defined as an absolute 10-year risk of ≥20%, should have a target low-density lipoprotein level <100 mg/dL and should receive statin therapy if needed to achieve this goal. Stroke, however, is not included as one of the outcomes contributing to these absolute risk levels. Included in the group of patients with elevated risk, moreover, are those who already have ischemic heart disease, as well as patients deemed to be “coronary heart disease (CHD) risk equivalents,” indicating those at the same elevated risk as patients with ischemic heart disease. CHD risk equivalents include patients with diabetes mellitus, those with multiple risk factors that put them at elevated risk based on calculation of their Framingham Score, and patients with “other forms of symptomatic atherosclerotic disease.” The latter group is further defined to include those with peripheral arterial disease (PAD), abdominal aortic aneurysm (AAA), and carotid artery disease. The category of “risk equivalents” in the ATP III guidelines, however, does not include the vast majority (≈80%3) of ischemic stroke patients without carotid artery disease as cause of their stroke. Ischemic stroke is therefore notably excluded from the list of outcomes contributing to …

Physical Activity Intensity Measurement and Association With Adolescent Health: Chartering New Frontiers

Background: Understanding the interactions between age and comorbidities is crucial for assessing COVID-19 mortality, particularly in patients with cardiac and pulmonary conditions. This study investigates the relationship between comorbidities and mortality outcomes in a cohort of hospitalized COVID-19 patients, emphasizing the interplay of age, cardiac, and pulmonary conditions. Methods: We analyzed a cohort of 3005 patients hospitalized with COVID-19 between 2020 and 2022. Key variables included age, comorbidities (diabetes, cardiac, pulmonary, and neoplasms), and clinical outcomes. Chi-square tests and logistic regression models were used to assess the association between comorbidities and mortality. Stratified analyses by age, diabetes, and pulmonary conditions were conducted to explore interaction effects. Additionally, interaction terms were included in multivariable logistic regression models to evaluate the combined impact of age, comorbidities, and mortality. Results: Cardiac conditions such as hypertension, ischemic cardiopathy, and myocardial infarction showed significant protective effects against mortality in younger patients and in those without pulmonary conditions (p < 0.001). However, these protective effects were diminished in older patients and those with pulmonary comorbidities. Age was found to be a significant modifier of the relationship between cardiac conditions and mortality, with a stronger protective effect observed in patients under the median age (p < 0.001). Pulmonary comorbidities significantly increased the risk of mortality, particularly when co-occurring with cardiac conditions (p < 0.001). Diabetes did not significantly modify the relationship between cardiac conditions and mortality. Conclusions: The findings highlight the complex interactions between age, cardiac conditions, and pulmonary conditions in predicting COVID-19 mortality. Younger patients with cardiac comorbidities show a protective effect against mortality, while pulmonary conditions increase mortality risk, especially in older patients. These insights suggest that individualized risk assessments incorporating age and comorbidities are essential for managing COVID-19 outcomes.

Objectives: Certain heart conditions and diseases are common in Down syndrome (DS; trisomy 21), but their role in early onset dementia that is prevalent in older adults with DS has not been evaluated. To address this knowledge gap, we conducted a study of risk factors for low neurocognitive/behavioral scores obtained with a published dementia test battery (DTB). Participants were adults with DS living in New York (N = 29; average age 46 years). We asked three questions. 1. Does having any type of heart disease affect the association between DTB scores and chronological age? 2. Does thyroid status affect the association between heart disease and DTB scores? 3. Are the E4 or E2 alleles of apolipoprotein E (APOE) associated with DTB scores or with heart disease?Method: The study was retrospective, pilot, and exploratory. It involved analysis of information in a database previously established for the study of aging in DS. Participants had moderate intellectual disability on average. Information for each person included: gender, age, a single DTB score obtained by combining results from individual subscales of the DTB, the presence or absence of heart disease, thyroid status (treated hypothyroidism or normal), and APOE genotype. Trends were visualized by inspection of graphs and contingency tables. Statistical methods used to evaluate associations included Pearson correlation analysis, Fisher’s exact tests (2-tailed), and odds ratio analysis. P values were interpreted at the 95% confidence level without Bonferroni correction. P values >.05<.1 were considered trends.Results: The negative correlation between DTB scores and age was significant in those with heart disease but not in those without. Heart disease was significantly associated with DTB scores >1 SD below the sample mean; there was a strong association between heart disease and low DTB scores in those with treated hypothyroidism but not in those with normal thyroid status. The APOE genotype was weakly associated with heart disease (E4, predisposing; E2, protective) in males.Conclusions: On the basis of the potentially important findings from the present study, large prospective studies are warranted to confirm and extend the observations. In these, particular heart conditions or diseases and other medical comorbidities in individuals should be documented.

Basic science: Pathophysiology: the CardioRenal Metabolic Syndrome

Outcome After Surgery and Percutaneous Intervention for Cardiogenic Shock and Left Main Disease

The EXCEL trial (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) demonstrated in patients with left main coronary artery disease, no significant difference between coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) with everolimus-eluting stents for the composite end point of death, stroke, or myocardial infarction at 5 years. However, all-cause mortality at 5 years was higher with PCI. Long-term cost-effectiveness of these 2 strategies has heretofore not been evaluated. From 2010 to 2014, 1905 patients with left main coronary artery disease were randomized to CABG (n=957) or PCI (n=948). Costs ($2019) were assessed over 5 years using resource-based costing and Medicare reimbursement rates. Health utilities were assessed using the EuroQOL 5-dimension questionnaire. Five-year EXCEL data in combination with US lifetables were used to develop a Markov model to evaluate lifetime cost-effectiveness. An incremental cost-effectiveness ratio <$50 000 per quality-adjusted life year (QALY) gained was considered highly cost-effective. Index revascularization procedure costs were $4,850/patient higher with CABG, and total costs for the index hospitalization were $17 610/patient higher with CABG ($32 297 versus $19 687, P<0.001). Cumulative 5-year costs were $20 449/patient higher with CABG. CABG was projected to increase lifetime costs by $21 551 while increasing quality-adjusted life expectancy by 0.49 QALYs, yielding an incremental cost-effectiveness ratio of $44 235/QALY. In a post hoc sensitivity analysis using mortality hazard ratios from a meta-analysis of all randomized CABG versus PCI in left main disease trials, the gain associated with CABG was 0.08 to 0.14 QALYs, resulting in an incremental cost-effectiveness ratio of $139 775 to $232 710/QALY gained. Based on data from the EXCEL trial, CABG is an economically attractive revascularization strategy compared with PCI over a lifetime horizon for patients with significant left main coronary artery disease. However, this conclusion is sensitive to the long-term mortality rates with the 2 strategies, and CABG is no longer highly cost-effective when substituting the pooled treatment effect from the 4 major PCI versus CABG trials for left main disease. URL: https://www. gov; Unique identifier: NCT01205776.