Acute Cardiovascular Events Research Articles

Abstract 4138374: Coronary Endothelial Dysfunction Plays Important Roles on Development of Acute Coronary Syndrome and Fatal Cardiovascular Events During Long-Term Follow-up Over 10 Years

Introduction: Although coronary endothelial dysfunction is thought to affect coronary atherothrombogenic processes, there has been little practical evidence for the relationship between clinical evolution of fatal or non-fatal acute coronary syndrome and coronary endothelial dysfunction. Hypothesis: We assessed hypothesis that coronary endothelial dysfunction has clinical impacts on development of acute coronary syndrome and fatal cardiovascular events. Methods: Coronary endothelial dysfunction was practically graded by the flow-mediated endothelium-dependent reactive changes in coronary artery diameter (CFMD) to infusion of adenosine triphosphate (ATP ; 50μg) into the normal left coronary artery using quantitative coronary arteriography in 150 patients with stable coronary artery disease. The enrolled patients were categorized into tertile groups according to the values of CFMD, and we prospectively followed-up major adverse clinical cardiac events including acute coronary syndrome and cardiovascular death. Results: For a mean follow-up period of 132 months (range; 120 to 144) with complete follow-up, the patients in the lower third with severe coronary endothelial dysfunction (Group-L) more frequently developed acute coronary syndrome than those in the middle third with mild coronary endothelial dysfunction (Group-M) plus those in the higher third without coronary endothelial dysfunction (Group-H) [Group-L versus Group-M plus Group-H: 15(30%) versus 5(10%) plus 0(0%), p<0.001, by Kaplan-Meier analysis]. Majority of the patients who resulted in cardiovascular death belonged to Group-L, [6(12%) versus 1(2%) plus 0(0%), p=0.014, by Kaplan-Meier analysis]. Cox hazard proportional model analyses including clinical and angiographical variables indicated that severe coronary endothelial dysfunction was the strong predictor for future acute coronary syndrome (hazard ratio=7.53, 95%confidential interval; 1.78-12.25, p<0.001) and future cardiovascular death (hazard ratio=13.50, 95%confidential interval; 1.55-25.25, p=0.005). Conclusions: This is the novel and longest follow-up investigation that demonstrates coronary endothelial dysfunction plays important roles on development of acute coronary syndrome and fatal cardiovascular events and therefore the strategies based on practical status of coronary endothelial dysfunction are required to prevent major adverse ischemic cardiac events.

ITACARE-P/SIGG/SIGOT/SICGE position paper: referral of elderly cardiac patient from geriatrics to cardiac rehabilitation.

Cardiac rehabilitation (CR) is Class IA indication in patients after an acute cardiovascular (CV) event, with efficacy confirmed even in elderly or frail CV patients CV and geriatric outcomes. However, rate of referral and admission to CR of elderly CV patients remains very low. CV patients admitted in geriatric wards are often complex, multimorbid and frail. Therefore, the present position paper addressees their possible referral to CR, since many have various forms of CV diseases amenable to improve with CR. The multidisciplinary and comprehensive model of CR is applicable to these patients where evaluation and interventions should be tailored to the patient functional and clinical status, aiming to appropriate targets. Cardiologist, Geriatrician and other professionals, should synergistically integrate their competences, thus outlining also the new paradigm of "Cardiogeriatric Rehabilitation and Prevention", possibly leading to an increased awareness of the beneficial effect of CR and to an increased referral to CR from Geriatric departments. Operative recommendations are given, based on appropriateness and priority of indications, clinical risk and frailty level, integrating different expertise to reach more effective programs of care.

Sudden Cardiac Death Risk Prediction Based on Noise Interfered Single-Lead ECG Signals

Sudden cardiac death (SCD) represents a critical acute cardiovascular event characterized by rapid onset of cardiac and respiratory arrest, posing a significant threat to patients due to its high fatality rate. Monitoring indices related to SCD using wearable devices holds profound implications for preemptive measures aimed at reducing the incidence of such life-threatening events. Hence, this study proposed a predictive algorithm for SCD leveraging single-lead electrocardiogram (ECG) signals featuring low signal-to-noise ratios. Initially, simulated electrode motion artifact noise was introduced to ideal ECG signals to emulate the signal conditions with low signal-to-noise ratios encountered in everyday scenarios. To meet the criteria of simplicity and cost-effectiveness required for wearable devices, the analysis focused exclusively on single-lead signals. The proposed algorithm in this study employed a lightweight machine learning approach to extract 12-dimensional features encompassing ventricular late potentials, T-wave electrical alternation, and corrected QT intervals from the signal. The algorithm achieved an average prediction accuracy of 93.22% within 30 min prior to SCD onset, and 95.43% when utilizing a normal sinus rhythm database as a control, demonstrating robust performance. Additionally, a comprehensive Sudden Cardiac Death Index (SCDI) was devised to quantify the risk of SCD, formulated by integrating pivotal two-dimensional features contributing significantly to the algorithm. This index effectively distinguishes high-risk signals indicative of SCD from normal signals, thereby offering valuable supplementary insights in clinical settings.

Long-term cardiovascular outcomes of patients experiencing intra-cranial hemorrhage with or without acute cardiovascular events

Abstract Background Acute cardiovascular (CV) events would happen during the acute stage of ischemic stroke or intra-cranial hemorrhage (ICH), so called "Stroke-Heart Syndrome". However, long-term outcomes of patients who experienced acute CV events during the acute stage of ICH were unclear. In the present study, we aimed to report and compare long-term prognosis of patients with or without acute CV events after ICH. Methods A total of 104,955 patients who experienced ICH and survived longer than 90 days without past history of acute myocardial infarction (AMI), heart failure (HF), atrial fibrillation (AF) and ventricular arrhythmia (VA) were identified from the Taiwan National Health Insurance Research Database. Among them, 1,888 patients experienced CV events (AMI, HF, AF or VA) within 90 days after ICH, while 103,067 did not. Results Compared to patients without acute CV events, patients with acute CV events were older (73.53 vs 62.46 years, p<0.001), less males (57.89% vs 61.83%, p<0.001) and had more comorbidities , such as hypertension (77.17% vs 61.58%), diabetes mellitus (35.81% vs 26.54%), vascular diseases (3.5% vs 2.02%) and chronic obstructive pulmonary disease (15.57% vs 9.88%), all p<0.001. Compared to patients without acute CV events, those experiencing acute CV events had a higher adjusted risk of ischemic stroke (adjusted hazard ratio [aHR] 1.564), recurrent ICH (aHR 1.266), HF (aHR 4.693), AF (aHR 19.116), VA (aHR 3.485), AMI (aHR 2.463), sudden cardiac death (aHR 1.609) and mortality (aHR 1.855)(Figure). Conclusions Acute CV events occurring during acute stage of ICH were not a benign course simply related to acute stress and were associated with a poor long-term outcome. How to improve long-term clinical outcomes of these patients deserves more attentions, efforts and studies involving both cardiologists and neurologists.

Lipid-lowering prescription patterns after a non-fatal acute coronary syndrome

Abstract Introduction After an acute atherosclerotic cardiovascular event, high-intensity lipid-lowering therapy (LLT) is needed to reduce the risk of recurrence. Moreover, despite 2016/2019 ESC/EAS guidance on lipid management according to risk, several studies indicate that most patients do not attain low-density lipoprotein-cholesterol (LDL-C) goals. The present study aims to describe LLT prescription patterns after a non-fatal acute coronary syndrome (ACS) and identify opportunities for improvement in secondary preventive measures, namely LDL-C control. Methods Retrospective cohort study featuring adults aged 40-80 residing in a Portuguese municipality Portugal, using Electronic Health Records between 2016 and 2022. Selected patients had ≥1 general practice appointment three years before the occurrence of an ACS, which was considered an index date. Sub-analysis was made based on patients’ age (under and high or equal to 65 years), gender, and whether their LDL-C levels were controlled according to gradual upper thresholds of 100 mg/dL in the period before the ACS event and 55 mg/dL at one-year post-ACS. Results Among the 544 selected patients, 270 were younger than 65 years. Females comprised 30% (164 patients) of the total cohort, 27% of the under-65 group, and nearly 38% of the 65 and older group. In younger patients, LDL-C levels were higher at presentation (132 mg/dL) and had a significantly greater decrease during the follow-up period compared to the older group. In the period before the ACS, 71.1% of men and 56.7% of women had no previous prescription of LLT, and younger patients had worse levels of LDL-C control (24.1%) compared to older patients (46.0%). One year post-ACS, the pattern of LLT revealed a substantial drop in patients without any LLT prescription from 66.7% to 13.6% and an increase in high-intensity LLT from 2.4% to 16.5%. Still, moderate-intensity LLT (66%) remained the most frequently used LLT. An increase in LLT potency was observed in the follow-up, although there was a decrease in patients achieving LDL-C control. Previous to the ACS event, 35.3% of men and 34.8% of women had initially controlled LDL-C levels according to defined thresholds, which significantly reduced to 11.3% and 8.5%, respectively, at one-year post-ACS. Conclusion Despite initiating or intensifying LLT after ACS, LDL-C goals were not achieved in approximately 9 out of 10 patients at 1-year follow-up, highlighting that the LLT adjustment was insufficient. Therefore, there is a need for better optimisation of LLT after ACS, unveiling an alarming gap in guideline implementation in clinical practice.

RGS5 balances macrophage vs vascular smooth muscle cell origin of foam cells in apoE-deficient plaques

Abstract Background G Protein Coupled Receptors and regulators of G-protein signalling (RGS), play a pivotal role in the signalling processes associated with atherosclerosis [1]. RGS5 is highly expressed in aortic tissue [2]. Development of atherosclerotic plaque is a complex process that involves foam cells originating from macrophages (Mϕ) and/or vascular smooth muscle cells (VSMCs). Differentiation of Mϕ and VSMC into various intermediary cells of varying inflammatory potency affects atherosclerotic plaque composition and vulnerability [3]. We hypothesize that RGS5 is involved in signalling of foam cell transition and thus, plaque biology. Purpose To evaluate the role of RGS5 on atherosclerotic plaque complexity and shifts of foam cell origin. Methods ApoE-/-RGS5+/+ and ApoE-/-RGS5-/- mice were fed a high fat Western Diet for 14 weeks. Cryosections bearing aortic valve cusps were used for staining. Lesion size was quantified on hematoxylin and eosin staining. Plaque composition was assessed by CD68, CD45, Oil red O and collagen staining. Triple staining was performed for CD45, CD68 and aSMA. Double immunofluorescent staining for CD45 and pro- and anti-inflammatory markers was carried out. Co-Localisation was analysed by Zeiss Zen. Data were analysed using Mann-Whitney-U test. Results Lesion size was significantly reduced in RGS5-deficient mice in comparison to control (in mm2: 0.398±0.02 vs 0.191±0.09, p=0.0001, n=15). Relative areas positive for Oil Red O and collagen did not differ between genotypes. Area positive for leukocyte marker CD45 increased significantly by 30.8% (p<0.0001, n=15), whereas area positive for CD68 was reduced by 10.3% (p=0.0292, n=15) in RGS5-deficient mice. Absence of RGS5 decreased co-localization of Mϕ-derived foam cells by 23% (p=0.03734, n=4-5) while leading to an 5.8% increase in aSMA-derived foam cells compared to control. Area positive for pro-inflammatory M1 Mϕ marker CD86 and iNOS increased by 36.3% and 36.8% after RGS5 knock-out (p<0.0001, n=15). No difference in M2 Mϕ positive area was observed when RGS5 was lacking. Conclusion RGS5 promotes plaque formation. The number of Mϕ-derived foam cells is increased by RGS5, while it reduces inflammatory M1 Mϕ. Interestingly, there were no differences in numbers of M2 Mϕ, indicating RGS5 inhibits VSMCs transition to M1 Mϕ resulting in an overall decrease of CD68-positive foam cells. Further study is required to determine molecular signalling of RGS5 that modulates the phenotype of Mϕ- and VSMC-derived cells. RGS5 could be useful as therapeutic target to suppress undesirable plaque phenotypes and to reduce acute cardiovascular events.

Recreational drugs use as prognostic factor of major adverse cardiovascular and cerebrovascular events in patients hospitalised for acute cardiovascular events

Abstract Background Among patients admitted to the intensive cardiac care unit (ICCU), systematic screening for recreational drugs evidenced a significant prevalence of recent use and was associated with a higher rate in-hospital outcomes. However, long-term cardiovascular consequences of recreational drug use remain uncertain. Purpose We aimed to evaluate the prognostic impact of recreational drugs use at 1-year follow-up to predict major adverse cardiovascular and cerebrovascular events (MACCE) in consecutive patients admitted to ICCUs for acute cardiovascular events from the Addiction in Intensive Cardiac Care Units (ADDICT-ICCU) study. Methods In this prospective multicentric study, all consecutive patients admitted to ICCUs over two weeks in April 2021 at 39 centres across France were included. Screening for recreational drugs use was performed by systematic urinary testing. One-year follow-up consisted of a clinical visit or direct contact with the patient and the referring cardiologist. The primary composite outcome was the occurrence of one of the combined MACCE defined as cardiovascular death, nonfatal myocardial infarction (MI) or stroke. Subgroup analysis was performed in patients hospitalised at baseline for acute coronary syndrome. Results Of the 1499 consecutive patients screened, 1392 (93%) patients (63±15 years, 70% males) had a complete 1-year follow-up. Among them, 157 (11%) had an initial positive test for recreational drug use (cannabis, opioids, cocaine, amphetamines, 3,4-methylenedioxymethamphetamine [MDMA]). After 1-year of follow, 94 (7%) patients experimented MACCE. Patients with positive testing exhibited a higher rate of MACCE than non-users (13% vs 6%, respectively, p=0.002). After adjustment for traditional prognosticators, recreational drug use was independently associated with the occurrence of MACCE (HR=2.99; 95% CI: 1.73-5.16, p<0.001). In the subgroup analysis of 713 patients hospitalised at baseline for acute coronary syndrome, 96 (14%) had a positive recreational drug test and 50 (7%) experienced MACCE. Using a multivariable Cox analysis in this population, recreational drug use was still independently associated with MACCE after adjustment for traditional prognosticators (HR=2.98; 95% CI: 1.43-6.21, p=0.004). Conclusions In a large cohort of consecutive patients admitted to ICCUs for acute cardiovascular events, the prevalence of recreational drug use was 11%. Recreational drug use was strongly associated with the occurrence of 1-year MACCE even after adjustment for traditional prognosticators.Central illustrationPrognostic impact of drug use

Challenges posed by climate hazards to cardiovascular health and cardiac intensive care: implications for mitigation and adaptation.

Global warming, driven by increased greenhouse gas emissions, has led to unprecedented extreme weather events, contributing to higher morbidity and mortality rates from a variety of health conditions, including cardiovascular disease (CVD). The disruption of multiple planetary boundaries has increased the probability of connected, cascading, and catastrophic disasters with magnified health impacts on vulnerable populations. While the impact of climate change can be manifold, non-optimal air temperatures (NOTs) pose significant health risks from cardiovascular events. Vulnerable populations, especially those with pre-existing CVD, face increased risks of acute cardiovascular events during NOT. Factors such as age, socio-economic status, minority populations, and environmental conditions (especially air pollution) amplify these risks. With rising global surface temperatures, the frequency and intensity of heatwaves and cold spells are expected to increase, emphasizing the need to address their health impacts. The World Health Organization recommends implementing heat-health action plans, which include early warning systems, public education on recognizing heat-related symptoms, and guidelines for adjusting medications during heatwaves. Additionally, intensive care units must be prepared to handle increased patient loads and the specific challenges posed by extreme heat. Comprehensive and proactive adaptation and mitigation strategies with health as a primary consideration and measures to enhance resilience are essential to protect vulnerable populations and reduce the health burden associated with NOTs. The current educational review will explore the impact on cardiovascular events, future health projections, pathophysiology, drug interactions, and intensive care challenges and recommend actions for effective patient care.

A regional multicentre prospective survey addressing sport-related myocardial infarction: clinical characteristics of 155 patients and one year follow-up

Abstract Background Exercise is a keystone of cardiovascular prevention; however, it is also a powerful trigger of acute cardiovascular events including sudden cardiac arrest and acute myocardial infarction. Contemporary studies addressing these sport-related myocardial infarction (SR-MI) are scarce. Aim To describe clinical characteristics and follow-up of SR-MI. Methods We conducted a regional multicentric prospective survey addressing patients admitted for a SR-MI in 2 intensive coronary units. SR-MI was defined as MI onset occurring during sport or within the 1st hour of recovery. A one-year follow-up was performed by phone call. Results From April 1st 2018 to February 23th 2023, 155 SRMI were included, of whom 13 (8.4%) were female, median age was 61-y. (IQR 54-66). Cycling was the most frequent sport (32.5%) followed by fitness and hiking (12.6% each) then jogging (11.3%) (Figure). Most were ST elevation MI (68.8%). The main risk factors were dyslipidaemia (33.8%), hypertension (27.3%) and tobacco smoking (24.5%). No cardiovascular risk factor other than age was identified in 38 patients (25.7%). Prodromal symptoms were reported by 66 subjects (42.6%). SR-MI occurred mostly during exercise (60.6%). Out of hospital cardiac arrest (OHCA) occurred in 20 (12.6%) patients, more commonly among patients with prior coronary artery disease (CAD) (p = 0.02) and tobacco smoking (p=0.047). A significant single vessel disease was observed in 67 patients (43.2%); revascularization was performed by stenting in 134 patients (86.5%) and surgery in 11 (7.1%). In-hospital death occurred in 4 patients and was associated to OHCA (p=0.007). Among the survivors at time of discharge (151 patients), 141 were eligible to follow-up, none one lost: one patient died suddenly at home, one suffered from a recurrent MI, one experienced a cardioversion from his implantable cardioverter defibrillator (ICD) and an ICD was implanted in 4 others. A cardiovascular rehabilitation was performed in 101 patients (65.2%); from the 30 smokers at the time of SRMI, 26 declared smoking cessation. Conclusions Among patients admitted for a SR-MI, most were male. Prodromal symptoms were common but neglected. OHCA occurred in 1 patient out of 8 and was associated with history of CAD, tobacco smoking and in-hospital death. Such findings highlight the need for mass education to prevention including recognition of prodromal symptoms and management of cardiac arrest. In this exercising population, rehabilitation rate was high and quitting tobacco was commonly achieved.Table

Comparison of risk factors and mortality in veterans with HIV and those without HIV suffering first major acute cardiovascular events.

Previous studies have demonstrated that people with HIV have an increased atherosclerotic plaque vulnerability, making them more susceptible to severe cardiovascular complications. This study aimed to examine the clinical characteristics of people with HIV in comparison to people without HIV admitted to Veterans Health Administration (VHA) with their first major acute cardiovascular events (MACE) and compare their total mortality. We used national VHA data to extract data of those admitted to VHA hospitals with MACE defined as acute myocardial infarction (AMI), acute cerebrovascular accident (CVA) or cardiac arrest during the fiscal years 2003-2021. The hazard ratio (HR) of mortality for people with HIV versus people without HIV was estimated using Cox proportional hazard regression analysis. Out of 280 311 veterans, 2510 people with HIV and 277 801 people without HIV had their first MACE during the study period. People with HIV were younger, more likely to be African American, had a lower prevalence of diabetes mellitus and hypertension, similar total cholesterol levels and a lower mean 10-year cardiovascular risk score (25.4 in people with HIV vs. 28.7 in people without HIV). Among MACE components, people with HIV had a higher proportion of CVA (27% vs. 21.3%, p < 0.001) and cardiac arrest (13.0% vs. 8.4%, p < 0.001) but a lower incidence of AMI (62.4% vs. 72.5%, p < 0.001) than people without HIV. Additionally, people with HIV had a higher risk of total mortality (adjusted HR: 2.05, 95% confidence interval: 1.90-2.22) compared with people without HIV. People with HIV experience MACE at younger ages despite lower cardiovascular risks and similar baseline cholesterol and blood pressure levels. People with HIV had higher mortality and a higher risk of having ventricular fibrillation arrest and stroke as their first MACE.

Novel risk score for predicting acute cardiovascular and cerebrovascular events after chest radiotherapy in patients with breast or lung cancer.

Radiation therapy (RT) is an integral component of cancer therapy but associated with adverse events. Our goal was to establish risk prediction models for major adverse cardiovascular and cerebrovascular events (MACCE) after chest RT. A retrospective study of lung/breast cancer patients who had chest RT with planning CT at Mayo Clinic between 01/2010 and 01/2014. Predictive models were developed based on weighted independent predictors using a derivation (406 lung and 711 breast cancer) and validation cohort (179 lung and 234 breast cancer). Patient characteristics, pre-RT CT for coronary artery calcification (CAC), and post-RT MACCE data were reviewed. Post-RT MACCE occurred in 6.1 and 5.6% in the derivation and validation cohort over a mean follow-up of 42 ± 13 months. Post-therapy model (C2AD2) included CAC (two points), MACCE history (two points), age ≥74 (three points), DM (two points), and mean heart radiation dose ≥ 850 mGy (two points), and pre-therapy model (C2AD) included post-therapy model parameters minus mean heart radiation dose. Both models stratified patients into three risk groups: low (0-2), intermediate (3-5), and high (≥6). Post-RT MACCE across these groups were 2.7, 8.9, and 19.8% in the derivation, and 3.9, 6.6, and 16.4% in the validation cohort for post-therapy model (C2AD2) and 2.8, 9.2, and 20.4% in the derivation and 3.7, 9.2, and 13.2% in the validation cohort for pre-therapy model. Both models showed statistically significant graded survival outcome. Post-therapy (C2AD2) and pre-therapy (C2AD) models are simple, easy to use and effective tools to stratify breast and lung cancer patients undergoing chest radiation for post-RT MACCE.

CHARACTERISTICS OF THE HOSPITALIZATION PERIOD IN PATIENTS WHO DIED AS A RESULT OF COVID-19 WITH ACUTE CARDIOVASCULAR COMPLICATIONS

The aim. To identify adverse risk factors in hospitalized patients with fatal consequences of the coronavirus disease-2019 and its acute cardiovascular complications. Materials and methods. A retrospective study was conducted of 66 people in the study group with acute respiratory failure and cardiovascular complications due to COVID-19. The comparison group was 48 people who died of acute cardiovascular events without SARS-CoV-2 infection or other bacterial or viral diseases. The criteria for inclusion in the study group were the presence of confirmed SARS-CoV-2 infection by the polymerase chain reaction method, the presence of acute cardiovascular complications during COVID-19, and patients hospitalized during its treatment. Inclusion criteria for the comparison group were hospitalized patients with acute cardiovascular diseases that led to death without SARS-CoV-2 infection. The exclusion criteria for both groups were: age before 18 years old; absence of informed consent of the authorized person of dead person or the decision of the authorized person to withdraw from the study at any of the stages; the presence of other co-infections that could have a cumulative negative effect on the state of the respiratory and cardiovascular systems (flu virus, hepatitis virus, human immunodeficiency virus, pathogens that led to symptoms of acute intestinal infections). Age and gender distribution, comorbidities, length of hospitalization, and laboratory markers were evaluated in both cohorts. Cardiovascular complications were confirmed by the results of ultrasound examinations, computed tomography angiography and comparison with postmortem morphological findings in autopsy reports for the analysis of the current study,. The results. There were 48 men (72.7%) and 18 women (27.3%) in the study group of 66 patients who developed cardiovascular complications at the background of COVID-19, and in the comparison group – 39 men (81.3%) and 9 women (18.7%), which indicates acceptable comparability of the groups among themselves due to sex (p=0.374) and age (p=0.338). In particular, the age median for men in the study group was 65 years (IQR - 21 years), with minimum and maximum age values ​​– 36 and 83 years, respectively; the median age for women in the study group was also 65 years (IQR – 12.5 years), with the lower and upper age limits in the group being 41 and 78 years. The age median for men in the comparison group was 62 years (IQR 15 years), with a lower and upper age range of 54 and 81 years. The age median for women in the comparison group was 68 years (IQR – 16.5 years), with the lower and upper age values ​​in the group being 55 and 79 years. Men and women of the comparison group did not statistically differ from each other in terms of age (р=0.412). A significant difference was found between the length of hospitalization in both cohorts (р˂0.00001) – the median length of stay in hospital for the study group was 15 days, and for the comparison group – 10 days. It was established that malignant diseases were an additional concomitant factor of mortality in the group of patients with COVID-19 (р=0.043). The percentage ratio of neutrophils (p=0.048) and lymphocytes (p=0.031) in patients of the study group significantly differed. Conclusions. Unfavorable risk factors in patients with fatal consequences of Coronavirus disease-2019 and acute cardiovascular complications were concomitant oncological pathology, a long period of hospitalization, and changes in the percentage ratio of neutrophils and lymphocytes.

The Increasing Problem of Resistant Hypertension: We'll Manage till Help Comes!

Arterial hypertension remains the major cardiovascular risk worldwide. It is estimated that under 50 years of age one in every three adults is hypertensive while beyond the age of 50 the prevalence is almost 50% globally. The latest World Health Organization (WHO) Global Report on Hypertension indicated that the global number of hypertensive patients almost doubled in the last three decades, with related increasing deaths, disability, and costs annually. Because of this global increase, early diagnosis and timely treatment is of great importance. However, based on the WHO Global Report, it is estimated that up to 46% of individuals were never diagnosed. Of those diagnosed, less than 50% were on treatment, with nearly half among these at target according to the current guidelines. It is also important to note that an increasing number of hypertensive patients, despite the use of three or more drugs, still do not achieve a blood pressure normalization, thus defining the clinical scenario of resistant hypertension (RH). This condition is associated to a higher risk of hypertension-mediated organ damage and hospitalization due to acute cardiovascular events. Current guidelines recommend a triple combination therapy (renin angiotensin system blocking agent + a thiazide or thiazide-like diuretic + a dihydropyridinic calcium-channel blocker) to all patients with RH. Beta-blockers and mineralocorticoid receptor antagonists, alone or in combination, should be also considered based on concomitant conditions and potential contraindications. Finally, the renal denervation is also proposed in patients with preserved kidney function that remain hypertensive despite the use of maximum tolerated medical treatment. However, the failure of this procedure in the long term and the contraindication in patients with kidney failure is a strong call for a new therapeutic approach. In the present review, we will discuss the pharmacological novelties to come for the management of hypertension and RH in the next future.

Risk Factors, Clinical Profile, and Outcomes of Coronary Artery Disease in the Elderly

Objectives This study aimed to identify risk factors in patients diagnosed with angiographically significant coronary artery disease (CAD) after 65 years of age (elderly) with a subset analysis of more than 75 years, analyze their clinical, angiographic profile and assess their major acute cardiovascular and cerebrovascular events (MACCE). Methods This was an observational retrospective and prospective study conducted from January 2022 to June 2023 among consecutive elderly who underwent CAG for suspected or diagnosed CAD between 2010 and 2018 at a tertiary center in South India. Results A total of 1,511 patients satisfied eligibility criteria with mean age of 69.38 years and male preponderance (69%). Male gender, dyslipidemia and current tobacco use contributed to angiographically significant CAD by multiple logistic regression analysis but none of the risk factors contributed in the more than 75-year age group. Female patients had higher incidence of atypical presentation, less revascularizations and higher MACCE. Fourteen percent of patients with significant CAD developed MACCE over a median 3.5-year hospital follow-up. Survival analysis of 1,027 patients with significant CAD showed one, three, 5-year mortality rate of 4.3%, 6.9% and 10.8%, respectively, with left ventricular dysfunction and triple vessel disease being associated with worse survival. MACCE and 5-year survival was significantly better among those who underwent revascularization including those with significant left main or triple vessel disease. Conclusion This study showed a high prevalence of traditional risk factors in elderly patients among which male gender, dyslipidemia, current tobacco use were found to predict angiographically significant CAD. Triple vessel disease and left ventricular dysfunction were associated with worse survival. Mortality was significantly lower among elderly who underwent revascularization compared to medical management.

High expression levels of haem oxygenase-1 promote ferroptosis in macrophage-derived foam cells and exacerbate plaque instability

Plaque rupture with consequent thrombosis is the leading cause of acute cardiovascular events, during which macrophage death is a hallmark. Ferroptosis is a pivotal intermediate link between early and advanced atherosclerosis. Existing evidence indicates the involvement of macrophage ferroptosis in plaque vulnerability; however, the exact mechanism remains elusive. The aim of this study was to explore key ferroptosis-related genes (FRGs) involved in plaque progression and the underlying molecular mechanisms involved. The expression landscape of FRGs was obtained from atherosclerosis-related GEO datasets. Molecular mechanism studies of ferroptosis were performed using bone marrow-derived macrophages (BMDMs) and macrophage-derived foam cells (MDFCs). Bioinformatics analysis and immunohistochemistry revealed that macrophage haem oxygenase-1 (HMOX1) is the key FRG involved in plaque destabilization. Hypoxic conditions induced a significant increase in Hmox1 expression in MDFCs but not in macrophages. In addition, the beneficial or deleterious effects of Hmox1 were dependent on the degree of Hmox1 induction. Hmox1 overexpression drove inflammatory responses and ferroptotic oxidative stress in MDFCs and aggravated the plaque burden in atherosclerotic model mice. Further mechanistic investigations demonstrated that hypoxia-mediated degradation of egl-9 family hypoxia-inducible factor 3 (Egln3) stabilized Hif1a, which subsequently promoted Hmox1 transcription. Our findings suggest that high Hmox1 expression under hypoxia is deleterious to MDFC viability and plaque stability, providing a reference for the management of acute cardiovascular events.

Impact of successful secondary hyperparathyroidism treatment on cardiovascular morbidity in patients with chronic kidney disease KDIGO stages G3b-5.

Chronic kidney disease is common, with a projected increase to 5.4 million people in need of kidney replacement therapy by 2030. As many as 61.7% of patients on hemodialysis have secondary hyperparathyroidism (SHPT). This has been associated with high cardiovascular morbidity. The present study investigates the effect of SHPT treatment success on cardiovascular morbidity in patients with CKD KDIGO stages G3b, 4, and 5. A retrospective single center analysis of 211 chronic kidney disease stages G3b-5 patients undergoing computed tomography for coronary artery calcium (CAC) scoring at the University Hospital of Zurich between 2015 and 2019was performed. The presence of and control of SHPT was assessed at the timepoint of CAC scoring and 6-12 months prior. Information on left ventricular ejection fraction (LVEF), left ventricular hypertrophy (LVH), and left ventricular myocardial mass index (LVMMI) were calculated from echocardiography values obtained at the timepoint of CAC scoring. Occurrence of major acute cardiovascular events, including acute coronary syndrome (ACS), within 1 year of CAC scoring was drawn from the charts. Independent predictive factors for ACS and LVH were assessed by multivariable analysis. Thirty-four percent (n=72) of the patients had uncontrolled SHPT, whereas 66% (n=139) had either no (n=18%, n=39) or a controlled SHPT (n=48%, n=100). The CKD stage G3b-5 patients with uncontrolled SHPT had a significantly lower LVEF (p=0.028) and significantly more pronounced LVH (p=0.003) and a higher LVMMI (p=0.002) than the group with either no SHPT or well-controlled SHPT. Uncontrolled SHPT in the observed CKD cohort had a significantly higher risk for developing ACS (p=0.011, HR 2.76, 95%CI 1.26-6.05) compared to no or controlled SHPT patients (41.7% vs 31.7%). While patients with uncontrolled SHPT showed a median CAC score of 290 (IQR 18-866), those with no or controlled SHPT had a lower median CAC score of 194 (IQR 14-869), although not significant (p=0.490). Patients with CAC scores >400 displayed a significantly higher incidence of ACS (56.8% vs 33.1%, p=0.010). SHPT is common (82%) in advanced CKD (≥G3b) patients and insufficiently controlled in one-third of patients. Insufficient control of SHPT is associated with higher cardiovascular morbidity, lower LVEF, increased LVH, and a higher incidence of ACS. Thus, increased focus on SHPT control in CKD patients may have a beneficial impact on cardiovascular outcomes.

Serious Adverse Events Following COVID 19 Vaccination in India: A Retrospective Study

Abstract Introduction: The aim of this study was to identify the type and detail the serious adverse events following COVID-19 vaccination in India. Materials and Methods: The descriptive study was conducted by extracting the data from the website by the Ministry of Health and Family Welfare, Government of India https://shorturl.at/imwJY. The variables analysed were types of vaccines, types of SAEFI, thromboembolic (TE) events, neurological manifestations and consistent causal association as per the World Health Organization. Data were entered into MS Excel and analysed using the SPSS software version 25. Results: Out of the total 1.9 billion doses of COVID-19 vaccines, 1527 cases of SAEFI were reported. Among these, 51.7% were coincidental and 30.8% were associated with vaccination. All the allergic reactions (58), anaphylaxis (50), TE events (342) and Guillain–Barre syndrome (41) had consistent causal association. Out of the 598 deaths, 2% of deaths had consistent causal association. In comparison of exposure to Covaxin, Covishield had high odds of death (odds ratio [OR] =1.5; 95% confidence interval [CI] =1.11–2.07), acute febrile illness (OR = 2.07; 95% CI = 1–4.3), TE events (OR = 1.58; 95% CI = 1.08–2.31) and cardiovascular events (OR = 2.03; 95% CI = 1.32–3.13). Conclusions: Compared to other countries, similar types of SAEFIs were reported from India but at a lower rate.

Paracentral Acute Middle Maculopathy and Risk of Cardiovascular Disease, Stroke, and Death: A Longitudinal Study

To evaluate the risk of acute cardiovascular events (CVE), including cardiovascular diseases, cerebrovascular diseases, and all-cause mortality in patients with paracentral acute middle maculopathy (PAMM). Retrospective cohort study METHODS: We studied 43 individuals with optical coherence tomography -documented PAMM attending Moorfields Eye Hospital between January 2014 and June 2021. We excluded patients with preceding (< 2 years) major adverse cardiac events. We stratified patients by age (<50 years & ≥50 years) and whether associated with retinal vascular diseases (RVD) or isolated (iPAMM). We assessed risk factors, clinical characteristics, and visual prognosis of the patients. CVE risk was estimated using Kaplan-Meier curves, the log-rank test, and Cox proportional hazards regression. In young patients with iPAMM patients (n=12), underlying predisposing factors included six (50%) sickle cell disease and five (41.6%) others, including breakthrough bleeding in pregnancy, migraine, genetic cardiomyopathy, amphetamine use; among those with PAMM+RVD (n=12) one (9%) had a vascular disorder, and four (44.4%) oral contraceptive use. In the older group of 20 patients, 15 (75%) had at least one coronary risk factor. During a median follow-up of 14 months (range 12-54), older subjects with iPAMM had a higher risk of developing CVE than those with PAMM+RVD (p<0.001). Notably, iPAMM displayed a significantly earlier peak in peri-PAMM CVE risk compared to PAMM+RVD (median: 1 month, range 1-40 months vs. 36 months, range 12-54 months). Relative to those with PAMM+RVD, risk of CVE was significantly higher in patients with iPAMM, adjusted for age and sex (hazard ratio: 6.37, 95% Confidence Interval 1.68-24.14, p=0.017). No young patients experienced adverse CVE. At baseline, older iPAMM patients mean best corrected visual acuity of 0.7 (0-1.8) LogMAR, which improved significantly to 0.2 (0-1.30) LogMAR at the latest visit (p=0.033). Young individuals with iPAMM have a higher prevalence of predisposing factors compared to those presenting with combined PAMM+RVD. Older patients with iPAMM had a higher risk of CVE than those with PAMM+RVD, especially in the peri-onset timeframe. This suggests the need for a prompt cardiovascular assessment to rule out systemic etiologies and optimize cardiovascular risk factors, in addition to ongoing ophthalmology input.

Technological Advances in the Diagnosis of Cardiovascular Disease: A Public Health Strategy.

This article reviews technological advances and global trends in the diagnosis, treatment, and monitoring of cardiovascular diseases. A bibliometric analysis was conducted using the SCOPUS database, following PRISMA-ScR guidelines, to identify relevant publications on technologies applied in the diagnosis and treatment of cardiovascular diseases. An increase in scientific output since 2018 was observed, reflecting a growing interest in the technologies available for the treatment of cardiovascular diseases, with terms such as "telemedicine", "artificial intelligence", "image analysis", and "cardiovascular disease" standing out as some of the most commonly used terms in reference to CVDs. Significant trends were identified, such as the use of artificial intelligence in precision medicine and machine learning algorithms to analyse data and predict cardiovascular risk, as well as advances in image analysis and 3D printing. Highlighting the role of artificial intelligence in the diagnosis and continuous monitoring of cardiovascular diseases, showing its potential to improve prognosis and reduce the incidence of acute cardiovascular events, this study presents the integration of traditional cardiology methods with digital health technologies-through a transdisciplinary approach-as a new direction in cardiovascular health, emphasising individualised care and improved clinical outcomes. These advances have great potential to impact healthcare, and as this field expands, it is crucial to understand the current research landscape and direction in order to take advantage of each technological advancement for improving the diagnosis, treatment, and quality of life of cardiovascular patients. It is concluded that the integration of these technologies into clinical practice has important implications for public health. Early detection and personalised treatment of cardiovascular diseases (CVDs) can significantly reduce the morbidity and mortality associated with these diseases. In addition, the optimisation of public health resources through telemedicine and telecare can improve access to quality care. The implementation of these technologies can be a crucial step towards reducing the global burden of cardiovascular diseases.

Serial increases in circulating lipoprotein(a) levels predict acute cardiovascular events

Serial increases in circulating lipoprotein(a) levels predict acute cardiovascular events