Burden Of Cardiovascular Risk Factors Research Articles

Burden of cardiovascular risk factors in stable HIV patients aged 50 years old and above

Background: Advancement in HIV treatment has revolutionized the disease from being an infection with high mortality to a chronic illness. As the PLHIV population ages, we foresee increasing number of patients suffering from dyslipidemia, diabetes mellitus or hypertension that will eventually increase their risk of cardiovascular disease. Methods and materials: The objectives of this study was to stratify the cardiovascular risk factors and determine the prevalence and control of these risk factors. This study was performed at a referral HIV/AIDS clinic in Klang Valley, Malaysia. The cohort studied patients who started follow-up from 2007 till 2015. Patients aged ≥50 years with HIV viral suppression of ≥2 years were included in the study. Definitions of dyslipidemia, hypertension and risk stratification of cardiovascular risk were based on the latest Malaysia clinical practice guidelines. Results: A total of 635 patients were included in the study. Majority of them were male (83.8%), Chinese (56.1%) with heterosexual (60%) as their main modes of transmission. The prevalence of LDL-C dyslipidemia, hypertension and diabetes mellitus were 71%, 38% and 18% respectively. While 52.3% of them belonged to intermediate cardiovascular risk group, almost one third (32.8%) fell under high and very high cardiovascular risk group. Overall, 67.2% of hypertensive patients and 65.9% of patients with LDL-C dyslipidemia did not achieve their target while on treatment. Based on regression analysis, factors associated with poor LDL-C control include younger age, lower CD4 count, higher systolic blood pressure, homosexual, and diabetes mellitus. There are no significant predictors for poor hypertensive control in our cohort of patients. Conclusion: With the high prevalence of these cardiovascular risk factors, emphasis on cardiovascular risk stratification and aggressive control of these risk factors based on respective treatment target is imperative to reduce their cardiovascular morbidity and mortality.

The Effect of Replacing Sitting With Standing on Cardiovascular Risk Factors: A Systematic Review and Meta-analysis.

ObjectiveTo investigate the effect of replacing sitting with standing on cardiovascular risk factors tested in clinical trials.MethodsWe searched databases from inception up to August 28, 2019, for studies examining the effect of replacing sitting with standing on fasting blood glucose, fasting insulin, and lipid levels; blood pressure; body fat mass; weight; and waist circumference in healthy adults. Differences in mean ± SD values were used for pooling the data and calculating the mean differences and CIs.ResultsThe search found 3507 abstracts. Nine clinical trials (8 randomized and 1 nonrandomized) with 877 (64.4% [n=565] women) participants met all inclusion criteria. The mean ± SD age was 45.34±5.41 years; mean follow-up was 3.81 months, and mean difference in standing time between the intervention and control groups was 1.33 hours per day. The follow-up fasting blood glucose and body fat mass values were slightly but significantly lower than baseline records in the intervention groups compared with control groups (−2.53; 95% CI, −4.27 to −0.79 mg/dL; and −0.75; 95% CI, −0.91 to −0.59 kg). The analysis for fasting insulin levels, lipid levels, blood pressure, weight, and waist circumference revealed no significant differences.ConclusionReplacing sitting with standing can result in very small but statistically significant decreases in fasting blood glucose levels and body fat mass with no significant effect on lipid levels, blood pressure, weight, and waist circumference. Replacing sitting with standing can be used as an adjunctive intervention to decrease the burden of cardiovascular risk factors but cannot be used as an alternative to physical activity to decrease sedentary time.

Abstract 14817: Assessing the Burden of Cardiovascular Risk Factors and Disease Across PVDOMICS Cohorts

Longitudinal trends demonstrate an increase in the prevalence of cardiovascular (CV) risk factors in the general population; however, the burden of CV risk factors or established disease in patients across WSPH groups remains unknown. Accordingly, we examined the prevalence of CV risk factors and established disease in the PVDOMICS (Redefining Pulmonary Hypertension through Pulmonary Vascular Disease Phenomics) cohort. PVDOMICS enrolled 1,097 subjects with pulmonary hypertension (PH) (mPA ≥ 25 mmHg) and at-risk disease comparators (mPa < 25 mmHg) from six US centers. Compared to participants with PH attributable to left heart disease (LHD-PH; WSPH Group 2, n=145) who are expected to have a high burden of CV risk factors and disease, patients with WSPH Groups 1,3,4,and 5 (non-LHD-PH)(n=618) were younger (56.2 ± 14.5 vs 67.7 ± 11.7 yrs, p<0.02) with no difference in %female or race. Non-LHD-PH had a lower prevalence of the CV disease risk factors hypertension (38.6% vs. 66.7%, p<0.02), diabetes mellitus (21.4 vs. 41.0%, p<0.02), and metabolic syndrome (30.8 vs. 48.4%, p<0.02) compared to LHD-PH, while smoking, hypercholesterolemia, and family history of CV disease were similar between groups. The prevalence of established CV disease, including myocardial infarction, CABG or stent, stroke, arrhythmia, or peripheral arterial disease was significantly lower in non-LHD-PH than in LHD-PH. At right heart catheterization, although mPA pressures were similar between the groups, PVR (5.5[3.3, 8.7] vs. 3.7[7.2, 5.7] WU, p<0.02), and cardiac output were higher (5.4 ± 1.9 vs. 4.9 ± 1.6 L/min, p<0.02) in non-LHD-PH compared to LHD-PH. This corresponded to a higher left ventricular ejection fraction by echo (62.2 ± 8.2 vs. 54.0 ± 14.0 %, p<0.02) and greater 6-minute walk distance (361.8 ± 134.7 vs. 294.7 ± 118.7 m, p<0.02). Non-LHD-PH also had better cardiovascular health compared to LHD-PH with higher modified American Heart Association Life’s Simple 7 scores (6.7 ± 1.6 vs. 5.8 ± 1.5, P<0.02). Taken together, these data demonstrate that CV disease risk factors and CV disease are frequent comorbidities that occur in patients with non-LHD-PH, although CV health is not as impaired as in patients with LHD-PH. How this affects PH-related outcomes remains to be determined.

Abstract 15488: Epidemiological Profile of Cardiovascular Risk Factors and Outcomes in Patients With Solid Organ and Haematological Malignancies

Introduction: Chemotherapy remains the cornerstone in the management of solid organ malignancies (SOM) and hematological malignancies (HM). Although life-prolonging, it is not without cost, with heart failure and arrhythmia becoming increasingly recognised complications of treatment. Although there is significant overlap in the chemotherapeutic management of SOM and HM, epidemiological information on the differential prevalence of baseline cardiovascular risk factors and outcomes in these populations is scarce. Hypothesis: A differential cardiovascular risk profile and clinical course will be appreciated in patients with SOM and HM undergoing chemotherapy. Methods: Retrospective observational study design. Patients admitted to our institution undergoing chemotherapy for SOM (2014-2018) or HM (2012-2015) were reviewed. Baseline demographic and clinical data was collated and patients were followed for up to five years following chemotherapy for occurrence of major adverse cardiac events (MACE) defined as the development of new-onset heart failure or arrhythmia. Results: 545 hematology and 435 oncology patients with malignancy were assessed. Compared to those with HM, those treated for SOM had a poorer cardiovascular risk profile (table 1). At mean follow-up period of 22.8±17.8 months, no significant difference in the incidence of the composite endpoint (9.4% vs 9.0%, p=0.45) or its components was observed. Higher rates of anthracycline therapy was observed in patients with HM (100% vs 17%, p < 0.01), however its use did not have a differential effect on MACE (12% vs 9%, p=0.25). Conclusions: Compared to patients treated for HM, patients with SOM had a greater burden of cardiovascular risk factors and lower use of anthracycline chemotherapy. Despite this, MACE occurred at similar rates in both groups. The use of anthracyclines was not associated with the development of MACE, suggesting alternative pathways contributing to its development.

Abstract 15043: Assessment of Cardiovascular Events Among Symptomatic Outpatients With Suspected Coronary Artery Disease Who Presented During COVID-19 Pandemic

Background: Infection mitigation efforts during the SARS-CoV-2 pandemic highlights a need to optimize evaluation of symptomatic outpatients (pts) with suspected coronary artery disease (CAD). Successful paradigms must have a low incidence of major adverse cardiovascular (CV) events (MACE) and be efficient and scalable across a large population. We describe a strategy implemented during peak interruption of usual clinical services across an integrated healthcare system looking at short-term clinical outcomes. Methods: We evaluated consecutive pts presenting to emergency departments (ED) from March to April 2020 within Intermountain Healthcare. Symptomatic pts were risk stratified using the HEART Score (HS). Those with HS of ≤3 were discharged to “active surveillance”comprised of weekly telephone calls to assess for symptom progression, prompting urgent stress testing. All pts with a HS of ≥4 received cardiac stress PET/SPECT imaging. Physician interpretation guided subsequent pt management. Short-term (minimum 30-day follow-up) clinical outcomes were incident MACE (all-cause mortality, acute MI, stroke, and return ED visits for suspected angina). Results: Those with a HS ≥4 (n=212) had an increased burden of CV risk factors compared to HS ≤3 (n=90) (Table 1). Three of the HS ≤3 group had progressive symptoms leading to urgent stress testing (resulting in low-risk findings and no intervention) and one had a MACE event (NSTE-ACS 10 days post index ED visit). In the HS ≥4 group, 123 tests were read as intermediate or high-risk, of which 59 proceeded to coronary angiography and 43 resulted in revascularization. Two pts with HS ≥4 died from complications related to preexisting heart failure. No additional MACE events occurred in the HS ≥4 group. Conclusion: Among symptomatic pts with suspected CAD who presented for ED evaluation during the SARS-CoV-2 pandemic, the HS combined with active clinical surveillance appears to be a safe and effective management strategy.

Abstract 16000: Patient Characteristics and Outcomes Associated With Troponin Testing

Introduction: Troponin I (TnI) is a principal biomarker in diagnosing acute myocardial infarction (AMI). However, large numbers of hospitalized patients are tested for TnI in whom AMI is unlikely or not expected. Hypothesis: We hypothesized the baseline comorbidities of those undergoing troponin testing differ from those not tested and that troponin testing is associated with outcomes. Methods: In total, 54,039 inpatient admissions from a 9-hospital system in Texas were reviewed over a 24-month period (2017-2018). Data were collected on primary international classification of disease (ICD-10) diagnoses, TnI, risk factors, and death during hospitalization or readmission within 30 days. Odds ratios were calculated for all patients adjusted for demographic differences in the population. Bivariate analysis was performed on the baseline risk factors for both troponin testing and troponin positivity. Results: TnI testing occurred in 30,173/54,039 (55.8%) individual hospital admissions. Of those, 19.9% had at least one elevated TnI value >99th% (0.1 ng/ml). Tested patients were older (70.1 [IQR 59.5, 80.9] vs 63.7 [IQR 53.4, 73.1] years), more likely to be male (14,497/30,173 (48.1%) vs 10,845/23,866 (45.4%)) and had a greater burden of cardiovascular disease and risk factors including: gender, race, smoking, hypertension, hyperlipidemia, type 2 diabetes mellitus, coronary artery disease, chronic kidney disease, chronic obstructive pulmonary disease, prior cerebrovascular accident, and prior AMI. Troponin testing was associated with death during hospitalization (OR 3.11, 95% CI 2.63, 3.71, p<0.0001), and an elevated troponin was found to be associated with mortality (OR 4.06, 95% CI 3.49, 4.72, p<0.0001). Conclusions: Troponin testing is associated with death during index hospitalization. Troponin values >99th% were associated only with increased mortality. This data suggest that selection plays a role in identifying patients at risk for in-hospital death.

Abstract 16424: Cardiovascular Risk Factors Among a Nationally Representative Adult Population With Inflammatory Bowel Disease and Without Clinical Atherosclerotic Cardiovascular Disease

Introduction: Inflammatory Bowel Disease (IBD), comprised of Ulcerative Colitis (UC) and Crohn’s Disease (CD) is a chronic inflammatory disease with systemic involvement. Inflammation predisposes to atherosclerosis and studies suggest that IBD is associated with premature atherosclerotic cardiovascular disease (ASCVD). There is, however, limited population-based data on cardiovascular risk factor (CRF) burden in IBD among those who have not yet developed clinical ASCVD. We sought to study the association between IBD and CRFs among a nationally representative population with IBD and without established ASCVD. Methods: The study population was derived from the 2015-2016 National Health Interview Survey database. ASCVD was defined as myocardial infarction, angina or stroke; those with ASCVD were excluded. IBD was defined as either CD or UC. We computed weighted prevalence estimates of various traditional CRFs for the US population by IBD status. Univariate and multivariate logistic regression models were used to evaluate associations between CRFs and IBD. Average and poor cardiovascular risk profiles were defined as 2-3 and ≥4 CRFs, respectively. Results: Overall 786 (1.2%) representing 2.6 million ASCVD-free adults reported IBD. Individuals with IBD had higher prevalence of multiple CRFs (Figure, top). In adjusted models those with IBD had significantly higher odds of having prevalent hypertension, diabetes mellitus and hypercholesterolemia (Figure, bottom). These associations were similar among elderly and young participants. Those with IBD were almost 2-fold more likely to have a poor cardiovascular risk profile. Conclusion: Our findings from a nationally representative US population suggest an increased burden and clustering of CRFs among IBD patients without clinical ASCVD. Future efforts are needed to understand the underlying mechanisms, and enhance the detection and treatment of these CRFs to reduce ASCVD risk in IBD patients.

High prevalence of cardiovascular risk factors in adults living in Greece: the EMENO National Health Examination Survey

BackgroundNationwide data on cardiovascular risk factors prevalence is lacking in Greece. This work presents the findings of the national health examination survey EMENO (2013–2016) regarding the prevalence of hypertension, hypercholesterolemia, diabetes, obesity and smoking.MethodsA random sample of adults (≥18 years) was drawn by multistage stratified random sampling based on 2011 Census. All EMENO participants with ≥1 measurement of interest [blood pressure (BP), fasting glucose, HbA1c, total cholesterol (TC), Body Mass Index (BMI)] were included. Hypertension was defined as BP ≥ 140/90 mmHg and/or antihypertensive treatment; diabetes as fasting glucose≥126 mg/dL and/or HbA1c ≥ 6.5% or self-reported diabetes; hypercholesterolemia as TC ≥ 190 mg/dL. Sampling weights were applied to adjust for study design and post-stratification weights to match sample age and sex distribution to population one. Non-response was adjusted by inverse probability weighting.ResultsOf 6006 EMENO participants, 4822 were included (51.5% females, median age:47.9 years). The prevalence of hypertension was 39.2%, higher in men (42.4%) than in women (36.1%); of hypercholesterolemia 60.2%, similar in men (59.5%) and women (60.9%); of diabetes 11.6%, similar men (12.4%) and women (10.9%); of obesity 32.1%, higher in women (33.5% vs 30.2%), although in subjects aged 18–40 year it was higher in men; of current smoking 38.2%, higher in men (44.0%) than in women (32.7%). The prevalence of all risk factors increased substantially with age, except smoking, which followed an inverse U shape.ConclusionsThe burden of cardiovascular risk factors among Greek adults is alarming. There is considerable preventive potential and actions at health care and societal level are urgently needed.

Effects of individual and integrated cumulative burden of blood pressure, glucose, low-density lipoprotein cholesterol, and C-reactive protein on cardiovascular risk.

This study aimed to demonstrate the impact of cumulative burden of cardiovascular risk factors (CVRFs) on risk of cardiovascular events (CVEs). A total of 34959 participants were enrolled who participated in the four surveys during 2006-2013. Cumulative CVRF burden was calculated as number of years (2006-2013) multiplied by the values of CVRFs including systolic blood pressure, fasting blood glucose (FBG), low-density lipoprotein cholesterol (LDL-C), and high-sensitive C-reactive protein (hs-CRP). The primary outcome was defined as the CVE during 2012-2017, including ischaemic stroke, myocardial infarction, and all-cause mortality. During 4.62 (±0.71) years follow-up on average, there were 2118 (6.06%) CVE, including 847 (2.42%) ischaemic stroke, 221 (0.63%) myocardial infarction, and 1185 (3.39%) all-cause mortality. Higher cumulative burden of individual CVRF was significantly associated with increased risk of outcomes, except for LDL-C for all-cause mortality, FBG for myocardial infarction, and hs-CRP for ischaemic stroke. In Cox proportional hazards model, compared with the group, of the lower quartile of integrated cumulative burden, the hazard ratio (95% confidence intervals) of the upper quartile was 2.45 (2.03-2.94) for CVE, 3.65 (2.68-4.96) for ischaemic stroke, 4.51 (2.19-9.27) for myocardial infarction, and 1.73 (1.36-2.21) for all-cause mortality. We demonstrated the correlation between cumulative burden of CVRFs and cardiovascular risk, except for cumulative burden of hs-CRP and ischaemic stroke. Thus, our study suggests the necessity to extend the observation duration of CVRFs in order to elucidate the life-course cumulative effect.

An absolute risk-guided approach to cardiovascular risk management within a chest pain clinic: the ARCPAC randomized trial

Abstract Background The majority of patients attending chest pain clinics are found not to have a cardiac cause of their symptoms, but have a high burden of cardiovascular risk factors that may be opportunistically addressed. Absolute risk calculators are recommended to guide risk factor management, although it is uncertain to what extent these calculations may assist with patient engagement in risk factor modification. Purpose We sought to determine the usefulness of a proactive, absolute risk-based approach, to guide opportunistic cardiovascular risk factor management within a chest pain clinic. Methods This was a prospective, open-label, blinded-endpoint study in 192 enhanced risk (estimated 5-year risk ≥8%, based on Australian Absolute Risk Calculator) patients presenting to a tertiary hospital chest pain clinic. Patients were randomized to best practice usual care, or intervention with development of a proactive cardiovascular risk management strategy framed around a discussion of the individual's absolute risk. Patients found to have a cardiac cause of symptoms were excluded as they constitute a secondary prevention population. Primary outcome was 5-year absolute cardiovascular risk score at minimum 12 months follow up. Secondary outcomes were individual modifiable risk factors (lipid profile, blood pressure, smoking status). Results 192 people entered the study; 100 in the intervention arm and 92 in usual care. There was no statistical difference between the two groups' baseline sociodemographic and clinical variables. The intervention group showed greater reduction in 5-year absolute risk scores (difference −2.77; p<0.001), and more favourable individual risk factors, although only smoking status and LDL cholesterol reached statistical significance (table). Conclusion An absolute risk-guided proactive risk factor management strategy employed opportunistically in a chest pain clinic significantly improves 5-year cardiovascular risk scores. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Tasmanian Community Fund

Clinical impact of peripheral artery disease on acute coronary syndrome

Abstract Introduction Peripheral artery disease (PAD) and acute coronary syndrome (ACS) are two diseases with high morbidity and mortality and, sometimes, may be present simultaneously, making patient management more complex. Purpose This study sought to characterize and evaluate the prognostic impact of PAD in patients with an ACS. Methods This was a retrospective study of patients admitted with an ACS, periodically included in a national multicenter registry, between October 2010 and September 2019. Results Of a total of 26036 patients, 1429 had previous history of PAD. This group had a higher predominance of men (79,5% vs 72,0%, p<0,001) and was older (71±11 years vs 66±14 years, p<0,001). Besides having a higher burden of cardiovascular risk factors, they also had more past history of myocardial infarction (MI), stroke and chronic kidney disease. In patients with PAD, non-ST segment elevation MI was the most frequent type of MI (58,6% vs 45,0%, p<0,001) and left ventricular ejection fraction assessed during hospitalization was lower (49±13% vs 51±12%, p<0,001). These patients were submitted less frequently to a coronary angiography (74,0% vs 85,2%, p<0,001) and, when performed, more cases of multivessel coronary artery disease were found (70,6% vs 50,4%, p<0,001). Nevertheless, they were less likely to undergo revascularization, with fewer angioplasties performed (47,8% vs 64,7%, p<0,001), despite the greater number of coronary artery bypass grafting (9,0% vs 6,0%, p<0,001). Both during hospitalization and at discharge, ticagrelor, beta-blockers and ACE inhibitors were less prescribed in the PAD group. Statins prescription was also lower, but only at discharge. In a multivariate regression analysis, we found that, during hospitalization, the presence of PAD was associated with a significant higher risk of myocardial reinfarction (OR 1,90 (CI 1,18–3,06)) and death (OR 1,43 (CI 1,03–2,00)). In addition, there was a tendency for more strokes (OR 1,88 (CI 0,98–3,61)). During a 1-year follow-up, PAD was also independently associated with a significant increase in mortality (HR 1,50 (CI 1,16–1,95)). Conclusions PAD is a disease present in patients with a higher number of comorbidities and is associated with more severe coronary events. Nevertheless, these patients seem to receive less evidence-based therapy. In this study, PAD was independently associated with a significant increase in short and medium-term major adverse events. Kaplan-Meier curves of 1-year follow-up Funding Acknowledgement Type of funding source: None

20-Year trend of high prevalence of zero coronary artery calcium in beach cities of Southern California: A blue zone?

BackgroundBlue zones are longevity hotspots around the world characterized by highest concentrations of healthy centenarians. Certified blue zone communities are designed by implementation of environmental and policy changes that promote healthy behaviors. ObjectiveTo examine the trends of prevalence of zero CAC, a marker of ideal cardiovascular and overall health status and burden of cardiovascular risk factors in Beach Cities/certified blue zones of Southern California and rest of California. MethodsThis is a population-based cohort study of persons aged 50 years or older in California, who underwent CAC screening between 2000 and 2019. A total of 3864 participants from Beach Cities of Southern California were identified by Zip Codes and compared with 35,537 participants from rest of California. We compared trends of prevalence of zero CAC and cardiovascular risk factors between the two groups, in 5-year intervals. ResultsAmong 39,401 participants (mean age, 58.1 years; 36% women), 13,374 (34%) had zero CAC. The prevalence of CAC ​= ​0 was significantly higher in Beach Cities compared to the rest of California (p ​< ​0.001). Across the study period, the prevalence of cardiac risk factors including obesity, smoking, diabetes and hypertension remain significantly lower in Beach Cities. (p ​< ​0.001) ConclusionsThis study, shows for the first time, that higher prevalence of zero CAC in Beach Cities of California, adds validity to excellent prognosis and longevity in these areas. The impact of policy implementation and environmental changes on lifestyle patterns, cardiovascular health and healthy ageing needs to be evaluated.

Increased burden of cardiovascular risk among youth suicide attempters.

Suicide and cardiovascular disease rank among the leading causes of disability and premature mortality worldwide. Young adult suicide attempters are at increased risk of mortality from cardiovascular disease even compared to those with major depressive disorder suggesting an increased burden of cardiovascular risk factors. We compared the cardiovascular risk burden between youth attempters and other high-risk individuals. Participants were from the Collaborative Psychiatric Epidemiology Surveys (CPES), a U.S. population-based study, aged 18-30 years [suicide attempt (SA): n = 303; suicidal ideation (SI): n = 451; controls: n = 3671]; and psychiatric inpatients admitted for a SA (n = 38) or SI (n = 40) and healthy controls (n = 37) aged 15-30 years. We computed a cardiovascular risk score and high- and low-risk latent classes based on risk factors of high blood pressure, obesity, and smoking. Suicide attempters showed an increased cardiovascular risk score (CPES: B = 0.43, 95% confidence interval (CI) 0.31-0.54, p < 0.001; inpatient sample: B = 1.61, 95% CI 0.53-2.68, p = 0.004) compared to controls. They were also more likely to be classified in the high cardiovascular risk group (CPES: odds ratio (OR) 3.36, 95% CI 1.67-6.78, p = 0.001; inpatient sample: OR 9.89, 95% CI 1.38-85.39, p = 0.03) compared to those with SI (CPES: OR 1.15, 95% CI 0.55-2.39, p = 0.71; inpatient sample: OR 1.91, 95% CI 0.25-15.00, p = 0.53). Youth attempters show an increased burden for cardiovascular risk compared to other high-risk individuals in inpatient and population-based samples. Clinicians should pay particular attention to cardiovascular risk factors among suicide attempters in order to reduce their risk for cardiovascular events.

South Asian ethnicity as a risk factor for coronary heart disease

Background and aimsSouth Asian ethnicity has been associated with increased cardiovascular risk, in the context of a greater burden of traditional cardiovascular disease risk factors. We aimed to identify the 10-year incidence of coronary heart disease (CHD) in South Asians, as compared to other racial-ethnic groups, in a retrospective cohort study, using the Kaiser Permanente Northern California integrated health care system, and to understand whether traditional risk factors could explain differences in outcomes. Methods and resultsA study cohort established in 2006, with 10-year follow-up, identified a total n = 341,309 patients, including 5149 South Asians, aged 30–70 years who underwent a screening lipid panel and had no prior history of CHD. There were a total of 460 (8.93%) patients with at least one cardiovascular event, including cardiovascular death, coronary artery revascularization, and myocardial infarction, in South Asians, as compared to 5.66% patients in the total population (p < 0.0001). In a multivariable logistic regression analysis, South Asian ethnicity, compared to White race, was associated with an adjusted odds ratio (aOR) = 2.04 (95%CI: 1.83, 2.28) in predicting the cardiovascular outcomes. ConclusionsSouth Asian ethnicity, even after adjustment for traditional risk factors, is associated with an increased risk of coronary heart disease outcomes. This risk was greater than other studied racial-ethnic groups and second only to diabetes in CHD risk prediction.

“Man Is as Old as His Arteries” Taken Literally

“Man Is as Old as His Arteries” Taken Literally

Characteristics of Large-Vessel Occlusion Associated with COVID-19 and Ischemic Stroke.

The mechanisms and phenotype of ischemic stroke associated with coronavirus disease 2019 (COVID-19) remain uncertain. A retrospective study was conducted in patients with COVID-19 presenting with ischemic stroke from March 1 to May 25, 2020, and cases with large-vessel occlusion were identified. To provide baseline institutional stroke data within and outside the COVID-19 pandemic, all consecutive ischemic stroke and TIA admissions (COVID and non-COVID) to the hospital during a 10-week period from March 1 to May 10, 2020, were collected and compared with data from the same time period in 2019. Among 20 patients with COVID-19 and acute ischemic stroke, 15 (75%) had large-vessel occlusion. These patients were young (mean age, 46.5 years), male (93%), without major burden of traditional cardiovascular risk factors, and had a severe stroke presentation. Large-vessel occlusions were observed in multiple vessels (40%), uncommonly affected vessels, and atypical locations with a large thrombus burden. Systemic thrombosis separate from large-vessel occlusion was not uncommon (26%). At short-term follow-up, stroke etiology remained undetermined in 46% of patients and functional outcome was poor. The above findings raise the possibility of stroke related to mechanisms induced by the COVID-19 infection itself, including a hypercoagulable state and/or endothelial damage. In addition, they document the severe presentation and poor outcomes of large-vessel occlusion in COVID-19 ischemic stroke.

Trends in cardiovascular diseases burden and vascular risk factors in Italy: The Global Burden of Disease study 1990–2017

An exhaustive and updated estimation of cardiovascular disease burden and vascular risk factors is still lacking in European countries. This study aims to fill this gap assessing the global Italian cardiovascular disease burden and its changes from 1990 to 2017 and comparing the Italian situation with European countries. All accessible data sources from the 2017 Global Burden of Disease study were used to estimate the cardiovascular disease prevalence, mortality and disability-adjusted life years and cardiovascular disease attributable risk factors burden in Italy from 1990 to 2017. Furthermore, we compared the cardiovascular disease burden within the 28 European Union countries. Since 1990, we observed a significant decrease of cardiovascular disease burden, particularly in the age-standardised prevalence (-12.7%), mortality rate (-53.8%), and disability-adjusted life years rate (-55.5%). Similar improvements were observed in the majority of European countries. However, we found an increase in all-ages prevalence of cardiovascular diseases from 5.75 m to 7.49 m Italian residents. Cardiovascular diseases still remain the first cause of death (34.8% of total mortality). More than 80% of the cardiovascular disease burden could be attributed to known modifiable risk factors such as high systolic blood pressure, dietary risks, high low density lipoprotein cholesterol, and impaired kidney function. Our study shows a decline in cardiovascular mortality and disability-adjusted life years, which reflects the success in reducing disability, premature death and early incidence of cardiovascular diseases. However, the burden of cardiovascular diseases is still high. An approach that includes the cooperation and coordination of all stakeholders of the Italian National Health System is required to further reduce this burden.

Imaging of Clinically Unrecognized Myocardial Fibrosis in Patients With Suspected Coronary Artery Disease

BackgroundStress cardiac magnetic resonance (CMR) provides accurate assessment of both myocardial infarction (MI) and ischemia. ObjectivesThis study aimed to evaluate the incremental prognostic value of unrecognized myocardial infarction (UMI), detected during assessment of coronary artery disease (CAD) by stress CMR, beyond cardiac function and ischemia. MethodsIn the multicenter SPINS (Stress CMR Perfusion Imaging in the United States) study, 2,349 consecutive patients (63 ± 11 years of age, 53% were male) with suspected CAD were assessed by stress CMR and followed over a median of 5.4 years. UMI was defined as the presence of late gadolinium enhancement consistent with MI in the absence of medical history of MI. This study investigated the association of UMI with all-cause mortality and nonfatal MI (death and/or MI), and major adverse cardiac events (MACE). ResultsUMI was detected in 347 patients (14.8%) and clinically recognized myocardial infarction (RMI) in 358 patients (15.2%). Compared with patients with RMI, patients with UMI had a similar burden of cardiovascular risk factors, but significantly lower left ventricular ejection fraction (p < 0.001) and lower rates of guideline-directed medical therapies, including aspirin (p < 0.001), statin (p < 0.001), and beta-blockers (p = 0.002). During follow-up, 328 deaths and/or MIs and 528 MACE occurred. In univariate analysis, UMI and RMI were strongly associated with death and/or MI (UMI: hazard ratio [HR]: 2.15; 95% confidence interval [CI]: 1.63 to 2.83; p < 0.001; RMI: HR: 2.45; 95% CI: 1.89 to 3.18) and MACE. Compared with patients with RMI, patients with UMI presented an increased risk for heart failure hospitalization (UMI vs. RMI: HR: 2.60; 95% CI: 1.48 to 4.58; p < 0.001). In a multivariate model including ischemia and left ventricular ejection fraction, UMI and RMI maintained robust prognostic association with death and/or MI (UMI: HR: 1.82; 95% CI: 1.37 to 2.42; p < 0.001; RMI: HR: 1.54; 95% CI: 1.14 to 2.09) and MACE. ConclusionsIn a multicenter cohort of patients with suspected CAD, presence of UMI or RMI portended an equally significant risk for death and/or MI, independently of the presence of ischemia. Compared with RMI patients, those with UMI were less likely to receive guideline-directed medical therapies and presented an increased risk for heart failure hospitalization that warrants further study. (Stress CMR Perfusion Imaging in the United States [SPINS]; NCT03192891)

Left Ventricular Mass Index Is Associated With Cognitive Function in Middle-Age: Bogalusa Heart Study.

Elevated cardiovascular disease risk factor burden is a recognized contributor to poorer cognitive function; however, the physiological mechanisms underlying this association are not well understood. We sought to assess the potential mediation effect of left ventricular (LV) remodeling on the association between lifetime systolic blood pressure and cognitive function in a community-based cohort of middle-aged adults. Nine hundred sixty participants of the Bogalusa Heart Study (59.2% women, 33.8% black, aged 48.4±5.1 years) received 2-dimensional echocardiography to quantify relative wall thickness, LV mass, and diastolic and systolic LV function; and a standardized neurocognitive battery to assess memory, executive functioning, and language processing. Multivariable linear regression assessed the association of cardiac structure and function with a global composite cognitive function score, adjusting for traditional cardiovascular disease risk factors. Mediation analysis assessed the effect of LV mass index on the association between lifetime systolic blood pressure burden and cognitive function. There were 233 (24.3%) and 136 (14.2%) individuals with concentric LV remodeling and concentric LV hypertrophy, respectively. Each g/m2.7 increment in LV mass index was associated with a 0.03 standardized unit decrement in global cognitive function (P=0.03). Individuals with concentric LV remodeling and isolated diastolic dysfunction had the poorest cognitive function, and a greater ratio between early mitral inflow velocity and early diastolic mitral annular velocity (E/e') was associated with poorer cognitive function, even after adjustment for LV mass index (B=-0.12; P=0.03). A total of 18.8% of the association between lifetime systolic blood pressure burden and midlife cognitive function was accounted for by LV mass index. Cardiac remodeling partially mediates the association between lifespan systolic blood pressure burden and adult cognition in individuals without dementia or clinical cardiovascular disease. Slowing or reversing the progression of cardiac remodeling in middle-age may be a novel therapeutic approach to prevent cognitive decline.

Association of Cardiovascular Disease Risk Factor Burden With Progression of Coronary Atherosclerosis Assessed by Serial Coronary Computed Tomographic Angiography

Several studies have reported that the progression of coronary atherosclerosis, as measured by serial coronary computed tomographic (CT) angiography, is associated with the risk of future cardiovascular events. However, the cumulative consequences of multiple risk factors for plaque progression and the development of adverse plaque characteristics have not been well characterized. To examine the association of cardiovascular risk factor burden, as assessed by atherosclerotic cardiovascular disease (ASCVD) risk score, with the progression of coronary atherosclerosis and the development of adverse plaque characteristics. This cohort study is a subgroup analysis of participant data from the prospective observational Progression of Atherosclerotic Plaque Determined by Computed Tomographic Angiography Imaging (PARADIGM) study, which evaluated the association between serial coronary CT angiography findings and clinical presentation. The PARADIGM international multicenter registry, which includes 13 centers in 7 countries (Brazil, Canada, Germany, Italy, Portugal, South Korea, and the US), was used to identify 1005 adult patients without known coronary artery disease who underwent serial coronary CT angiography scans (median interscan interval, 3.3 years; interquartile range [IQR], 2.6-4.8 years) between December 24, 2003, and December 16, 2015. Based on the 10-year ASCVD risk score, the cardiovascular risk factor burden was classified as low (<7.5%), intermediate (7.5%-20.0%), or high (>20.0%). Data were analyzed from February 8, 2019, to April 17, 2020. Association of baseline ASCVD risk burden with plaque progression. Noncalcified plaque, calcified plaque, and total plaque volumes (mm3) were measured. Noncalcified plaque was subclassified using predefined Hounsfield unit thresholds for fibrous, fibrofatty, and low-attenuation plaque. The percent atheroma volume (PAV) was defined as plaque volume divided by vessel volume. Adverse plaque characteristics were defined as the presence of positive remodeling, low-attenuation plaque, or spotty calcification. In total, 1005 patients (mean [SD] age, 60 [8] years; 575 men [57.2%]) were included in the analysis. Of those, 463 patients (46.1%) had a low 10-year ASCVD risk score (low-risk group), 373 patients (37.1%) had an intermediate ASCVD risk score (intermediate-risk group), and 169 patients (16.8%) had a high ASCVD risk score (high-risk group). The annualized progression rate of PAV for total plaque, calcified plaque, and noncalcified plaque was associated with increasing ASCVD risk (r = 0.26 for total plaque, r = 0.23 for calcified plaque, and r = 0.11 for noncalcified plaque; P < .001). The annualized PAV progression of total plaque, calcified plaque, and noncalcified plaque was significantly greater in the high-risk group compared with the low-risk and intermediate-risk groups (for total plaque, 0.99% vs 0.45% and 0.58%, respectively; P < .001; for calcified plaque, 0.61% vs 0.23% and 0.36%; P < .001; and for noncalcified plaque, 0.38%vs 0.22% and 0.23%; P = .01). When further subclassified by noncalcified plaque type, the annualized PAV progression of fibrofatty and low-attenuation plaque was greater in the high-risk group (0.09% and 0.02%, respectively) compared with the low- to intermediate-risk group (n = 836; 0.02% [P = .02] and 0.001% [P = .008], respectively). The interval development of adverse plaque characteristics was greater in the high-risk group compared with the low-risk and intermediate-risk groups (for new positive remodeling, 73 patients [43.2%] vs 151 patients [32.6%] and 133 patients [35.7%], respectively; P = .02; for new low-attenuation plaque, 26 patients [15.4%] vs 44 patients [9.5%] and 35 patients [9.4%]; P = .02; and for new spotty calcification, 37 patients [21.9%] vs 52 patients [11.2%] and 54 patients [14.5%]; P = .002). The progression of noncalcified plaque subclasses and the interval development of adverse plaque characteristics did not significantly differ between the low-risk and intermediate-risk groups. Progression of coronary atherosclerosis occurred across all ASCVD risk groups and was associated with an increase in 10-year ASCVD risk. The progression of fibrofatty and low-attenuation plaques and the development of adverse plaque characteristics was greater in patients with a high risk of ASCVD.