Coronary Events Research Articles

Footsteps to Wellness: A Systematic Review and Meta-Analysis of Walking Pace and Coronary Artery Disease Event.

Coronary artery disease (CAD) poses a global health challenge, necessitating effective preventive strategies. Despite the pivotal role of physical activity in cardiovascular health, many fall short of recommended guidelines for daily physical activity. Simple and accessible, walking presents an opportunity, with increased pace emerging as a potential strategy for reducing the risk of cardiovascular diseases. Thus, we aimed to elucidate the potential association between walking pace and the risk of CAD events in adults without a prior history of CAD through a systematic review. We searched PubMed, Scopus, Web of Science, and ScienceDirect without publication date restrictions to identify prospective cohorts that analyzed walking pace and adult CAD events. The literature search conducted from April 02, 2023, to August 21, 2023, identified a total of four studies (six cohorts) for meta-analysis using random-effects models. The Newcastle-Ottawa Scale was used to assess study quality, and data extraction involved two independent reviewers. The analysis calculated overall relative risks (RRs) and 95% confidence intervals (CIs) for those with the quickest walking paces compared to those with the slowest walking paces. A funnel plot analysis for publication bias and subgroup analysis were also conducted. Results from the meta-analysis involving 160,519 participants and 3,351 CAD events demonstrated a 46% decreased risk for those walking at the quickest pace (pooled RR = 0.54, 95% CI = 0.45-0.66). No significant heterogeneity was observed. In conclusion, walking pace emerges as a significant risk factor for CAD events in adults without a prior history of CAD. It serves as a potential screening tool to identify individuals at higher risk. Promoting a faster walking pace as a daily activity may effectively mitigate the burden of CAD.

Cholesterol-Lowering Strategies for Cardiovascular Disease Prevention: The Importance of Intensive Treatment and the Simplification of Medical Therapy.

Cardiovascular diseases (CVDs) are a leading global cause of mortality and are primarily driven by atherosclerotic coronary artery disease. Their pathogenesis involves multi-factorial mechanisms, among which low-density lipoprotein (LDL) plays a causative role. Recent ESC/EAS guidelines advocate for a shift toward new risk estimation algorithms that better emphasize non-fatal cardiovascular events, lifetime risk prediction, and tailored pharmacological approaches, including statin + ezetimibe and triple therapy, in specific cases. Intensive lipid-lowering therapy has been shown to be pivotal, especially in post-acute coronary events. Intracoronary imaging has revealed insights into the composition of plaque and demonstrated the significant regression that can be achieved through the use of statins such as rosuvastatin and atorvastatin. The positive effects of Proprotein Convertase Subtilisin/Kexin type 9 (PCSK9) inhibitors, particularly alirocumab and evolocumab, on plaque regression, have been demonstrated. Inclisiran, which targets PCSK9 gene expression, significantly reduces LDL cholesterol. The associated challenges include hesitancy to prescribe intensive regimens and limited treatment adherence, highlighting the need for pharmacological combinations to improve therapeutic outcomes.

Impact of changes in Achilles tendon thickening on cardiovascular events in patients with familial hypercholesterolemia

BackgroundAchilles tendon thickening (ATT) can be ameliorated by lowering low-density lipoprotein (LDL) levels in patients with familial hypercholesterolemia (FH). The Japan Atherosclerosis Society (JAS) defines ATT as ≥8.0 mm in males and ≥7.5 mm in females. We aimed to determine the clinical impact of changes in ATT on the development of major adverse cardiovascular events (MACE). MethodsPatients with clinically diagnosed heterozygous FH (HeFH) (N = 1273; 614 males, 659 females) with ATT data from X-ray were assessed. Patients were divided into four groups: patients without ATT from baseline until follow-up (group 1), patients without ATT at baseline but developed ATT at follow-up (group 2), patients with ATT at baseline but regressed at follow-up (group 3), and patients with ATT from baseline until follow-up (group 4). Cox proportional hazard models were used to assess the factors associated with MACE, including cardiovascular death and any coronary events. ResultsOn follow-up (median: 10.9 years), 142 MACEs were observed, and the median ATT regressed from 7.8 to 7.6 mm. Changes in ATT were significantly associated with the occurrence of MACE in all groups, when compared to group 1 (hazard ratio [HR]: 2.73; 95 % confidence interval [CI]: 1.33–4.13 [p < 0.001], HR: 2.18, 95 % CI: 1.08–3.28, [p < 0.001], HR: 6.34, 95 % CI: 3.10–9.58, [p < 0.001], in groups 2, 3, and 4, respectively). ConclusionsAssessing ATT has diagnostic value and allows for risk stratification among patients with HeFH.

Causal association of TSH with ischemic heart diseases and heart failure: A 2-sample Mendelian randomization study.

Thyroid dysfunction is associated with the risk of cardiovascular disease; however, whether plasma thyroid-stimulating hormone (TSH) levels in subjects with euthyroidism affect the risk of cardiovascular disease remains unclear. This study aimed to investigate the causal association between plasma TSH levels and cardiovascular diseases, particularly ischemic heart disease and heart failure (HF). Summary statistics from the Integrative Epidemiology Unit Open genome-wide association studies Project and FinnGen consortium were used to investigate the causal relationship between plasma TSH levels and the risk of cardiovascular diseases. Two-sample Mendelian randomization analysis using inverse-variance weighting as the primary method was performed. The MR Pleiotropy RESidual Sum and Outlier and leave-one-out methods were used to ensure the robustness of our findings. Genetically determined plasma TSH levels were associated with major coronary heart disease events (OR 1.0557, 95% CI 1.0141-1.0991), all-cause HF (OR 0.9587, 95% CI 0.9231-0.9956), and HF + non-ischemic cardiomyopathy (OR 0.9318, 95% CI 0.8786-0.9882). After the Bonferroni correction, the causation described above disappeared. In the secondary analysis, genetically determined higher TSH levels were associated with a higher risk for unstable angina pectoris (OR 1.0913, 95% CI 1.0350-1.1507), but were associated with a lower risk for HF + overweight (OR 0.9265, 95% CI 0.8821-0.9731). These results were further validated using sensitivity analysis. Our findings show that increased plasma TSH levels in patients with euthyroidism may increase the risk of unstable angina pectoris but reduce the risk of HF in overweight patients. This evidence indicates that plasma TSH levels may need to be carefully controlled in specific patients.

Using Principles of Digital Development for a Smartphone App to Support Data Collection in Patients With Acute Myocardial Infarction and Physical Activity Intolerance: Case Study.

Advances in health have highlighted the need to implement technologies as a fundamental part of the diagnosis, treatment, and recovery of patients at risk of or with health alterations. For this purpose, digital platforms have demonstrated their applicability in the identification of care needs. Nursing is a fundamental component in the care of patients with cardiovascular disorders and plays a crucial role in diagnosing human responses to these health conditions. Consequently, the validation of nursing diagnoses through ongoing research processes has become a necessity that can significantly impact both patients and health care professionals. We aimed to describe the process of developing a mobile app to validate the nursing diagnosis "intolerance to physical activity" in patients with acute myocardial infarction. We describe the development and pilot-testing of a mobile system to support data collection for validating the nursing diagnosis of activity intolerance. This was a descriptive study conducted with 11 adults (aged ≥18 years) who attended a health institution for highly complex needs with a suspected diagnosis of coronary syndrome between August and September 2019 in Floridablanca, Colombia. An app for the clinical validation of activity intolerance (North American Nursing Diagnosis Association [NANDA] code 00092) in patients with acute coronary syndrome was developed in two steps: (1) operationalization of the nursing diagnosis and (2) the app development process, which included an evaluation of the initial requirements, development and digitization of the forms, and a pilot test. The agreement level between the 2 evaluating nurses was evaluated with the κ index. We developed a form that included sociodemographic data, hospital admission data, medical history, current pharmacological treatment, and thrombolysis in myocardial infarction risk score (TIMI-RS) and GRACE (Global Registry of Acute Coronary Events) scores. To identify the defining characteristics, we included official guidelines, physiological measurements, and scales such as the Piper fatigue scale and Borg scale. Participants in the pilot test (n=11) had an average age of 63.2 (SD 4.0) years and were 82% (9/11) men; 18% (2/11) had incomplete primary schooling. The agreement between the evaluators was approximately 80% for most of the defining characteristics. The most prevalent characteristics were exercise discomfort (10/11, 91%), weakness (7/11, 64%), dyspnea (3/11, 27%), abnormal heart rate in response to exercise (2/10, 20%), electrocardiogram abnormalities (1/10, 9%), and abnormal blood pressure in response to activity (1/10, 10%). We developed a mobile app for validating the diagnosis of "activity intolerance." Its use will guarantee not only optimal data collection, minimizing errors to perform validation, but will also allow the identification of individual care needs.

Development and validation of a prognostic score integrating remote heart failure symptoms and clinical variables in mortality risk prediction after myocardial infarction: the PragueMi score.

While heart failure (HF) symptoms are associated with adverse prognosis after myocardial infarction (MI), they are not routinely used for patients' stratification. The primary objective of this study was to develop and validate a score to predict mortality risk after MI, combining remotely recorded HF symptoms and clinical risk factors, and to compare it against the guideline-recommended Global Registry of Acute Coronary Events (GRACE) score. A cohort study design using prospectively collected data from consecutive patients hospitalized for MI at a large tertiary heart centre between June 2017 and September 2022 was used. Data from 1135 patients (aged 64 ± 12 years, 26.7% women), were split into derivation (70%) and validation cohort (30%). Components of the 23-item Kansas City Cardiomyopathy Questionnaire and clinical variables were used as possible predictors. The best model included the following variables: age, HF history, admission creatinine and heart rate, ejection fraction at hospital discharge, and HF symptoms 1 month after discharge including walking impairment, leg swelling, and change in HF symptoms. Based on these variables, the PragueMi score was developed. In the validation cohort, the PragueMi score showed superior discrimination to the GRACE score for 6 months [the area under the receiver operating curve (AUC) 90.1, 95% confidence interval (CI) 81.8-98.4 vs. 77.4, 95% CI 62.2-92.5, P = 0.04) and 1-year risk prediction (AUC 89.7, 95% CI 83.5-96.0 vs. 76.2, 95% CI 64.7-87.7, P = 0.004). The PragueMi score combining HF symptoms and clinical variables performs better than the currently recommended GRACE score.

Health and Economic Value of Eliminating Socioeconomic Disparities in US Youth Physical Activity

There are considerable socioeconomic status (SES) disparities in youth physical activity (PA) levels. For example, studies show that lower-SES youth are less active, have lower participation in organized sports and physical education classes, and have more limited access to PA equipment. To determine the potential public health and economic effects of eliminating disparities in PA levels among US youth SES groups. An agent-based model representing all 6- to 17-year-old children in the US was used to simulate the epidemiological, clinical, and economic effects of disparities in PA levels among different SES groups and the effect of reducing these disparities. Anthropometric measures (eg, body mass index) and the presence and severity of risk factors associated with weight (stroke, coronary heart disease, type 2 diabetes, or cancer), as well as direct and indirect cost savings. This model, representing all 50 million US children and adolescents 6 to 17 years old, found that if the US eliminates the disparity in youth PA levels across SES groups, absolute overweight and obesity prevalence would decrease by 0.826% (95% CI, 0.821%-0.832%), resulting in approximately 383 000 (95% CI, 368 000-399 000) fewer cases of overweight and obesity and 101 000 (95% CI, 98 000-105 000) fewer cases of weight-related diseases (stroke and coronary heart disease events, type 2 diabetes, or cancer). This would result in more than $15.60 (95% CI, $15.01-$16.10) billion in cost savings over the youth cohort's lifetime. There are meaningful benefits even when reducing the disparity by just 25%, which would result in $1.85 (95% CI, $1.70-$2.00) billion in direct medical costs averted and $2.48 (95% CI, $2.04-$2.92) billion in productivity losses averted. For every 1% in disparity reduction, total productivity losses would decrease by about $83.8 million, and total direct medical costs would decrease by about $68.7 million. This study quantified the potential savings from eliminating or reducing PA disparities, which can help policymakers, health care systems, schools, funders, sports organizations, and other businesses better prioritize investments toward addressing these disparities.

Pulmonary edema in a young male with severe uncontrolled cardiovascular risk factors and pan-vascular atherosclerosis: a case report.

Cardiovascular risk factors are the cause of atherosclerotic disease, which can involve all the elastic and muscolo-elastic arteries. The etiopathogenesis of atherosclerosis is multifactorial since genetics, lifestyle, and comorbidities can be simultaneously involved. Clinical manifestations can be heterogeneous and include myocardial infarction, stroke, aortic aneurysms, renal artery stenosis, renal insufficiency, peripheral artery disease, etc. Currently, 70% of clinical events cannot be prevented with available drug therapy, statins included, and at least 10% of coronary events occur in apparently healthy individuals in the absence of major traditional risk factors. The case of a young male with a history of coronary artery disease and multiple atherosclerotic risk factors not properly treated who was admitted to the emergency department for pulmonary edema and high blood pressure is presented. During the diagnostic workup, a dramatic atherosclerotic involvement of all arterial trees emerged. Moreover, the patient presented with thrombosis of the right subclavian artery, which was treated with a heparin infusion and later complicated by cerebral hemorrhage with residual hemiplegia.

Secondary Analysis of the Salt Substitute and Stroke Study (SSaSS): Effects of Potassium-Enriched Salt on Cardiac Outcomes.

The SSaSS (Salt Substitute and Stroke Study) has shown that use of a potassium-enriched salt lowers the risk of stroke, total cardiovascular events, and premature death. The effects on cause-specific cardiac outcomes are reported here. SSaSS was an unblinded, cluster-randomised trial assessing the effects of potassium-enriched salt compared with regular salt among 20 995 Chinese adults with established stroke and older age and uncontrolled hypertension. Post hoc efficacy analyses were performed using an intention-to-treat method and a hierarchical Poisson regression model adjusting for clustering to obtain rate ratios and 95% CIs. We assessed acute coronary syndrome, heart failure, arrhythmia, and sudden death. Over a mean 4.74 years follow-up, there were 695 acute coronary syndrome events, 454 heart failure events, 230 arrhythmia events, and 1133 sudden deaths recorded. The rates of events were lower in potassium-enriched salt group for all outcomes but CIs were wide for most: acute coronary syndrome (6.32 versus 7.65 events per 1000 person-years; rate ratio, 0.80 [95% CI, 0.65-0.99]); heart failure (9.14 versus 11.32 events per 1000 person-years; rate ratio, 0.88 [95% CI, 0.60-1.28]); arrhythmia (4.43 versus 6.20 events per 1000 person-years; rate ratio, 0.59 [95% CI, 0.35-0.98]); and sudden death (11.01 versus 11.76 events per 1000 person-years; rate ratio, 0.94 [95% CI, 0.82-1.07]; all P>0.05 with adjustment for multiple comparisons). These results suggest that use of potassium-enriched salt is more likely to prevent than cause cardiac disease but the post hoc nature of these analyses precludes definitive conclusions. URL: https://www.clinicaltrials.gov; Unique identifier: NCT02092090.

Patients' preferences for secondary prevention following a coronary event

ObjectiveDespite clear evidence on the effectiveness of secondary prevention, patients with coronary artery disease frequently fail to reach guideline-based risk factor targets. Integrating patients’ preferences into treatment decisions has been recommended to reduce this gap. However, this requires knowledge about patient treatment preferences. Therefore, through a survey study, we aimed to explore which risk factors patients self-perceived, prioritised for improvement, and needed support with after a recent hospitalisation for coronary heart disease. MethodsA digital questionnaire was presented to patients > 18 years recently discharged (≤3 months) from an acute coronary care unit in the Netherlands (Europe). Patients could select from eight cardiovascular risk factors that they (1) self-perceived, (2) prioritised for improvement, and (3) needed support to improve. Patients’ perceived risk factors were compared to those documented in the medical records. ResultsRespondents (N = 254, 26 % women), mean age 64 (SD 10) years, identified ‘physical inactivity’ more frequently than their medical records (140 patients vs. 91 records, p < 0.001), while three other risk factors were reported with equal and four with lower frequency. ‘Physical inactivity’, ‘overweight’ and ‘stress’ were most frequently prioritised for improvement (82 %, 88 % and 78 %) and professional support (64 %, 50 % and 58 %), with 87 % preferring lifestyle optimisation if this would reduce drug use. ConclusionsPatients with a recent coronary event show significant disparities in identifying risk factors compared to their medical records. They tend to prefer improving lifestyle- over drug-modifiable risk factors, particularly physical inactivity, overweight and stress, and indicate the need for support in improving these factors.

Prevalence, clinical features and prognosis of familial hypercholesterolemia in Chinese Han patients with acute coronary syndrome after a coronary event: a retrospective observational study

BackgroundFamilial hypercholesterolemia (FH) is an autosomal semi-dominant disease, characterized by markedly elevated levels of low-density lipoprotein cholesterol (LDL-c) from conception and accelerated atherosclerotic cardiovascular disease, often resulting in early death. The aim of this study was to evaluate the prevalence of clinically defined FH in Chinese Han patients with acute coronary syndrome (ACS) and compare the long-term prognosis of ACS patients with and without FH receiving lipid-lowering therapy containing statins after a coronary event.MethodsAll ACS patients were screened at the Second Affiliated Hospital of Xi’an Jiaotong University between Jan 2019 and Sep 2020, and 531 participants were enrolled. All were examined for FH under the Dutch Lipid Clinical Network (DLCN) criteria, and those patients were divided into definite/probable FH, possible FH and unlikely FH. The severity of coronary artery disease was evaluated by the Gensini scoring system. Plasma levels of total cholesterol (TC), triacylglycerol (TG), HDL-cholesterol (HDL-c), LDL-cholesterol (LDL-c), very low-density lipoproteins-cholesterol (VLDL-c), apolipoprotein A1 (apoA1), apolipoprotein B (apoB) and lipoprotein (a) (Lp(a)) were determined centrally at baseline and the last follow-up visit in the fasting state. The non-high-density lipoprotein cholesterol (non-HDL-c) concentration, the TC/HDL-c and apoB/apoA1 ratios were calculated. After FH patients received lipid-lowering treatment containing statin, the target LDL-c levels recommended by the guidelines (LDL-c < 1.8 mmol/L or < 1.4 mmol/L and a reduction > 50% from baseline) were evaluated, and the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE) during the 12-month follow-up was recorded.ResultsThe prevalence of clinically definite or probable FH was 4.3%, and the prevalence of possible FH was 10.6%. Compared with the unlikely FH patients with ACS, the FH patients had higher levels of TC, LDL-c, apoB, Lp(a), non-HDL-c, TC/HDL-c and apoB/apoA1 ratio, more severe coronary artery diseases and greater prevalence of left main and triple or multiple vessel lesions. After lipid-lowering therapy containing statins, a minority of FH patients reached the target LDL-c levels defined by the guidelines (χ2 = 33.527, P < 0.001). During the 12-month follow-up, a total of 72 patients experienced MACCE. The survival curve in patients in the FH group was significantly lower than that in the unlikely FH group (HR = 1.530, log-rank test: P < 0.05). Furthermore, the survival curve in patients with high LDL-c (≥ 1.8 mmol/L) was significantly lower than that in patients with low LDL-c (< 1.8 mmol/L) at the 12-month follow-up visit (HR = 1.394, log-rank test: P < 0.05). No significant difference was observed between patients with LDL-c levels ≥ 1.4 mmol/L and with < 1.4 mmol/L at the 12-month follow-up visit by using Kaplan–Meier survival analysis (HR = 1.282, log-rank test: P > 0.05).ConclusionsFH was an independent risk factor for MACCE in adult patients after a coronary event during long-term follow-up. However, there was inadequate high-intensity statins prescriptions for high-risk patients in this current study. It is important for FH patients to optimize lipid-lowering treatment strategies to reach the target LDL-c level to improve the long-term prognosis of clinical outcomes.

A Non-Coronary, Peripheral Arterial Atherosclerotic Disease (Carotid, Renal, Lower Limb) in Elderly Patients-A Review PART II-Pharmacological Approach for Management of Elderly Patients with Peripheral Atherosclerotic Lesions outside Coronary Territory.

Aging is a key risk factor for atherosclerosis progression that is associated with increased incidence of ischemic events in supplied organs, including stroke, coronary events, limb ischemia, or renal failure. Cardiovascular disease is the leading cause of death and major disability in adults ≥ 75 years of age. Atherosclerotic occlusive disease affects everyday activity, quality of life, and it is associated with reduced life expectancy. As most multicenter randomized trials exclude elderly and very elderly patients, particularly those with severe comorbidities, physical or cognitive dysfunctions, frailty, or residence in a nursing home, there is insufficient data on the management of older patients presenting with atherosclerotic lesions outside coronary territory. This results in serious critical gaps in knowledge and a lack of guidance on the appropriate medical treatment. In addition, due to a variety of severe comorbidities in the elderly, the average daily number of pills taken by octogenarians exceeds nine. Polypharmacy frequently results in drug therapy problems related to interactions, drug toxicity, falls with injury, delirium, and non-adherence. Therefore, we have attempted to gather data on the medical treatment in patients with extra-cardiac atherosclerotic lesions indicating where there is some evidence of the management in elderly patients and where there are gaps in evidence-based medicine. Public PubMed databases were searched to review existing evidence on the effectiveness of lipid-lowering, antithrombotic, and new glucose-lowering medications in patients with extra-cardiac atherosclerotic occlusive disease.

Economic aspects of the cardiology program expansion of additional drugs provision by effective lipidlowering drugs for hypercholesterolemia control

The federal program of preferential drug provision in cardiology shows its effectiveness. However, hypercholesterolemia (HCH) remains a significant problem in patients in whom high-dose statin therapy does not provide the target level of low-density lipoprotein cholesterol (LDL cholesterol). The solution to the problem lies in the plane of prescribing lipid-lowering drugs of a different mechanism of action, for example, inhibitors of the PCSK9 enzyme. To recommend the inclusion of such kind drugs in the program, it is necessary not only to have evidence of their life-saving effect, but also the economic feasibility of their use. Aim: to evaluate the economic efficacy of alirocumab (INN) including in the federal program for patients who have suffered an acute coronary event, are receiving statins and have an LDL CH level of 5.0 mmol/l and higher.Materials and methods. Modeling was applied in a target group of 3029 patients of working age who had undergone ACS during the previous 12 months with severe, including familial, HCH, with LDL cholesterol 5.0 mmol/l and higher, receiving statins taking into account previously determined outcomes when using alirocumab + statins for 5 years. Direct medical and non-medical costs, as well as indirect costs, are identified. The cost-effectiveness analysis was applied from the point of view of the effectiveness of treatment (effects on mortality, temporary disability, disability) and direct health care costs (additional drug provision and outpatient follow-up, specialized, including high-tech, medical care in a 24‑hour hospital). Two healthcare technologies were compared: statin therapy and use of alirocumab + statins. The calculations used according to domestic methods used the cost of medical treatment, temporary disability, hospitalizations, loss of GDP and other parameters.Results. Modeling has shown a decrease in mortality, morbidity and disability when using alirocumab in even the first year of use. The economic effect of alirocumab from a decrease in temporary disability in the 1st year is 304.5 mln rub., in the 2nd — 301.5 mln rub., in the 3rd — 321.1 mln rub., in the 4th — 333.1 mln rub. The estimated amount of prevented GDP losses from mortality in the target group for 4 years in the case of alirocumab use amounted to 1,260.2 mln rub. The annual amount of avoidable GDP losses from mortality in the target group in the case of alirocumab is 27–30 %. The annual average savings per patient in the case of alirocumab use are from 7 to 17 %. The greatest impact on reducing losses from disability and mortality of the target group is noted in the group of people aged 40–59 years. Only for this group, if alirocumab is used, it is possible to reduce losses from disability and mortality by 159.2 million rubles per year (83 % of the total economic effect). Starting from the 4th year of alirocumab use, it is possible to obtain a positive economic effect in terms of hospitalization costs.Conclusion. When alirocumab is included in the program of additional drug provision in cardiology, the share of costs for the purchase of alirocumab for the target group may be only 0.01 %. At the same time, the economic effect of inclusion in the first year alone will amount to at least 393.4 million rubles of budget funds. The total amount of avoidable losses due to the alirocumab usage may amount to 1,638 million rubles over 4 years.

A Non-Coronary, Peripheral Arterial Atherosclerotic Disease (Carotid, Renal, Lower Limb) in Elderly Patients-A Review: Part I-Epidemiology, Risk Factors, and Atherosclerosis-Related Diversities in Elderly Patients.

Atherosclerosis is a generalized and progressive disease. Ageing is a key risk factor for atherosclerosis progression that is associated with the increased incidence of ischemic events in supplied organs, including stroke, coronary events, limb ischemia, or renal failure. Cardiovascular disease is the leading cause of death and major disability in adults ≥ 75 years of age. Atherosclerotic occlusive disease affects everyday activity and quality of life, and it is associated with reduced life expectancy. Although there is evidence on coronary artery disease management in the elderly, there is insufficient data on the management in older patients presented with atherosclerotic lesions outside the coronary territory. Despite this, trials and observational studies systematically exclude older patients, particularly those with severe comorbidities, physical or cognitive dysfunctions, frailty, or residence in a nursing home. This results in serious critical gaps in knowledge and a lack of guidance on the appropriate medical treatment and referral for endovascular or surgical interventions. Therefore, we attempted to gather data on the prevalence, risk factors, and management strategies in patients with extra-coronary atherosclerotic lesions.

Ceramides: a potential cardiovascular biomarker in young adult childhood cancer survivors?

The aim of this study was to investigate circulating ceramides involved in cardiovascular disease (CVD) in young adult childhood cancer survivors (CCS) and their correlations to previously reported adverse cardiovascular changes in this cohort. Fifty-seven CCS and 53 healthy controls (age 20-30 years) were studied. Plasma long-chain ceramides, known to be cardiotoxic (C16:0, C18:0, C24:0, and C24:1), were analysed by mass spectrometry. The coronary event risk test 2 (CERT2) score was calculated from the ceramide data. Cardiac and carotid artery ultrasound data and lipid data available from previous studies of this cohort were used to study partial correlations with ceramide and CERT2 score data. All four analysed ceramides were elevated in CCS compared with controls (P ≤ 0.012). The greatest difference was noted for C18:0, which was 33% higher in CCS compared with controls adjusted for sex, age, and body mass index (BMI) (P < 0.001). The CERT2 score was higher in CCS compared with controls (P < 0.001). In the CCS group, 35% had a high to very high CERT2 score (7-12) when compared with 9% in the control group (P < 0.001). The CCS subgroup with a CERT2 score ≥ 7 had higher heart rate, systolic blood pressure, and higher levels of apolipoprotein B compared with CCS with a CERT2 score < 6 (P ≤ 0.011). When adjusted for age, sex, and BMI, CERT2 score was significantly correlated with arterial stiffness, growth hormone, and cranial radiotherapy (P < 0.044). Ceramides could be important biomarkers in understanding the pathophysiology of CVD and in predicting CVD disease risk in young adult CCS.

Circadian Variation of Stroke in a Tertiary Level Hospital

Introduction: Stroke, a primary global health concern, is the fifth leading cause of death in Bangladesh, with a prevalence of 0.3%. While 85% of stroke cases globally are cerebral infarctions, Asian countries exhibit stroke patients on average 15 years younger than developed countries. Survival studies reveal strokes exceeding coronary events in hypertensive patients. Observational data suggests circadian, circaseptan, and circannual variations in stroke occurrence, with a morning peak. Circadian rhythm in ischemic stroke is higher in the early morning. Thrombotic strokes, influenced by platelet aggregation and fibrinolysis, often occur in the morning. Haemorrhagic strokes result from blood vessel ruptures. Population-specific circadian patterns remain unconfirmed.&#x0D; Aim of the Study: The study aims to find out the relation of circadian variation of stroke.&#x0D; Methods: This cross-sectional study, conducted at Sylhet MAG Osmani Medical College Hospital, Bangladesh, analyzed 100 stroke patients over six months. Ethical approval was obtained, and informed consent was taken. Inclusion criteria covered patients with clinical and imaging stroke diagnoses, while exclusion criteria excluded transient ischemic attack, previous stroke, head injury history, and refusal to participate. Stroke onset time was categorized into four six-hour intervals. Demographic data, risk factors, and comorbidities were recorded, and brain CT scans were performed. Data analysis used SPSS version 22, employing descriptive statistics, Chi-square Test, and Student's t-test. Significance was set at p&lt;0.05. Results were presented in tables.&#x0D; Results: The study involves 100 participants, primarily aged 60-70 (50%), predominantly male (76%), residing 62% in urban and 38% in rural areas. Occupationally, 35% are businessmen, 24% are housewives, and 15% are service holders and laborers. Smoking status shows 58% smokers. Stroke types include 57% ischemic strokes and 39% hemorrhagic strokes. Hypertension (72%) is the significant risk factor. Stroke symptoms predominantly occur between 06:01 and 12:00 (46%). These insights comprehensively understand the study population's demographics, lifestyle, and clinical characteristics.&#x0D; Conclusion: The study established circadian patterns in stroke onset, with the highest frequency between 06:00-12:00 and the lowest between 18:01-24:00. Ischemic stroke was the most common subtype, followed by hemorrhagic stroke and fewer subarachnoid hemorrhages. Managing blood pressure and coagulation during peak onset times could aid stroke prevention, but further extensive studies are needed for validation.

Vaccination in Prevention of Acute Cardiovascular Events in Adults

Epidemiological studies have shown that acute coronary events, heart failure, atrial fibrillation with fast ventricular rate and brain stroke events have increased prevalence in winter season. Infections have a pivotal role in triggering such events. Vaccination against influenza and pneumococcus has been documented to prevent such events in large epidemiological studies. Majority of the deaths during Corona virus-19 (COVID-19) pandemic were related to cardiovascular event apart from serious lung condition. Vaccination has been proven to reduce risk of recurrent hospitalizations and death especially in sick and frail patients with heart failure, chronic obstructive lung diseases, renal failure and acute coronary syndromes. It becomes more relevant in countries like India where patient has to pay huge amounts for hospitalization from the pocket. On the other hand, it reduces unnecessary strain on the healthcare manpower and resources. Practice of vaccination in addition to guidelines based pharmacological, device or surgical therapy, is to help both the patients and physicians.

Capecitabine-induced-coronary-vasospasm leading to polymorphic ventricular tachycardia and cardiac arrest

Capecitabine, a pro-drug of 5-fluorouracil, is commonly used in the treatment of breast and colorectal cancer. Its side effects, including nausea, vomiting, diarrhea, fatigue, loss of appetite, and bone marrow suppression, are well recognized. However, coronary vasospasm represents a less commonly recognized but significant complication of fluoropyrimidine-based therapies such as capecitabine. Proposed mechanisms for this adverse effect complication include direct endothelium-independent vasoconstriction, activation of protein kinase C, and activation of the cyclooxygenase pathway. In this report, we present a case of capecitabine-induced coronary vasospasm leading to progressive, focal ST-elevations, myocardial ischemia, and subsequently polymorphic ventricular tachycardia. These events were captured on telemetry, in a male in his early 40s, diagnosed with stage IIIB sigmoid colon cancer. Notably, the patient had no pre-existing coronary artery disease or other cardiovascular risk factors. Upon diagnosis, the patient was initiated on a calcium channel blocker, verapamil, to mitigate further coronary vasospasm events. After thorough discussions that prioritized the patient’s input and values, an implantable cardioverter-defibrillator was placed subcutaneously. Following discharge, the patient restarted capecitabine therapy along with verapamil prophylaxis and did not experience any subsequent shocks from his ICD as assessed during his outpatient follow-up visits. This case emphasizes the need to involve patients in decision-making processes, especially when managing unexpected and serious complications, to ensure treatments align with their quality of life and personal preferences.

Age shock index as an early predictor of cardiovascular death in acute coronary syndrome patients.

The shock index (SI), reflecting heart rate (HR) to SBP ratio, is established for predicting adverse outcomes in acute coronary syndrome (ACS) patients. Exploring the age shock index (ASI), obtained by multiplying SI with age, could offer further insights into ACS prognosis. Assess ASI's effectiveness in predicting in-hospital death in individuals with ACS. This study encompassed patients with acute myocardial infarction, drawn from a national registry spanning October 2010 to January 2022. The optimal ASI threshold was established using receiver operating characteristic (ROC) curve analysis. The primary outcome was in-hospital mortality. A total of 27 312 patients were enrolled, exhibiting a mean age of 66 ± 13 years, with 72.3% being male and 47.5% having ST-elevation myocardial infarction. ROC analysis yielded an area under the curve (AUC) of 0.80, identifying the optimal ASI cutoff as 44. Multivariate regression analysis, adjusting for potential confounders, established ASI ≥ 44 as an independent predictor of in-hospital death [hazard ratio: 3.09, 95% confidence interval: 2.56-3.71, P < 0.001]. Furthermore, ASI emerged as a notably superior predictor of in-hospital death compared to the SI (AUC ASI = 0.80 vs. AUC SI = 0.72, P < 0.0001), though it did not outperform the Global Registry of Acute Coronary Events (GRACE) score (AUC ASI = 0.80 vs. AUC GRACE = 0.85, P < 0.001) or thrombolysis in myocardial infarction (TIMI) risk index (AUC ASI = 0.80 vs. AUC TIMI = 0.84, P < 0.001). The ASI offers an expedient mean to promptly identify ACS patients at elevated risk of in-hospital death. Its simplicity and effectiveness could render it a valuable tool for early risk stratification in this population.

Sociodemographic, Clinical and angiographic Overview of Women with Acute Coronary Syndrome: A Current Prospective Hospital Based Study in Bangladesh

Background: Women’s life cycles are more complex than men’s, and because female sex hormone shields premenopausal women from overt atherosclerosis, their risk of coronary events is lower. Postmenopausal women experience various comorbidities and more severe cases of coronary artery disease (CAD). Nevertheless, there is a paucity of information comparing pre- and postmenopausal women with acute coronary syndrome (ACS) in terms of their sociodemographic profiles, risk factors, clinical features, and angiographic severity of coronary artery disease. The purpose of this study was to evaluate the sociodemographic, clinical and angiographic aspects of premenopausal and postmenopausal women with ACS. Methods: In this cross sectional observational study a total of 140 female patients with acute coronary syndrome were enrolled. They were divided in group-I (premenopausal) and group-II (postmenopausal) on the basis of the state of menopause. The sociodemographic profile, clinical data and coronary angiographic characteristics severity were compared between the premenopausal and postmenopausal ACS groups. Results: The mean age of ACS patients who were premenopausal was 41.53 ± 5.45 years, while that of postmenopausal patients was 57.23 ± 7.45 years. These differences were statistically significant (p= 0.001). Most of the patient among both the groups didn’t complete their secondary school certificate (42.9% vs 65.7%). Premenopausal individuals had a considerably higher family history of early CAD (50% vs. 32.9%; p=0.017) than postmenopausal individuals. In the postmenopausal group, DM and smokeless tobacco were more common (68.6% vs. 40%; p=0.001 and 20% vs. 2.9%; p=0.002). In the premenopausal group, atypical presentations were more common (30% vs. 12.9%; p=0.013). The majority of patients in both groups initially had unstable angina, then STEMI and NSTEMI. The postmenopausal group had a lower mean left ventricular ejection fraction (50.71 ± 8.38% vs. 53.74 ± 7.46%; p=0.026) and RWMA (55.7% vs 62.9%; p=0.390) than the premenopausal group. In the premenopausal group, normal coronary angiography and single vessel disease were more common (31.4% vs 17.1%; p=0.04 and 31.4% vs 15.7%; p=0.002), while triple vessel disease was more common in the postmenopausal group (48.6% vs 20%; p=0.001). The postmenopausal group’s most often affected vascular was the left anterior descending artery (95.7% vs. 85.7%; p=0.04). In the postmenopausal group, the mean Gensini score was greater than in the premenopausal group (56.1 ± 43.4 vs. 33.5 ± 36.9; p=0.001). Conclusion: Premenopausal ACS patients were more likely to have a family history of early CAD and an unusual presentation, while postmenopausal patients were more likely to have diabetes and smokeless tobacco. Both the groups didn’t complete their secondary school certificate. In the premenopausal group, normal coronary angiography and single vessel disease were more common, whereas in the postmenopausal group, triple vessel disease was more common. CAD in the postmenopausal group was more severe.