CV Mortality Research Articles

AB1320-HPR THE ASSOCIATION BETWEEN PHYSICAL ACTIVITY AND CARDIORESPIRATORY FITNESS IN PATIENTS WITH RHEUMATOID ARTHRITIS AND HIGH CARDIOVASCULAR RISK

Background:Rheumatoid arthritis (RA) is associated with increased risk of cardiovascular disease (CVD) disease and CV mortality1. High values of cardiorespiratory fitness (CRF) are protective against CVD and CV mortality2. Physical activity levels in patients with RA are low. Knowledge on whether physical activity is associated with CRF in patients with RA and high CV risk is scarce. This knowledge is important because improving the level of physical activity could improve CRF and lower CV risk in this group of patients with RA and high CV risk. However, it is unclear whether physical activity is associated with CRF in this group of patients. This study presents the preliminary results at baseline of the association of physical activity with CRF from an ongoing pilot study aimed at improving CRF through exercise therapy in patients with RA and high CV risk.Objectives:To determine (i) the level of physical activity in patients with RA and high CV risk and (ii) whether physical activity is associated with CRF in patients with RA and high CV risk.Methods:Patients with RA and high CV risk participated in this pilot study. Increased 10-year risk of CV mortality was determined by using the Dutch SCORE-table. Anthropometrics and disease characteristics were collected. Physical activity was assessed with an Actigraph accelerometer to determine the number of steps and intensity of physical activity expressed in terms of sedentary, light, and moderate-to-vigorous time per day. Participants wore the accelerometer for seven days. A minimum of four measurement days with a wear time of at least 10 hours was required. The VO2max measured with a graded maximal exercise test was used to determine the CRF. Pearson correlation coefficients were calculated for the associations between the different measures of physical activity and VO2max. For the variables that were associated, linear regression analysis was carried out, with pain and disease activity as possible confounders.Results:Thirteen females and five males were included in the study. The mean age was 66.5 (± 15.0) years. Only 22% of the patients met public health physical activity guidelines for the minimal amount of 150 minutes a week. The mean step count was 6237 (± 2297) steps per day and mean moderate-to-vigorous physical activity time was 16.50 (± 23.56) minutes per day. The median VO2max was 16.23 [4.63] ml·kg-1·min-1, which is under the standard. Pearson correlations showed a significant positive association for step count with VO2max. No associations were found for sedentary, light, and moderate-to-vigorous physical activity with VO2max. The significant association between step count and VO2max(p = 0.01) was not confounded by disease severity and pain.Discussion:Since better CRF protects against CVD, increasing daily step count may be a simple way to reduce the risk of CVD in patients with RA and high CV risk. However, these results need to be confirmed in a larger study group. Future research should investigate if improving daily step count will lead to better CRF levels and ultimately will lead to a reduction in CV risk in patients with RA and high CV risk.Conclusion:Physical activity levels of patients with RA and high CV risk do not meet public health requirements for physical activity criteria and the VO2max was under the standard. Step count is positively associated with CRF.

0593 Hypoxemia During Sleep Disordered Breathing and Cardiovascular Disease: A Comparison of Different Oxygen Desaturation Measures

Abstract Introduction The apnea-hypopnea index has been used to characterize obstructive sleep apnea (OSA) severity. However, this metric is limited in providing information about cardiovascular disease (CVD) risk. Recent studies proposed alternative metrics that capture frequency, duration, depth, and combinations of duration and depth of hypoxemia. This study provides a systematic evaluation of the association between conventional or novel nocturnal hypoxemia metrics and the incidence of CVD and CV mortality in the Sleep Heart Health Study (SHHS). Methods We used data from 5,042 participants of the SHHS. Over 10.7 years, there were 1,312 (26.0%) incident CVD events and 359 (7.1%) CV deaths. We calculated standardized (z-scored) values of eight nocturnal hypoxemia indices, including conventional (e.g., oxygen desaturation index) and novel metrics (e.g., hypoxic burden, respiratory event-related area under desaturation curve and desaturation severity, corresponding to alternative quantitative measurements looking at the shape of each desaturation event). The association between each metric and incidence of CVD or CV mortality was evaluated using Cox proportional hazards models. Age, sex, body mass index, race, ethnicity, smoking, total sleep time, number of respiratory events, and prevalent CVD at baseline were used as covariates. Hazard ratios (HR) are presented as the effect of one standard deviation increase in each correponding metric. Results In unadjusted models, all nocturnal hypoxemia indices were associated with increased incidence of CVD and CV mortality. In adjusted models, longer average desaturation duration was associated with lower CVD incidence (HR[95%CI]=0.93[0.86-0.99];p=0.034), higher hypoxic burden with increased CV mortality (HR[95%CI]=1.22[1.04-1.43];p=0.017), and higher % sleep time with oxygen saturation less than 90% (Tlt90%) with increased CV mortality (HR[95%CI]=1.12[1.00-1.26];p=0.040). Conclusion Different metrics of nocturnal hypoxemia derived from polysomnography were associated with CV risk in the SHHS. However, after covariate adjustment, only shorter average desaturation duration, and higher hypoxic burden and Tlt90% were independent CV risk factors. Support AASM Foundation (194-SR-18,188-SR-17); American Heart Association (19CDA34660137); NIH (U01HL53940,U01HL53941,U01HL63463,U01HL53937, U01HL53938,U01HL53916,U01HL53934,U01HL63429,U01HL53931,HL114473, P01HL094307,HL134015,R35HL135818,1R21HL145492-01,R01HL102321,R01HL128658); The State Research Funding (KUH: 5041767, 5041768; TUH: VTR3242, VTR3228, EVO2089), Academy of Finland (313697, 323536), Business Finland (5133/31/2018), Respiratory Foundation of Kuopio Region, Tampere Tuberculosis Foundation, Research Foundation of Pulmonary Diseases, Foundation of Finnish Anti-Tuberculosis Association.

Comparison of different ankle-brachial indices in the prediction of overall and cardiovascular mortality

Background and aimsLow ankle-brachial index (ABI) calculated using systolic blood pressure (SBP) is associated with poor prognosis. However, there is no study assessing ABI calculated using mean artery pressure (MAP) and diastolic blood pressure (DBP) in predicting mortality. MethodsTwo cohort populations were enrolled. The first population comprised 379 patients (106 patients with angiography-proved peripheral artery disease (PAD) and 273 relative normal patients) to evaluate the best cutoff values of ABImbp and ABIdbp for prediction of PAD. The second population included 941 patients undergoing echocardiographic examinations to assess the ability of different ABIs in predicting mortality. ABIs were measured using an ABI-form device. ResultsThe best cutoff values of ABImbp and ABIdbp for prediction of PAD were 0.92 and 0.88. In our second population, median follow-up to mortality was 93 months. There were 87 cardiovascular and 228 overall deaths. Multivariable analysis showed ABIsbp, ABImap, ABIdbp, ABIsbp <0.9, and ABImap <0.92 could predict overall and cardiovascular mortality (all p < 0.001). ABIdbp <0.88 could only predict CV mortality (p = 0.033). In a direct comparison of 6 multivariable models, the basic model consisting of significant variables in the univariable analysis plus ABImap <0.92 had the highest predictive value for overall and cardiovascular mortality (all p < 0.001). ConclusionsIn a direct comparison of 6 multivariable models, the basic model + ABImap < 0.92 was the best model in predicting overall and cardiovascular mortality. Hence, calculation of ABI using MAP except SBP might provide extra benefit in survival prediction.

A meta-analysis of efficacy and safety of genotype-guided versus standard of care treatment strategies in selecting antiplatelet therapy in patients with acute coronary syndrome.

Previous studies have shown similar rates of major adverse cardiovascular events (MACE) in acute coronary syndrome (ACS) patients, treated with P2Y12 inhibitors based on genotype guidance compared to standard treatment. However, given lower than expected event rates, these studies were underpowered to assess hard outcomes. We sought to systematically analyze this evidence using pooled data from multiple studies. Electronic databases were searched for studies of ACS patients that underwent genotype-guided treatment (GGT) with P2Y12 inhibitors versus standard of care treatment (SCT). Studies with a minimum follow-up of 12 months were included. Rate of MACE (defined as a composite of cardiovascular [CV] mortality, nonfatal myocardial infarction [MI], and nonfatal stroke) was the primary outcome. Secondary outcomes were individual components of MI, CV mortality, ischemic stroke, stent thrombosis, and major bleeding. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were calculated and combined using random effects model meta-analysis. A total of 4,095 patients (2007 in the GGT and 2088 in the SCT group were analyzed from three studies). Significantly lower odds of MACE (6.0 vs. 9.2%; OR: 0.63, 95% CI: 0.50-0.80, p < .001, I2 = 0%) and MI (3.3 vs. 5.45%; OR: 0.63; CI 0.41-0.96; p = .03; I2 = 46%) were noted in the GGT group compared to SCT. No significant difference was noted with respect to CV and other secondary outcomes. In patients with ACS, genotype-guided initiation of P2Y12 inhibitors was associated with lower odds of MACE and similar bleeding risk in comparison to SCT.

Vitamin K for the Treatment of Cardiovascular Disease in End-Stage Renal Disease Patients: Is there Hope?

In Chronic Kidney Disease, vascular calcification (VC) is highly prevalent even at early stages and is gradually enhanced, along with disease progression to End-Stage Renal Disease (ESRD). The calcification pattern in uremia includes all types of mineralization and contributes to the heavy cardiovascular (CV) burden that is common in these patients. Ectopic mineralization is the result of the imbalance between inhibitors and promoters of vascular calcification, with the latter overwhelming the former. The most powerful, natural inhibitor of calcification is Matrix Gla Protein (MGP), a small vitamin K dependent protein, secreted by chondrocytes and vascular smooth muscle cells. In uremia, MGP was reported as the only molecule able to reverse VC by "sweeping" calcium and hydroxyapatite crystals away from the arterial wall. To become biologically active, this protein needs to undergo carboxylation and phosphorylation, reactions highly dependent on vitamin K status. The inactive form of MGP reflects the deficiency of vitamin K and has been associated with CV events and mortality in ESRD patients. During the past decade, vitamin K status has emerged as a novel risk factor for vascular calcification and CV disease in various populations, including dialysis patients. This review presents evidence regarding the association between vitamin K and CV disease in ESRD patients, which are prone to atherosclerosis and atheromatosis.

GENDER AND RACE RELATED CARDIOVASCULAR MORBIDITY AND MORTALITY OF PATIENTS HOSPITALIZED WITH HIV

With newer antiretroviral therapies (ART), life expectancy of patients with HIV has increased. This led to an increased burden of cardiovascular diseases (CVD). To date, data on the race and gender-based trends and prevalence of various subtypes of CVD and CV mortality is scarce. Using the US

1 YEAR FOLLOW UP RESULTS OF ARTIM HF TRIAL (ANGIOTENSIN RECEPTOR NEPRILYSIN INHIBITOR EFFECT ON TEI INDEX & LEFT VENTRICULAR MASS IN HEART FAILURE)

Sacubitril/Valsartan (ARNI) is FDA approved drug for treatment of heart failure. It promotes effects of natriuretic peptides by inhibiting neprilysin with Sacubitril and blocking angiotensin II type 1 receptors with Valsartan. It has been shown to reduce CV morbidity & mortality in HFrEF but not

PERFORMANCE OF A NOVEL GENETIC RISK SCORE TO IDENTIFY RISK OF VENOUS THROMBOEMBOLISM IN PATIENTS WITH CARDIOMETABOLIC DISEASE

Venous thromboembolism (VTE) is the third leading cause of CV mortality and has an established genetic predisposition. We tested the performance of a 10-SNP genetic risk score (GRS) for its ability to predict VTE in 3 TIMI trials. We included patients from the FOURIER, PEGASUS-TIMI 54, and SAVOR-

Prescription opioids and population cardiovascular mortality in US South female non-Hispanic whites

Recent ecological studies have demonstrated that mid-life mortality rates in US American Indians and non-Hispanic whites (NHW) have been rising for the past 20 years and are correlated with prescription opioid sales. The study hypothesis was that temporal correlations exist between annual hydrocodone and oxycodone sales and female NHW CV mortality rates in the Deep South USA. Six states in the Deep South were studied across the 2000–2017 timeframe: Alabama, Arkansas, Louisiana, Mississippi, Oklahoma, and South Carolina. Female NHW mortality rates in the 35–44-, 45–54-, and 55–64-, and 65–74-year-old groups were obtained from the CDC Wonder Detailed Mortality database. Hydrocodone and oxycodone sales data were obtained from the State Health Access Data Assistance Center database. Time-series datasets were graphed and analyzed using Spearman rank correlation testing, after second differencing to control for trend. A 1-year adjustment was made to accommodate a 1-year temporal lag of mortality behind opioid sales. Annual CV mortality in 35–44-year-old NHW females was not associated with annual opioid sales. Annual CV mortality in 45–54-year-old NHW females was correlated with hydrocodone sales [rs(13) 0.650; P = 0.009], oxycodone [rs(13) 0.454; P = 0.090], and combined hydrocodone–oxycodone [rs(13) 0.764; P = 0.001]. Annual cardiovascular mortality in 55–64-year-old NHW females was associated with hydrocodone sales [rs(13) 0.499; P = 0.059], oxycodone [rs(13) 0.561; P = 0.030], and combined hydrocodone–oxycodone [rs(13) 0.545; P = 0.036]. Annual CV mortality in 65–74-year-old NHW females was associated with oxycodone [rs(13) 0.696; P = 0.004]. At the population level, prescription opioid sales are temporally correlated with cardiovascular mortality rates in NHW females of the Deep South.

The Inhibitory Roles of Vitamin K in Progression of Vascular Calcification.

Vitamin K is a fat-soluble vitamin that is indispensable for the activation of vitamin K-dependent proteins (VKDPs) and may be implicated in cardiovascular disease (CVD). Vascular calcification is intimately associated with CV events and mortality and is a chronic inflammatory process in which activated macrophages promote osteoblastic differentiation of vascular smooth muscle cells (VSMCs) through the production of proinflammatory cytokines such as IL-1β, IL-6, TNF-α, and oncostatin M (OSM) in both intimal and medial layers of arterial walls. This process may be mainly mediated through NF-κB signaling pathway. Vitamin K has been demonstrated to exert anti-inflammatory effects through antagonizing NF-κB signaling in both in vitro and in vivo studies, suggesting that vitamin K may prevent vascular calcification via anti-inflammatory mechanisms. Matrix Gla protein (MGP) is a major inhibitor of soft tissue calcification and contributes to preventing both intimal and medial vascular calcification. Vitamin K may also inhibit progression of vascular calcification by enhancing the activity of MGP through facilitating its γ-carboxylation. In support of this hypothesis, the procalcific effects of warfarin, an antagonist of vitamin K, on arterial calcification have been demonstrated in several clinical studies. Among the inactive MGP forms, dephospho-uncarboxylated MGP (dp-ucMGP) may be regarded as the most useful biomarker of not only vitamin K deficiency, but also vascular calcification and CVD. There have been several studies showing the association of circulating levels of dp-ucMGP with vitamin K intake, vascular calcification, mortality, and CVD. However, additional larger prospective studies including randomized controlled trials are necessary to confirm the beneficial effects of vitamin K supplementation on CV health.

Sex Differences in Coronary Artery Calcium and Long-term CV Mortality.

To summarize differences in plaque depositions, coronary artery calcium (CAC) scoring, and the role of CAC in predicting atherosclerotic cardiovascular disease (ASCVD) mortality in men and women. Women have coronary plaque that is more lipid-rich, dense, and less calcified than their male counterparts. CAC scoring has emerged as a useful tool to quantify ASCVD burden. However, recent evidence favors the use of sex-adjusted CAC cutoffs for women to account for the relatively lower overall CAC burden and therefore risk stratify women appropriately. Several studies have identified CAC distribution patterns in women associated with increased CV mortality, particularly the number of lesions involved, CAC volume, and size. Multiple studies have shown that the pathophysiology and associated risks of ASCVD are different in women when compared with men. CAC scoring is a tool that is widely being used for ASCVD risk stratification. Recent studies have shown that although men have higher CAC burdens, women are more likely to develop plaque erosions with non-calcified plaque that carries a greater risk for cardiovascular events. Providers should be aware of sex-specific CAC patterns carrying increased mortality risk for women, particularly increasing lesion size and number. Given the differences in plaque composition and distribution, revised sex-adjusted CAC scoring is suggested to better risk stratify patients, especially those deemed intermediate risk, and decrease CV mortality.

Low gradient aortic stenosis and TAVI: The differential prognostic value of valvular and aortic calcifications may traduce a particular pathophysiology

Low gradient aortic stenosis (LGAS) is still poorly understood. The valular aspect may be less prominent than in the other forms of aortic stenosis (AS) and intertwined with other aspects such as vascular ones. The severity of the valvular disease was assessed from aortic valvular calcifications (VAC) and that of aorta from thoracic aortic calcifications (TAC). To assess the prognostic significance of VAC and TAC in patients with and without LGAS treated by TAVI. Ancillary study of the C4CAPRI trial including 1282 consecutive patients from 4 French hospitals. The primary outcome was 3 years CV mortality after TAVI. 397 (31%) had a LGAS. They were more frequently men, younger, with atrial fibrillation (AF), and lower left ventricular ejection fraction (LVEF), P < 0.05 for all. VAC was lower in LGAS (1.05 cm 3 ± 0.7 vs. 0.75 cm 3 ± 0.5), P < 0.001, while the opposite was noticed for TAC, (3.1 cm 3 ± 3 vs. 3.7 cm 3 ± 3.7), P = 0.01. After 3 years, 227 (17.7%) patients died from CV causes; respectively 85(21.4%) and 142(16.1%) patients with and without LGAS, P = 0.02. Multivariate analysis was adjusted for TAC, VAC, age, gender, AF, LVEF, pulmonary systolic pressures, history of diabetes, chronic respiratory disease, renal insufficiency and peripheral vascular disease. In LGAS patients TAC HR 1.090 CI (1.02–1.16) but not VAC was a predictor of CV mortality while in patients without LGAS, VAC HR 1.377 CI (1.049–1.809) but not TAC was associated with CV mortality. The present study confirms that valvular disease seems less prevailing in LGAS patients than in other forms of AS. On the other hand, vascular after load, estimated by TAC, conveys a major prognostic information in this subgroups. This has clinical impact: VAC may be a marker of early and periprocedural mortality and aortic regurgitation in non-LGAS patients, while TAC may continue to increase left ventricular after load in patients with LGAS whom LVEF is often impaired.

Facing the Unseen - Metabolic Syndrome in Psoriatic Arthritis.

Psoriatic arthritis (PsA) is a heterogeneous multifaceted inflammatory artropathy, associated or not with psoriasis, part of the spondyloarthropaties group. Beyond articular and skin manifestations, patients with psoriatic disease are prone to associated comorbidities, including cardiovascular disease (CVD), obesity and metabolic syndrome, diabetes, or fatty liver disease; in order to improve the prognosis and the quality of life for these patients, it is mandatory to prevent, identify and properly manage any of the comorbidities. We aimed to assess the presence of traditional CV risk factors and MetS in a group of PsA patients, compared to controls and their possible inter-relation. We performed an observational study on 41 consecutive patients diagnosed with PsA based on CASPAR established criteria. Our subjects met the criteria of MetS in a percentage of 43.90% of the cases and AHT, frequently reported in higher percentages for PsA or psoriasis patients, compared to general population was also revealed in significant percentages by our data. Regarding dyslipidemia, it is confirmed and validated by several studies that patients diagnosed with PsA or psoriasis associate an altered lipid metabolism and our study noticed data accordingly. As PsA is a condition characterized by chronic inflammation, a non-traditional CV risk factor, each patient should benefit from a periodic close evaluation in order to approach a compete and early therapeutic intervention and reduce further CV morbidity and mortality rates.

Pattern of Electrocardiographic and Echocardiographic Abnormalities Among HIV Patients in Port Harcourt, Nigeria

Infection with HIV is independently associated with an increased risk of cardiovascular disease, while therapeutic use of HAART has been shown to increase the risk of metabolic derangements which may have potentially damaging effects on the cardiovascular system. The study was carried out to assess the pattern of electrocardiographic (ECG) and echocardiographic (ECHO) abnormalities among HAART experienced and HAART naive HIV patients. This was a cross-sectional study of one hundred (100) HIV seropositive subjects and 100 age and sex matched controls to assess cardiovascular risk among HIV seropositive persons in Port-Harcourt, Rivers State, Nigeria. The results showed that the prevalence of ECG abnormalities among the cases was 49 (49%) compared to 42 (42%) of the controls (c2=0.020, p=0.886). Sinus tachycardia was the most common ECG abnormality in all study participants and was present in 37 (37%) of the control subjects when compared to 21 (21%) of the cases and this was statistically significant. T-wave inversion and prolonged QT interval were the next two most prevalent findings seen in 23% and 18% of the cases compared with 8% and 5% of the controls respectively and these were also statistically significant (p=0.004 and 0.003 respectively). Among the cases 10% had grade 1-2 diastolic dysfunctions compared with 23% of the controls and this was statistically significant (p=0.013). Ninety percent (90%) however had normal diastolic function compared with 77% of the controls. Systolic dysfunction was found in only 2% of the HAART experienced cases compared to 10 (10%) of the HAART naive controls and this was also statistically significant (p=0.017). The study showed that electrocardiographic and echocardiographic abnormalities are common in HIV seropositive patients with ECG abnormalities being more common among the HAART treated subjects. These ECG & ECHO abnormalities generally increase the cardiovascular risk profile of PLWHIV/AIDS and are independent predictors of CV mortality hence the need for prompt diagnosis and interventions.

Prognostic impact of a therapeutic strategy using BNP to optimize ambulatory patient management with heart failure and reduced ejection fraction

Heart failure with reduced ejection fraction (HFrFE) is associated with a high morbidity and mortality. His care has seen a lot of progress in recent years. Good practice guidelines have been established but, unfortunately, insufficiently applied in clinical practice and therapeutic goals are often not achieved. Some randomized trials have suggested that BNP or Nt-proBNP is useful in this follow-up, but the evidence is not established. The purpose of our study is that a biomarker-guided therapy of HFrFE would reduce cardiovascular events compared to a therapeutic strategy based solely on clinical judgment, over a period of follow-up of 1 year in patients with HfrEF. We performed a prospective randomized, unblinded, therapeutic follow-up study. Patients were randomized into two arms: conventional follow-up with treatment optimization according to international guidelines and arm followed by Nt-proBNP with an additional objective, that of reaching a level of Nt-proBNP ≤ 1000 pg/ml. 252 patients were enrolled, the average age is 59 years. The ischemic etiology is the most predominant, the mean FE was ≈ 30%. At the end of the follow-up, the main endpoint (CV death, CV hospitalization, worsening of HF) occurred in 41.13% of the BNP group and 44.53% of the classic follow-up group with a total of 240 recorded events (115 in the BNP group) and 125 in the 2nd group ( P = 0.585). The 12-month CV mortality rate in the BNP group is 14.5% and 17.2% in the SOC group ( P = 0.562). The number of hospitalizations for cardiovascular causes is 21.77% in the BNP group and 24.21% in the 2nd group ( P = 0.873). In patients with HfrEF, NT-proBNP-guided therapy strategy was no more effective than a standard care strategy for improving morbidity and mortality.

Usefulness of CHA2 DS2 -VASc score to predict mortality and hospitalization in patients with inflammatory arthritis.

Inflammatory arthritis including rheumatoid arthritis (RA), ankylosing spondylitis (AS) and psoriatic arthritis (PsA) are disorders at increased risk of morbidity and mortality for which a validated prognostic tool for facilitating clinical management is needed. CHA2 DS2 -VASc (congestive heart failure/hypertension/age diabetes/stroke/vascular disease/age/sex category) score was initially conceived and used to estimate thromboembolic risk in non-valvular atrial fibrillation, and then successfully applied in community populations with sinus rhythm. We tested CHA2 DS2 -VASc-score as a prognosticator of adverse outcomes in patients in sinus rhythm with RA/AS/PsA. Between March 2014 and March 2015, 414 patients (214 RA, 75 AS, 125 PsA) in sinus rhythm without cardiac disease were consecutively analyzed and prospectively followed-up. Primary and co-primary end-points were a composite of all-cause death/all-cause hospitalization and CV death/CV hospitalization, respectively. Patients were divided into LOWscore and HIGHscore groups if CHA2 DS2 -VASc was=0/1 point or greater than 1 point, respectively. The HIGHscore group comprised 190 patients who were older with higher prevalence of CV risk factors and arthritis disease activity than 224 LOWscore patients. During a follow up of 36months, the event rate for primary and co-primary end-point was 37% and 12% in the HIGHscore vs 22% and 4% in LOWscore group (P=.001 and .002 respectively). At multivariate Cox regression analysis CHA2 DS2 -VASc-score was related to primary end-point (hazards ratio [HR] 1.30 [1.07-1.59], P=.009) and co-primary end-point (HR 1.35 [1.01-1.79], P=.04) independently of traditional CV risk factors analyzed individually and indexes of inflammation or disease duration. CHA2 DS2 -VASc-score accurately identifies in the mid-term patients in sinus rhythm with RA/AS/PsA at different risks for CV and non-CV mortality and hospitalization.

Hypoglycemia and the Risk of Cardiovascular Events: Causality or (Just) an Epidemiological Association?!

Since the early termination of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial in 2008 due to higher mortality in the intensive glucose arm, the relationship between hypoglycemia, mainly severe hypoglycemic episodes (SHE), and negative outcomes (with focus on cardiovascular [CV] events and mortality, and all-cause mortality) started to be more carefully scrutinized by scientific researchers and avoidance of hypoglycemia has been included in all diabetes guidelines among the targets set for the management of hyperglycemia. Numerous randomized clinical trials and epidemiological studies found a robust association between SHE and incident major CV events and mortality, as well as all-cause deaths but this association was not found for non-severe hypoglycemia. Two recent reports suggest that a “frail” T2D phenotype, characterized by older age, longer diabetes duration, lower glomerular filtration rate, who were more frequently non-White, insulin treated, and had prior CV or heart failure events, increased susceptibility to both SHEs and CV events and that SHEs do not cause deleterious CV outcomes. Nevertheless, other researchers claim that the causality exists between SHEs and increased risk for subsequent CV events and mortality. Avoidance of hypoglycemia remains a target of antihyperglycemic strategies while efforts to attain and maintain individualized glucose targets should be done from the time of diagnosis and throughout all diabetes duration.

Combination of low blood pressure response, low exercise capacity and slow heart rate recovery during an exercise test significantly increases mortality risk

Aims: We investigated the combination of low systolic blood pressure (SBP) response, low exercise capacity (EC) and slow heart rate recovery (HRR) during an exercise test in mortality prediction.Patients and methods: Our population consisted of 3456 patients from the Finnish Cardiovascular Study. A failure of SBP to increase >42 mmHg was defined as a low response. Low EC was defined as < 8 metabolic equivalents. 1-minute HRR ≤18 bpm from maximum was defined as slow HRR.Results: During a median follow up of 10.0 years, 537 participants died. Reduced SBP response, low EC and slow HRR were independent predictors of all-cause and CV mortality (p < .001 for all). Patients with reduced SBP response, low EC and slow HRR had a very high mortality rate of 42.1% during follow up compared to only 4.5% of the patients without any of these risk factors. The hazard ratios for all-cause mortality in patients with one, two or three of the studied risk factors were 3.2, 6.0, and 10.6, respectively (p < .001 for all).Conclusion: The combination of reduced SBP response, low exercise capacity, and reduced HRR in an exercise test is associated with very high mortality and can be used in risk stratification.Key messagesThe combination of low blood pressure response, low exercise capacity and slow heart rate recovery in an exercise test is able to identify a group of patients in a very high mortality risk.These parameters are easily derived from an exercise test.All parameters are commonly available in clinical practice.

Asian management of hypertension: Current status, home blood pressure, and specific concerns in Malaysia.

Cardiovascular disease (CVD) accounts for a third of all deaths in Malaysia. The background CV risk of Malaysia is much higher than that of developed countries in the west and in Asia. This high CV mortality is contributed by the high prevalence of CV risk factors especially hypertension which is very prevalent, coupled with low awareness and low control rates. This highlights the importance of home blood pressure measurements (HBPM). HBPM is an important adjunct in the management of hypertension, particularly to identify those unaware as well as white-coat hypertension which is high in treated hypertensive patients in Malaysia. Ownership of HBPM devices in Malaysia is high, and this is an opportunity as well as timely to encourage more use of HBPM. The Malaysian national guidelines do not require HBPM for the diagnosis of hypertension but do recommend HBPM for specific situations. The most commonly prescribed anti-hypertensives are calcium channel blockers, followed by renin-angiotensin system blockers. Despite the wide availability of anti-hypertensive agents, BP control rates remain low. It is important that strategies are in place to ensure that individuals are aware of the need to have their BP monitored regularly and this can be facilitated by the use of HBPM. Hence, there is a plan to develop a local HBPM consensus document. Strategies to reduce salt intake would also be beneficial. In summary, identification of those unaware and better control of BP with the help of HBPM would help reduce the burden of CV mortality and morbidity in Malaysia.

Prognostic role of circulating neutrophil extracellular traps levels for long-term mortality in new end-stage renal disease patients

Dysregulation of innate immunity has been proposed as an important contributing factor for advanced atherosclerosis and resultant high mortality in hemodialysis (HD) patients. To evaluate the long-term prognostic role of in vivo neutrophil extracellular traps (NETs), we measured circulating serum nucleosome, myeloperoxidase (MPO), and DNase I levels in 281 incident HD patients. Circulating nucleosome level was significantly higher in HD patients compared to controls, and it was closely associated with MPO levels, suggesting increased in vivo NETs in uremia. Patients in the nucleosome Q4 group had significantly increased all-cause and adverse CV mortality compared to those in the Q1–3 group even after adjusting traditional risk factors Also, serum DNase I level was significantly higher in HD patients than controls (2.76 ± 1.02 ng/ml and 1.93 ± 0.85 ng/ml), but it had no correlation with NETs. Interestingly, it serves an additive biomarker for predicting poor CV outcomes. The two novel biomarkers might provide an importance independent prognostic significance in incident HD patients.