Lower Risk Of Cardiovascular Mortality Research Articles

Associations of the serum vitamin D with mortality in postmenopausal women

PurposeCurrent evidence on the association of serum vitamin D with mortality in postmenopausal women is limited and inconsistent. Therefore, the purpose of this study was to examine the relationship between serum vitamin D and mortality in postmenopausal women. MethodsIn this study, we used data from the NHANES (2001–2018) and conducted a multivariate Cox regression model to examine associations between serum vitamin D and all-cause mortality, cardiovascular mortality (CVD), and cancer mortality. ResultsIn a median follow-up period of 8.3 years, 1905 deaths of all causes were reported, 601 were due to CVD, and 385 deaths were due to cancer. After multivariable adjustment, higher serum vitamin D levels were significantly associated with a reduced risk of death. Compared to participants with lower vitamin D levels (<25 nmol/L), those with higher vitamin D levels (≥75.0 nmol/L) had a lower risk of all-cause mortality (hazard ratio 0.60, 95% confidence interval 0.49 to 0.74), a lower risk of cardiovascular mortality (0.51, 0.35 to 0.74), and a lower risk of cancer mortality (0.43, 0.28 to 0.67). Moreover, we observed an L-shaped dose-response relationship of serum vitamin D levels with all-cause mortality, and cancer mortality, with this inflexion point being 55.9 nmol/L, and 51.2 nmol/L, respectively. ConclusionsHigher concentrations of serum vitamin D substantially correlated with a reduction in mortality risk from all-cause, CVD, and cancer in postmenopausal women. These results imply that upholding adequate vitamin D levels may help prevent premature death in postmenopausal women.

New-onset syncope in diabetic patients treated with sodium-glucose cotransporter-2 inhibitors versus dipeptidyl peptidase-4 inhibitors: a Chinese population-based cohort study.

Syncope is a symptom that poses an important diagnostic and therapeutic challenge, and generates significant cost for the healthcare system. Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have demonstrated beneficial cardiovascular effects, but their possible effects on incident syncope have not been fully investigated. This study compared the effects of SGLT2i and dipeptidyl peptidase-4 inhibitors (DPP4i) on new-onset syncope. This was a retrospective, territory-wide cohort study enrolling type 2 diabetes mellitus (T2DM) patients treated with SGLT2i or DPP4i between 1 January 2015 and 31 December 2020, in Hong Kong, China. The outcomes were hospitalization of new-onset syncope, cardiovascular mortality, and all-cause mortality. Multivariable Cox regression and different approaches using the propensity score were applied to evaluate the association between SGLT2i and DPP4i with incident syncope and mortality. After matching, a total of 37 502 patients with T2DM were included (18 751 SGLT2i users vs. 18 751 DPP4i users). During a median follow-up of 5.56 years, 907 patients were hospitalized for new-onset syncope (2.41%), and 2346 patients died from any cause (6.26%), among which 471 deaths (1.26%) were associated with cardiovascular causes. Compared with DPP4i users, SGLT2i therapy was associated with a 51% lower risk of new-onset syncope [HR 0.49; 95% confidence interval (CI) 0.41-0.57; P<0.001], 65% lower risk of cardiovascular mortality (HR 0.35; 95% CI 0.26-0.46; P<0.001), and a 70% lower risk of all-cause mortality (HR 0.30; 95% CI 0.26-0.34; P<0.001) in the fully adjusted model. Similar associations with syncope were observed for dapagliflozin (HR 0.70; 95% CI 0.58-0.85; P<0.001), canagliflozin (HR 0.48; 95% CI 0.36-0.63; P<0.001), and ertugliflozin (HR 0.45; 95% CI 0.30-0.68; P<0.001), but were attenuated for empagliflozin (HR 0.79; 95% CI 0.59-1.05; P=0.100) after adjusting for potential confounders. The subgroup analyses suggested that, compared with DPP4i, SGLT2i was associated with a significantly decreased risk of incident syncope among T2DM patients, regardless of gender, age, glucose control status, Charlson comorbidity index, and the association remained constant amongst those with common cardiovascular drugs and most antidiabetic drugs at baseline. Compared with DPP4i, SGLT2i was associated with a significantly lower risk of new-onset syncope in patients with T2DM, regardless of gender, age, degree of glycaemic control, and comorbidity burden.

Cause-specific death in heart failure across the ejection fraction spectrum

Abstract Background Heart failure (HF) is associated with increased cardiovascular (CV) and non-CV mortality, but little data is available on underlying causes of death in HF phenotypes based on ejection fraction (EF). Knowledge about causes of mortality may have implications for healthcare decisions, treatment priorities and clinical trial design. Purpose To examine cause-specific mortality in patients with HF with reduced EF (HFrEF), HF with mildly reduced EF (HFmrEF), and HF with preserved EF (HFpEF). Methods Patients enrolled in the Swedish Heart Failure Registry between 2000-2021 were included. The causes and incidence rates of death across the EF categories were studied. In addition, to examine the association between EF categories and cardiovascular (CV) and non-CV mortality, sub-distributional hazards models were performed accounting for competing risk of death from other causes and adjusted for age and sex. Results Among 100,584 patients (23% HFpEF, 23% HFmrEF, 53% HFrEF), median age (IQR) was 75.0 (66.0-82.0) and 36.5% were females. Of those who died within 5 years, most deaths were ascribed to CV deaths across all EF categories (65% in HFrEF, 59% in HFmrEF and 58% in HFpEF, respectively). Within 5 years, patients with HFpEF had higher risk of non-CV mortality (adjusted HR 1.38, 95% CI 1.33-1.43, p&amp;lt; 0.001) and lower risk of CV mortality (adjusted HR 0.80, 95% CI, 0.78-0.83, p&amp;lt; 0.001) compared to patients with HFrEF. Ischemic heart disease (IHD) was the most common cause of CV-death while cancer was the most common cause of non-CV death across all EF categories. The incidence rate of CV death due to IHD was higher in HFrEF while the incidence rates of CV death due to pulmonary vascular disease, stroke, valvular heart disease and atrial fibrillation were higher in HFpEF compared to HFrEF and HFmrEF (Figure 1). Patients with HFpEF had higher incidence rate of non-CV deaths due to cancer, respiratory disease, accidents and infections including covid -19 compared with HFrEF and HFmrEF patients (figure 2). Conclusion In this large and contemporary cohort of patients with HF, CV death was more common than non-CV death across all EF categories although the risk of non-CV mortality within 5-years was higher with increasing EF. IHD and cancer were the most common causes of CV and non-CV deaths, respectively, regardless of EF category. Patients with HFpEF had a higher burden of non-CV causes of death than patients with HFrEF and HFmrEF.Incidence rate CV deathIncidence rate non-CV death

Association of myocardial infarction with nonobstructive coronary arteries with long-term outcomes

Abstract Background Myocardial Infarction with Non-obstructive Coronary Arteries (MINOCA) is a disease classification that is not uncommonly encountered yet poorly characterized. The association of MINOCA with long-term cardiovascular (CV) outcomes has been inconsistently assessed with studies reporting conflicting results. The purpose of this meta-analysis is to evaluate the association of MINOCA with long-term cardiovascular outcomes. Methods A literature search was conducted for studies reporting on the association of MINOCA with clinical endpoints as compared to obstructive coronary artery disease (OCAD). The primary end-point was all-cause mortality. Secondary endpoints included CV mortality, need for revascularization, recurrence of acute coronary syndrome (ACS), CV rehospitalization, persistent angina after discharge, and major adverse cardiac events (MACE). Databases searched included Ovid MEDLINE, EMBASE, Web of Science, and Google Scholar. The search was not restricted to time or publication status. Results A total of 29 studies with 893134 patients with acute myocardial infarction (AMI) (48425 with MINOCA, 844709 with OCAD) met inclusion criteria. Mean follow-up was 39 months, mean age was 62, 66% were male. MINOCA was associated with significantly lower risk of all-cause mortality compared to OCAD (OR 0.69, 95% CI 0.60-0.78; p&amp;lt;0.01). The overall effect size was large (z=5.72). MINOCA was associated with significantly lower risk of CV mortality, need for revascularization, recurrent ACS, and persistent angina after discharge (OR 0.49, 95% CI 0.36-0.67; p&amp;lt;0.01; OR 0.09, 95% CI 0.03-0.31; p&amp;lt;0.01; OR 0.57, 95% CI 0.37-0.89; p=0.01; OR 0.23, 95% CI 0.11-0.51; p&amp;lt;0.01). MINOCA was not associated with a significant difference in risk of CV rehospitalization (OR 0.74, 95% 0.46-1.19; p=0.21). Conclusions In patients with AMI, MINOCA is associated with lower risk of all-cause mortality, CV mortality, need for revascularization, recurrent ACS, and persistent angina on long-term follow-up compared to OCAD. However, MINOCA is associated with similar risk of rehospitalization for CV events. Further studies are needed to determine the association between different medical therapies and clinical outcomes in patients with MINOCA.

Association between dietary intake of omega-3 polyunsaturated fatty acids and all-cause and cardiovascular mortality among hypertensive adults: Results from NHANES 1999–2018

Hypertensive adults are at a higher risk of cardiovascular morbidity and mortality. Dietary omega-3 polyunsaturated fatty acids (N3-PUFA) intake has been associated with cardiovascular benefits. However, few studies have specifically investigated whether dietary intake of N3-PUFA is associated with lower risk of all-cause and cardiovascular mortality among hypertensive adults in the U.S. This prospective cohort study included 26,914 hypertensive individuals 18 years or older who participated in 10 NHANES cycles from 1999 to 2018. Dietary levels of N3-PUFA were obtained from the 24-hour dietary recalls. The dietary data were linked to mortality records from the National Death Index through December 31, 2019. The associations between dietary N3-PUFA levels and mortality were evaluated by constructing the Multivariable Cox Proportional Hazards models. We observed an increasing trend of dietary N3-PUFA intake levels over the years, mainly driven by alpha-linolenic acid (ALA). Lower all-cause mortality risk was observed among hypertensive adults with higher consumption of total N3-PUFA [adjusted hazards ratio, 95% confidence interval: 0.91 (0.86, 0.97)], plant-based ALA [0.88 (0.83, 0.93)], fish oil-based eicosapentaenoic acid (EPA)+docosahexaenoic acid (DHA) [0.91 (0.83, 0.99)], EPA [0.93 (0.88, 0.98)], docosapentaenoic acid (DPA) [0.73 (0.58, 0.91)], or DHA [0.95 (0.90, 0.99)]. Hypertensive adults were at lower risk of cardiovascular mortality if their diet contained higher levels of total N3-PUFA [0.68 (0.53, 0.88)], ALA [0.89 (0.80, 0.99)], EPA [0.87 (0.79, 0.97)] or DPA [0.86 (0.78, 0.95)]. Weighted quantile sum analysis showed that ALA, EPA, and DPA were the main contributors of the N3-PUFA benefits against mortality among hypertensive adults. Dietary intake of N3-PUFA, particularly ALA, EPA, and DPA, was associated with lower risk of all-cause and cardiovascular mortality among U.S. hypertensive adults. These findings suggest that increasing dietary intake of N3-PUFA may serve as a potential strategy to lower hypertension-associated mortality risk.

599-P: The Effects of Cardiac Rehabilitation and Exercise Training in Hospital among Patients of Diabetic Cardiovascular Disease with Sarcopenic Obesity

Background: The patients of type 2 diabetes have known to have a higher chance of having Sarcopenic obesity, in which the increase of body fat and the decrease of extremity muscles is observed. A high level of lower-limb muscle has been known to associated with a lower risk of cardiovascular mortality in patients with cardiovascular diseases. The effects of cardiac rehabilitation (CR) on the patients of diabetic cardiovascular disease with sarcopenic obesity has not been well known. The aim of this study was to examined the change of body compositions and of lower-limb muscle strength between diabetic (DM) and nondiabetic (Non-DM) cardiovascular disease patients during CR. Methods: A total of 82 male patients were assigned to the study who discharged from the acute-phase treatments for ischemic heart disease (IHD) or heart failure (HF) (DM group; n=33, Non-DM group; n=49). The body compositions and the lower-limb muscle strength were evaluated before and after CR twice a week for 5 months and analyzed retrospectively. Results and Conclusions: The DM group before performing the CR showed significant increase in body fat and decrease in lower-limb muscle strength, compared with the non-DM group (p&amp;lt;0.05). The effects of increasing lower-limb muscle strength after CR were observed in both DM and non-DM groups (n,c). Moreover, HF patients had weaker lower-limb muscle strength before CR than IHD patients (p&amp;lt;0.05) and it was even weaker among the DM. However, after CR, the increasing effects of lower-limb muscle tended to be stronger in the DM group. These data showed that the patients with diabetic cardiovascular disease with sarcopenic obesity have a chance to have increase of the lower-limb muscle strength after CR as well as that of nondiabetic cardiovascular disease. A lower-limb muscle might be a new scale and a therapeutic target in patients with cardiovascular disease. Disclosure Y. Kayama: None.

Polyphenol intake and mortality: A nationwide cohort study in the adult population of Spain

Polyphenols are secondary metabolites present in small quantities in plant-based food and beverages, with antioxidant and anti-inflammatory properties. Main groups of polyphenols include flavonoids, phenolic acids, stilbenes, and lignans, but their association with mortality has barely been examined. We aimed to assess the association between the intake of 23 polyphenol subgroups and all-cause, cardiovascular, and cancer mortality in a representative sample of the Spanish adult population. Population-based cohort study conducted with 12,161 individuals aged 18+ recruited in 2008-2010 and followed-up during a mean of 12.5 years. At baseline, food consumption was obtained with a validated dietary history, and the Phenol-Explorer database was used to estimate polyphenol intake. Associations were examined using Cox regression adjusted for main confounders. During follow-up, 967 all-cause deaths occurred, 219 were cardiovascular, and 277 cancer. Comparing extreme categories of consumption, hazard ratios (95% CI) of total mortality for subgroups were: dihydroflavonols 0.85 (0.72-1.00; p-trend:0.046); flavonols 0.79 (0.63-0.97; p-trend:0.04); methoxyphenols 0.75 (0.59-0.94; p-trend:0.021); tyrosols 0.80 (0.65-0.98; p-trend:0.044); alkylmethoxyphenols 0.74 (0.59-0.93; p-trend:0.007); hydroxycinnamic acids 0.79 (0.64-0.98; p-trend:0.014); and hydroxyphenilacetic acids 0.82 (0.67-0.99; p-trend:0.064). For cardiovascular mortality, hazard ratios were: methoxyphenols 0.58 (0.38-0.89; p-trend:0.010); alkylmethoxyphenols 0.59 (0.39-0.90; p-trend:0.011); hydroxycinnamic acids 0.63 (0.42-0.94; p-trend:0.020); and hydroxyphenilacetic acids 0.69 (0.48-0.99; p-trend:0.044), when comparing extreme tertiles of consumption. No statistically significant associations were observed for cancer. The main food sources for these polyphenol subgroups were red wine, leafy green vegetables, olive oil, green olives, and coffee (the latter being the major contributor of methoxyphenols, alkylmethoxyphenols, and hydroxycinnamic acids). In the Spanish adult population, intake of specific polyphenol subgroups was prospectively associated with a 20% lower all-cause mortality risk. This decrease was mainly due to a 40% lower cardiovascular mortality risk over time.

Long-term follow-up after invasive or conservative management of stable coronary disease: the ISCHEMIA-EXTEND study.

The ISCHEMIA trial found no statistical difference in the primary endpoint between initial invasive and conservative management of patients with chronic coronary disease and moderate-to-severe ischaemia on stress testing. However, an invasive strategy increased peri-procedural myocardial infarction (MI) but decreased spontaneous MI with continued separation of curves over time. Thus, in order to assess the long-term effect of invasive management strategy on mortality, the ISCHEMIA-EXTEND observational study was planned including surviving participants from the initial phase of the ISCHEMIA trial with a projected median follow-up of nearly 10 years. Recently, an interim report of 7-year all-cause, cardiovascular (CV), and non-CV mortality rates has been published showing no difference in all-cause mortality between the two strategies, but with a lower risk of CV mortality and higher risk of non-CV mortality with an initial invasive strategy over a median follow-up of 5.7 years. The trade-offs in CV and non-CV mortality observed in ISCHEMIA-EXTEND raise many important questions regarding the heterogeneity of treatment effect, the drivers of mortality, and the relative importance and reliability of CV vs. all-cause mortality. Overall, findings from ISCHEMIA and ISCHEMIA-EXTEND trials might help physicians in shared decision-making as to whether to add invasive management to guideline-directed medical management in selected patients with chronic coronary artery disease and moderate or severe ischaemia.

Risk of Cardiovascular Death in Osteosarcoma.

To assess the risk of cardiovascular mortality (CVM) in patients with osteosarcoma. Descriptive study. Place and Duration of the Study:Department of Orthopaedics, The People's Hospital of Baoan, Shenzhen, Guangdong, China, from 1st January 2019 to 1st January 2022. Data on patients diagnosed with osteosarcoma, between 1975 and 2019, were obtained from the surveillance, epidemiology, and end results (SEER) database. Using the Nelson-Aalen cumulative risk curve to assess the risk of CVM in patients with osteosarcoma. Competing risk models were used for identifying and analysing independent risk factors for CVM in the patients. Data from a total of 1335 patients with osteosarcoma were obtained from the SEER database. The characteristics of patients with osteosarcoma independently related with a high risk of CVM were age over 65 years (HR: 2.528; 95% CI: 1.156 - 5.527), race of other categories (HR: 1.498; 95% CI: 1.044 - 2.151), and exposure radiotherapy (HR: 0.493; 95% CI: 0.244 - 0.998). Receiving chemotherapy was independently associated with a low risk of CVM (HR: 1.911; 95% CI: 1.016 - 3.593). Cardiovascular disease death from osteosarcoma was significantly associated with older age at diagnosis, race other class, receiving radiation therapy, and not undergoing chemotherapy. Osteosarcoma, Cancer risk factors, Epidemiology.

Longitudinal associations of housework with frailty and mortality in older adults: Singapore Longitudinal Ageing Study 2

BackgroundHousework may provide a sustainable form of physical activity for older adults and improve health and survival outcomes. Longitudinal studies on associations between housework status over time and health outcomes are lacking. We aim to assess the longitudinal association of intensity and duration of housework with frailty and mortality outcomes.MethodsAmong 3270 community-dwelling prospective cohort study participants, aged ≥55 years, data on light housework (N=2996) and heavy housework (N=3022) were available at baseline (March 6, 2009, to June 11, 2013) and follow-up at 3 to 5 years later, (January 16, 2013 to August 24, 2018). Median time spent per week on light (≥420min/week) and heavy (>0min/week) household activities at baseline and follow-up were used to categorise individuals into three groups (i) consistent low levels of housework at both baseline and follow-up, (ii) inconsistent high levels of housework at either baseline or follow-up and (iii) consistent high levels of housework at both baseline and follow-up. Baseline and follow-up frailty index >0.10, and all-cause, cancer and cardiovascular mortality from mean 9.5 years follow-up to March 31, 2021. Effect estimates were adjusted for socio-demographics, nutritional risk, lifestyle and other physical activities.ResultsOverall, participants had mean [SD] age, 66.9 [7.8] years; 1916 [62.7%] were female. Participation in high levels of light and heavy housework consistently over time was associated with decreased odds of prefrailty/frailty at follow-up, [OR,0.61;95%CI,0.40–0.94] and [OR,0.56;95%CI,0.34–0.90] respectively, in the older group aged ≥65, compared to participants with consistent low levels of housework at baseline and follow-up. Sex-stratified analysis revealed an association between regular heavy housework participation and lower prevalence of prefrailty/frailty at follow-up in older men but not women [OR,0.31;95%CI,0.13–0.72]. Regular participation in high levels of light housework was associated with 41% lower risk of all-cause mortality [95%CI,0.36–0.96] in women but not in men, and 54% lower risk of cardiovascular mortality [95%CI,0.22–0.96].ConclusionsRegular participation in above average levels of light housework is associated with decreased odds of prefrailty/frailty in older adults aged ≥65 years, and all-cause mortality in older women. Heavy housework participation is associated with decreased odds of prefrailty/frailty, especially in older men aged ≥65. Housework may be a meaningful occupation for older adults and should be encouraged for health and wellbeing.

Association of selenium and cadmium with heart failure and mortality based on the National Health and Nutrition Examination Survey.

The association of selenium and cadmium with heart failure and mortality has not been thoroughly explored. We analysed data from the National Health and Nutrition Examination Survey (NHANES) database over 12 years (1999-2000, 2003-2004 and 2011-2018), which includes blood selenium and cadmium. Multivariable logistic regression and Cox proportional hazards regression were used. In total, 15,689 participants were enrolled. The multivariate analysis showed that low blood selenium (odds ratio [OR] = 0.952, p < 0.001) and high blood cadmium (OR = 1.345, p < 0.001) were independent risk factors of heart failure. During 96802 person-year follow-up, 1697 deaths occurred. The multivariable adjusted hazard ratio (HR) for all-cause mortality was 0.82 (95% confidence interval [CI] = 0.71-0.95) for middle selenium levels and 0.76 (95% CI = 0.65-0.88) for high selenium levels compared to low selenium levels. Taking the low cadmium levels as reference, the multivariable adjusted HR for all-cause mortality among high cadmium levels was 1.68 (95% CI = 1.44-1.96). Furthermore, the association between selenium, cadmium and cardiovascular mortality was similar to that of all-cause mortality. A subgroup analysis of the study population showed that in individuals with heart failure, although selenium levels were not associated with risk of all-cause mortality, high selenium levels were associated with a lower risk of cardiovascular mortality (HR = 0.33, p = 0.0032). Low blood selenium and high blood cadmium were independent risk factors of heart failure. Blood selenium was inversely associated with all-cause mortality and cardiovascular mortality, whereas blood cadmium was positively associated with them. Furthermore, blood selenium was associated with a lower risk of cardiovascular mortality in individuals with heart failure.

Use of fish oil and mortality of patients with cardiometabolic multimorbidity: A prospective study of UK biobank

Background and aimsCardiometabolic multimorbidity (CMM) has risen as a global issue of public health, with an in-creasing prevalence and more severe clinical prognosis. This study aimed to estimate the association between use of fish oil and mortality among patients with CMM. Methods and ResultsIn this prospective study based on UK Biobank, participants with ≥2 of cardiometabolic diseases (CMDs, including coronary heart disease [CHD], diabetes, hypertension, and stroke in this study) at recruitment were included. Use of fish oil was derived from touchscreen questionnaires at baseline. All-cause and cardiovascular mortality were accessed via electronic health-related records. Kaplan–Meier curves and flexible parametric Royston-Parmar proportion-hazard models were fitted to assess the as-sociations of fish-oil use with all-cause, cardiovascular mortality, and related life expectancy alterations. Among 30 068 participants from UK Biobank (67.9% men; mean age 61.75 years), 5357 deaths were reported during 12.03 years of follow-up. For patients with CMM, use of fish oil was associated with a 17% lower risk of all-cause mortality (95% confidence interval [95% CI] 0.78–0.88, P < 0.001), and 19% lower risk of cardiovascular mortality (95% CI 0.72–0.90, P < 0.001) in multivariable-adjusted models. At 45 years old, using fish oil was associated with 1.66 years of life expectancy gained. ConclusionAmong patients with CMM, use of fish oil was associated with a significantly reduced risk of all-cause, cardiovascular mortality, and prolonged life expectancy.

Left ventricular volume change and long-term outcomes in ischaemic cardiomyopathy with or without surgical revascularisation: A post-hoc analysis of a randomised controlled trial.

SummaryBackgroundWhether the association between post-therapeutic left ventricular volume change and long-term outcomes in ischaemic cardiomyopathy is influenced by the performance of coronary artery bypass grafting (CABG) remains unclear. We sought to perform a post-hoc analysis of the Surgical Treatment of Ischaemic Heart Failure (STICH) trial to investigate this association in patients treated with medical therapy (MED) with or without CABG.MethodsFrom July 24, 2002, to May 5, 2007, 1212 patients with ischaemic cardiomyopathy were enrolled in the STICH trial (NCT00023595) from 99 sites in 22 countries, and were randomly assigned to undergo CABG plus MED or MED alone. We completed a post-hoc analysis of this trial. Patients with paired left ventricular end-systolic volume index (ESVI) measured at baseline and 4-months were included in our analysis. The association between change in ESVI from baseline to 4-months and cardiovascular mortality or all-cause mortality was assessed in MED arm and CABG plus MED arm.Findings523 patients were included, with 291 (55.6%) assigned to MED arm and 232 (44.4%) to CABG plus MED arm. At a 4-month follow-up, ESVI reduction was more likely to occur among patients undergoing CABG plus MED. After a median follow-up of 10.3 years, for each 26% (1- standard deviation) decrement in ESVI, it was associated with a 22% lower risk of cardiovascular mortality (HR 0.78; 95% CI, 0.65-0.94) and 19% lower risk of all-cause mortality (HR 0.81; 95% CI, 0.69-0.95) in MED arm, whereas this association was not shown in CABG plus MED arm (cardiovascular mortality: HR 0.90; 95%CI, 0.74-1.10; all-cause mortality: HR 0.93; 95%CI, 0.79-1.09). A 16% reduction in ESVI was determined to be the most appropriate threshold of change in ESVI in the MED arm.InterpretationIn patients with ischaemic cardiomyopathy, left ventricular volume change was associated with long-term prognosis after medical therapy alone, whereas was likely not an optimal benchmark for evaluating the survival benefits associated with CABG. A more than 16% reduction in ESVI might assist in therapeutic efficacy assessment and prognostic evaluation in medically treated patients.FundingNational Natural Science Foundation of China; Natural Science Funds of Guangdong Province.

Association of Peritonitis With Cardiovascular Mortality Over Time in the Peritoneal Dialysis Population: An Australia and New Zealand Dialysis and Transplant Registry Study

Though peritonitis is associated with increased mortality in patients receiving peritoneal dialysis (PD), its association with cardiovascular mortality remains uncertain. The study participants included adult patients (≥18 years old) commencing PD in Australia (from October 2003 to December 2019) using the Australia and New Zealand Dialysis and Transplant (ANZDATA) registry. Association between peritonitis and cardiovascular mortality was evaluated using Cox proportional hazards analysis and competing risks analysis. Associations between peritonitis rates between different eras and cardiovascular mortality were also compared using Jointpoint regression model to determine the time point when a significant change in peritonitis trend occurred to define the era for cardiovascular mortality. Subgroup analysis dividing the groups into 0, 1 and≥2 episodes of peritonitis and sensitivity analysis censoring at 90 days post-transfer to hemodialysis (HD) were performed. The study included 9699 incident PD patients. The overall peritonitis rate was 0.37 episodes per patient-year and declined by 4.7% (95% confidence interval [CI] 3.6-5.8%) during the study period. Peritonitis was associated with increased cardiovascular mortality risk (subdistribution hazard ratio [SHR] 1.53, 95% CI 1.39-1.69, P< 0.001) with increasing peritonitis episodes associated with higher risk (1 episode of peritonitis SHR 1.41, 95%CI 1.24-1.61;≥2 episodes of peritonitis SHR 1.69, 95% CI 1.47-1.93, P< 0.001). Patients who commenced PD between 2012 and 2019 had a lower risk of cardiovascular mortality (SHR 0.60, 95% CI 0.50-0.72, P< 0.001), compared to patients who commenced between 2003 and 2011. Results were consistent in the sensitivity analysis. Peritonitis is independently associated with an increased risk of cardiovascular mortality, and the association is episode-dependent. Prevention and adequate treatment of PD peritonitis may improve cardiovascular outcomes among patients receiving PD.

Positive psychology differences and risk stratification between STEMI and NSTEMI

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Spanish Society of Cardiology Introduction Clinical presentation of myocardial infarction (MI) is broad and can be differentiated into different risk groups based on electrocardiogram (ECG) presentation, ST-segment elevation MI (STEMI) or Non-ST-segment elevation MI (NSTEMI), with different in-hospital mortality rates and short-term mortality rates after discharge. Psychological variables also have an impact on post-MI prognosis. Factors such as stress, anxiety or depression have been associated with a higher cardiovascular risk and positive psychological variables, such as optimism, have has been related to a lower risk of cardiovascular mortality after MI. Patients may present different psychological profiles regarding the early ECG presentation which could be associated with differences in cardiovascular events and mortality. Purpose The aim of this study is to assess whether positive and negative psychological factors are associated with early ECG presentation. This is relevant as it could help refining risk stratification and improving secondary prevention, including psychological interventions. Methods 93 patients admitted to a tertiary hospital with MI were divided into groups based on the early electrocardiogram presentation (STEMI vs. NSTEMI). Differences in sociodemographic, clinical history, lifestyle, coping styles, mental and physical quality of life, anxiety, depression, stress, optimism, positive and negative affect and psychological well-being were assessed using Chi-Square test and Student-t test. Psychological well-being was composed by the following dimensions: self-acceptance, positive relationships, autonomy, environmental domain, personal growth and purpose in life. If any difference emerged in the sociodemographic control variables (age and sex), the corresponding analyses of covariance (ANCOVAs) were performed. Results STEMI patients (n = 64) had a significantly lower mean age (p = 0.02), lower BMI (p = 0.03) and presented less previous heart failure (p = 0.03). Significantly lower levels of optimism (p = 0.03) compared to the NSTEMI group (n = 29) were observed, difference that showed a medium effect size magnitude (d = 0.48). ECG presentation explain 8% variance of levels of optimism and age explain 6% of the variability of dispositional optimism. STEMI patients also perceived a significant higher level of mental quality of life comparing to NSTEMI group (p = 0.05), difference that had a medium magnitude (d = 0.43). ECG presentation contribute in 5% to the variability of mental quality of life, but the age had no significant effect (p = 0.37). No differences were observed between groups in coping styles, anxiety, depression, stress, positive and negative affect and psychological well-being. Conclusions STEMI patients seem to have different psychological profile compared with NSTEMI. Particularly for optimism and mental quality of life. This may have future implications for psychological rehabilitation of patients with MI.

Comparison of the Efficacy and Safety Endpoints of Five Therapies for Atrial Fibrillation: A Network Meta-Analysis

IntroductionAtrial fibrillation (AF) is a prevalent arrhythmia that occurs in 2–4% of adults and poses a threat to human health. Thus, comparison of the efficacy and safety of therapies for AF is warranted. Here, we used network analysis to compare efficacy (arrhythmia recurrence and re-hospitalization) and safety (ischemic cerebral vascular events, all-cause mortality, and cardiovascular mortality) endpoints among five major therapies for AF.MethodsThe PubMed, Cochrane, and Embase databases were searched, and relevant literature was retrieved. Only studies that made comparisons among the therapies of interest and involved patients with AF were included. Pairwise comparisons and frequentist method (SUCRA plot) analyses were conducted.ResultsIn total, 62 studies were included in the pooled analysis. In pairwise comparisons, atrioventricular nodal ablation plus permanent pacemaker (AVN + PPM) was associated with a significantly higher risk of atrial arrhythmia recurrence than surgical ablation [odds ratio (OR): 23.82, 95% confidence interval (CI): 1.97–287.59, fixed-effect model; 3.82, 95% CI: 1.01–559.74, random-effects model]. Furthermore, radiofrequency ablation was associated with a significantly lower risk of cardiovascular mortality than medication in pairwise comparison (OR: 0.49, 95% CI: 0.29–0.83, fixed-effect model; OR: 0.49, 95% CI: 0.27–0.9, random-effects model). Frequentist analysis indicated that AVN + PPM had the best performance in reducing the risk of safety and efficacy endpoints.ConclusionNon-pharmaceutical therapies showed superior performance to traditional drug therapy in lowering the risk of safety and efficiency endpoint events. AVN + PPM performed best in reducing the risk of safety and efficacy endpoints.

Dysregulated diurnal cortisol patterns are associated with cardiovascular mortality: Findings from the KORA-F3 study

Psychosocial stress has been associated with an increased risk for cardiovascular disease and death. Dysregulated diurnal cortisol slopes, which have also been associated with stress, might mediate this association. However, existing evidence on the cardiovascular health consequences of dysregulated cortisol slopes remains limited and inconclusive. To elucidate whether dysregulated diurnal cortisol slopes are related to cardiovascular mortality, we assessed salivary cortisol and cardiovascular morbidity and mortality in 1090 participants from the KORA-F3 study, a prospective, observational cohort study of a random representative sample from the general population. Eighty-seven deaths were registered during the mean follow-up period of approximately 11 years, 31 of which were classified as cardiovascular deaths. A more pronounced cortisol awakening response was associated with a lower risk of cardiovascular mortality in the adjusted Cox proportional hazards analysis (HR 0.59 [95-%-CI 0.36–0.96], p = 0.03). A greater diurnal cortisol peak-to-bedtime ratio at baseline also predicted a decreased risk of cardiovascular mortality (HR 0.50 [95-%-CI 0.34–0.73], p 0.01) and a decreased risk of stroke (HR 0.71 [95-%-CI 0.55–0.92], p 0.01). Increased levels of late night salivary cortisol predicted a higher risk of cardiovascular mortality (HR 1.49 [95-%-CI 1.13–1.97], p 0.01) and an increased risk of stroke (HR 1.24 [95-%-CI 1.01–1.52], p = 0.04). There was no association between measures of cortisol and non-cardiovascular related mortality. In conclusion, dysregulated diurnal cortisol patterns are associated with cardiovascular mortality, while greater diurnal cortisol variation seems to have a protective effect. This adds evidence to suggest a pathophysiological role of diurnal cortisol secretion patterns in cardiovascular health.

Impact of SGLT2 inhibitors on major clinical events and safety outcomes in heart failure patients: a meta-analysis of randomized clinical trials.

BACKGROUNDSodium-glucose co-transporter-2 inhibitors (SGLT2i) significantly reduce the risk of cardiovascular (CV) and renal adverse events in patients with diabetes mellitus, heart failure (HF) and/or chronic kidney disease. We performed a meta-analysis to explore the impact of several different SGLT2i on all-cause mortality, CV mortality, HF hospitalizations and the combined outcome CV death/HF hospitalization in HF patients across the spectrum of left ventricular ejection fraction (LVEF) phenotypes.METHODSA systematic search in MEDLINE database and Cochrane library through March 2021 was performed without limitations. Randomized clinical trials that provided data about the impact of SGLT2i on all-cause mortality, CV mortality, HF hospitalizations or the combined outcome of CV death/HF hospitalization in HF patients were included. A random effects model was used for calculating the effect estimates.RESULTSNine studies (n = 16,723 patients, mean age: 65.9 years, males: 70.7%) were included in the quantitative synthesis. Compared to placebo, SGLT2i use was associated with 14% lower risk of all-cause mortality [hazard ratio (HR) = 0.86, 95% CI: 0.78−0.94,I2 = 0, P = 0.0008], 32% lower risk of HF hospitalizations (HR = 0.68, 95% CI: 0.62−0.74,I2 = 0, P < 0.001), 14% lower risk of CV mortality (HR = 0.86, 95% CI: 0.77−0.95, I2 = 0, P = 0.003) and 26% lower risk of CV death/HF hospitalization (HR = 0.74, 95% CI: 0.68−0.80,I2 = 0, P < 0.001). Regarding the safety outcomes, our data revealed no significant differences between SGLT2i and placebo groups in drug related discontinuations, amputations, severe hypoglycemia, hypotension, volume depletion, ketoacidosis and genital infections. By contrast, a protective role of SGLT2i against placebo was found for serious adverse events and acute kidney injury. CONCLUSIONSIn patients with HF, regardless of LVEF phenotype, all SGLT2i had an excellent safety profile and significantly reduced the risk of all-cause mortality, CV mortality, HF hospitalizations and CV deaths/HF hospitalizations compared to placebo.

Urate lowering therapy is associated with a lower risk of heart failure hospitalisation or mortality in hyperuricaemic patients with heart failure: a comparative effectiveness study

Abstract Background There is a strong association between hyperuricemia (elevated serum uric acid) and the risk of heart failure. However, it remains unclear whether prescribing urate lowering therapies have any bearing on long term clinical outcomes. Purpose In this study, we assessed the impact of urate lowering therapy treatment on the risk of adverse health outcomes (hospitalisation for heart failure and all-cause mortality) in patients with hyperuricemia and heart failure. Methods We utilised data from Clinical Practice Research Datalink (CPRD) GOLD, a UK-based primary care database linked to secondary care (Hospital Episode Statistics) and mortality data (Office of National Statistics). The study population included patients with a first record of hyperuricemia (serum uric acid &amp;gt;7 mg/dl for men and &amp;gt;6 mg/dl for women or a gout diagnosis) between 1990 and 2019 with a history of heart failure. Incident urate lowering therapy users were identified post hyperuricemia diagnosis. To account for potential confounding variables and potential treatment paradigm changes over the study period, a propensity score matched cohort was constructed for urate lowering therapy initiators and non-initiators within 6 month accrual blocks. Adverse health outcomes were compared between matched treatment groups using Cox regression analysis adjusted for the same variables used in the propensity score. Due to extensive treatment switching and discontinuation, on-treatment analysis was the main analysis. Results A total of 2,174 propensity score matched pairs were identified. We found that urate lowering therapy was associated with a 43% lower risk of all-cause mortality or hospitalization for heart failure (Figure 1, adjusted hazard ratio 0.57, 95% confidence interval 0.51–0.65), and a 19% lower risk of cardiovascular mortality or hospitalization for heart failure (Figure 2, adjusted hazard ratio 0.81, 95% confidence interval 0.71–0.92) within five years compared to those not on therapy (on-treatment analysis). In an intention-to-treat sensitivity analysis, urate lowering therapy was associated with a 17% lower risk of all-cause mortality or hospitalization for heart failure (adjusted hazard ratio 0.83, 95% confidence interval 0.76–0.91), and a 11% lower risk of cardiovascular mortality or hospitalization for heart failure (adjusted hazard ratio 0.89, 95% confidence interval 0.81–0.98) within five years compared to those not on urate lowering therapy. Adjusted and non-adjusted hazard ratios were consistent for all outcomes. Conclusion We found that urate lowering therapy was associated with a lower risk of adverse outcomes in hyperuricemia or gout patients with a history of heart failure. These results are consistent with the hypothesis that uric acid lowering may lead to improved outcome in patients with heart failure and hyperuricemia, emphasizing the need to investigate the potential benefits of intense uric acid lowering in prospective randomized controlled trials. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): AstraZeneca Figure 1 (HF = heart failure)Figure 2 (CV = cardiovascular)

Long-term Benefits and Harms Associated With Genetic Cholesteryl Ester Transfer Protein Deficiency in the General Population

The balance between the potential long-term clinical benefits and harms associated with genetic cholesteryl ester transfer protein (CETP) deficiency, mimicking pharmacologic CETP inhibition, is unknown. To assess the relative benefits and harms associated with genetic CETP deficiency. This study examined 2 similar prospective cohorts of the Danish general population, with data on a total of 102 607 participants collected from October 10, 1991, through December 7, 2018. Weighted CETP allele scores. Incident cardiovascular mortality, ischemic heart disease, myocardial infarction, ischemic stroke, peripheral arterial disease, vascular dementia, Alzheimer disease, all-cause mortality, and age-related macular degeneration (AMD). The study first tested whether a CETP allele score was associated with morbidity and mortality, when scaled to genetically lower levels of non-high-density lipoprotein (HDL) cholesterol (ie, 17 mg/dL), corresponding to the reduction observed for anacetrapib vs placebo in the Randomized Evaluation of the Effects of Anacetrapib Through Lipid-Modification (REVEAL) trial. Second, the study assessed how much of the change in morbidity and mortality was associated with genetically lower levels of non-HDL cholesterol. Finally, the balance between the potential long-term clinical benefits and harms associated with genetic CETP deficiency was quantified. For AMD, the analyses also included higher levels of HDL cholesterol associated with genetic CETP deficiency. Of 102 607 individuals in the study, 56 559 (55%) were women (median age, 58 years [IQR, 47-67 years]). Multivariable adjusted hazard ratios showed that a genetically lower level of non-HDL cholesterol (ie, 17 mg/dL) was associated with a lower risk of cardiovascular mortality (hazard ratio [HR], 0.77 [95% CI, 0.62-0.95]), ischemic heart disease (HR, 0.80 [95% CI, 0.68-0.95]), myocardial infarction (HR, 0.72 [95% CI, 0.55-0.93]), peripheral arterial disease (HR, 0.80 [95% CI, 0.63-1.02]), and vascular dementia (HR, 0.38 [95% CI, 0.18-0.80]) and an increased risk of AMD (HR, 2.33 [95% CI, 1.63-3.30]) but was not associated with all-cause mortality (HR, 0.91 [95% CI, 0.81-1.02]), ischemic stroke (HR, 1.05 [95% CI, 0.81-1.36]), or Alzheimer disease (HR, 1.25 [95% CI, 0.89-1.76]). When scaled to a higher level of HDL cholesterol, the increased risk of AMD was even larger. A considerable fraction of the lower risk of cardiovascular end points was associated with genetically lower levels of non-HDL cholesterol, while the higher risk of AMD was associated with genetically higher levels of HDL cholesterol. Per 1 million person-years, the projected 1916 more AMD events associated with genetically higher levels of HDL cholesterol was similar to the 1962 fewer events of cardiovascular mortality and myocardial infarction combined associated with genetically lower levels of non-HDL cholesterol. This study suggests that genetic CETP deficiency, mimicking pharmacologic CETP inhibition, was associated with a lower risk of cardiovascular morbidity and mortality, but with a markedly higher risk of AMD.