Management Of Cardiovascular Risk Factors Research Articles

Trends in statin utilization and ischemic heart disease mortality in Lithuania and Sweden, 2000–2020

Aims: To compare statin utilization and ischemic heart disease (IHD) mortality trends in Lithuania and Sweden and to assess correlations between the total utilization of statins and IHD mortality. Methods: An ecological study assessing time trends in statin utilization (DDDs per 1000 inhabitants per day; DDD/TID) and IHD mortality in Lithuania and Sweden between 2000 and 2020. Statin utilization data in Lithuania were wholesale trade data, and Swedish data were drugs dispensed at pharmacies. IHD mortality data were extracted from national databases as rates per 100 000 inhabitants. Associations between statin utilization and IHD mortality in Lithuania and Sweden were examined using Spearman’s rank and Pearson’s correlation coefficients, respectively. Results: Statin utilization increased from 16.8 to 135.8 DDD/TID in Sweden and from 0.2 to 61.8 DDD/TID in Lithuania between 2000 and 2020. Medium intensity was the most common statin dosage in Lithuania, while Sweden used more high intensity than moderate-intensity statins from 2017. IHD mortality in Lithuania remained high between 2000 and 2020 (from 359.1 to 508.8 deaths per 100 000 population), while it decreased markedly in Sweden (from 226.87 to 88.7 deaths per 100 000 population). IHD mortality and statin utilization were inversely correlated in Sweden (r = -0.993, P < 0.001), while a positive correlation was found in Lithuania (rs = 0.871, P < 0.001). Conclusion: Despite the growing statin utilization in both countries, Lithuania recorded a slight increase in IHD mortality rates unlike the situation in Sweden. This indicates room for improvement in the management of modifiable cardiovascular risk factors in Lithuania including how statins are prescribed and used in clinical practice.

Independent predictors of MACE in patients with cancer

Abstract Funding Acknowledgements None. Background/Introduction Cardiovascular disease and cancer are the leading causes of death worldwide. Both disease entities share common risk factors. More importantly, the main cause of death after disease progression is cardiovascular disease in patients with cancer. Despite the recent advancements in the field of cardio-oncology, the main prognostic factors of major adverse cardiovascular events (MACE) remain elusive. Purpose To investigate prognostic factors of MACE in a single center cardio-oncology registry. Methods Consecutive patients referred to the cardio-oncology outpatient clinic of a tertiary center for cardiologic consultation were included. All patients were followed up clinically or by telephone. Data from national records were also used. Results In total, 115 patients were included in the analysis. Of them, 60 (52.2%) were female and the majority of study population suffered from breast cancer (27%). Thirteen patients (11.3%) had hematologic malignancies and the rest solid tumors. Chemotherapy was received by a total of 94 patients (81,7%). The mean follow -up duration was 446 days. During follow up, 32 MACEs (27.8%) occurred. Death from any cause occurred in 21 patients (including 2 cardiac deaths), hospitalization due to heart failure in 6, myocardial infarction in 2, pulmonary embolism in 3 and stroke in 1 patient. In multivariate logistic regression analysis, diabetes mellitus was an independent predictor of MACE, after adjustment for cardiovascular risk factors and body mass index (OR=3.37, 95% CI 1.14-9.99). In Kaplan Meier plots patients with diabetes mellitus showed higher incidence of MACE (log rank p=0.03). Conclusions In the present single center study, diabetes mellitus emerged as an independent predictor of MACE. This finding confirms the important and primary role of cardio-oncology units in the strict management of cardiovascular risk factors, leading to improved prognosis of this patient-population.Kaplan Meier Curve

Social and Structural Determinants of Cardiovascular Complications of Diabetes.

Cardiovascular disease (CVD) is the leading cause of mortality in people who have diabetes. Racial and ethnic minorities with diabetes have suboptimal management of cardiovascular risk factors, leading to higher mortality. Social and structural determinants of health are external factors that influence an individual's ability to choose positive health behaviors. In this review, we will discuss cardiovascular complications in people who have diabetes and their relationship to social determinants of health (SDOH). Recent innovations in diabetes treatment, including new devices and medications, have improved care and survival. However, disparities in the availability of these treatments to racial and ethnic minorities may contribute to continued inequities in CVD outcomes. Racial/ethnic disparities in CVD relate to inequities in economic opportunity, education and health literacy, neighborhoods and social cohesion, and health care access and quality driven by structural racism.

A study of carotid intima media thickness in patients with rheumatoid arthritis and its correlation with acute phase reactants and disease activity

Introduction: There is increased risk of cardiovascular morbidity and mortality in patients of rheumatoid arthritis (RA) due to accelerated atherosclerosis. In this study we measured Carotid artery intima media thickness (CIMT) as a surrogate marker for subclinical atherosclerosis in RA patients without pre-existing cardiovascular disease. This study also analyzed the correlation between CIMT, disease duration, Simplified Disease Activity Index (SDAI) and acute phase reactants. Methods: A cross-sectional study was conducted on 90 patients divided into two groups of 45 patients of RA and another 45 control subjects. Subjects with RA and age and sex matched healthy controls were included in the study without pre-existing CV risk factors. Complete clinical evaluation, hematological and biochemical profile done. ESR, CRP and platelet count were used as markers of acute phase reactants. All the RA patients included in the study were evaluated for their disease activity using Simplified Disease Activity Index (SDAI). All the subjects including the controls evaluated for carotid intima media thickness by using carotid ultrasonography. CIMT measured in common carotid artery bilaterally by examining throughout common carotid artery up to 2 cm proximal to bifurcation. CIMT measurement taken at the site of greatest thickness. All measurements taken in diastole, measured in phase when lumen diameter is at its smallest and IMT at its largest. Mean value of 6 readings (3 from each side) taken as final CIMT for evaluation. B mode (linear probe) USG was used to determine carotid IMT. Results: 45 cases and similar control subjects included in the study with mean age (SD) as 45.07 (14.81) years. We found female preponderance with 37 females out of 45 cases. Mean (SD) disease duration in male subjects was 5.38(2.40) years while in females was 5.09 (2.78) years. CRP was found to be significantly increased in cases group with mean (SD) of 5.75(8.85) mg/dl. ESR significantly raised to 35.22(13.55) mm/hour in cases group compared to control group where it was 16.16(5.71) mm/hr. Mean (SD) platelets (x10³/mm³) were 229.24(69.80) in cases while controls had 290.33(83.85), so platelets correlation with disease could not be established. CIMT was significantly raised in cases group. Mean (SD) CIMT in cases was 0.95(1.06) mm whereas in control group it was 0.60(0.16) mm with p value of 0.002. Moderate positive correlation was found between CIMT (mm) and SDAI and this correlation was statistically significant with p=0.001. For every 1 unit increase in CIMT, the SDAI increases by 2.92 units. A strong positive correlation between CIMT (mm) and Disease Duration (Years), and this correlation was statistically significant (rho = 0.9, p = <0.001). For every 1 unit increase in CIMT (mm), the Disease Duration (Years) increases by 1.26 units. Conversely, for every 1 unit increase in Disease Duration (Years), the CIMT (mm) increases by 0.19 units. Conclusion: A strong correlation was observed between CIMT and disease duration in rheumatoid arthritis. Hence, CIMT can be a useful surrogate marker for detecting atherosclerosis in patients with RA. In view of the relation to duration of disease, established RA patients should regularly be screened to identify the evidence of atherosclerosis and manage it earlier. Prevention of cardiovascular disease in RA requires an integrated approach encompassing cardiovascular risk factors screening and management, effective and sustained control of RA disease activity, high index of suspicion and prompt investigation of suspected cardiac disease.

Prediabetes is associated with increased cardiac events in patients with cancer who are prescribed anthracyclines.

Prediabetes, which is a precedent of overt diabetes, is a known risk factor for adverse cardiovascular outcomes. Its impact on adverse cardiovascular outcomes in patients with cancer who are prescribed anthracycline-containing chemotherapy (ACT) is uncertain. The objective of this study was to evaluate the association of prediabetes with cardiovascular events in patients with cancer who are prescribed ACT. The authors identified patients with cancer who received ACT from 2000 to 2019 from Clinical Data Analysis Reporting System of Hong Kong. Patients were divided into diabetes, prediabetes, and normoglycemia groups based on their baseline glycemic profile. The Primary outcome, a major adverse cardiovascular event (MACE), was the composite event of hospitalization for heart failure and cardiovascular death. Among 12,649 patients at baseline, 3997 had prediabetes, and 5622 had diabetes. Over median follow-up of 8.7 years, the incidence of MACE was 211 (7.0%) in the normoglycemia group, 358 (9.0%) in the prediabetes group, and 728 (12.9%) in the diabetes group. Compared with normoglycemia, prediabetes (adjusted hazard ratio [HR], 1.20; 95% confidence interval [CI], 1.01-1.43) and diabetes (adjusted HR, 1.46; 95% CI, 1.24-1.70) were associated with an increased risk of MACE. In the prediabetes group, 475 patients (18%) progressed to overt diabetes and exhibited a greater risk of MACE (adjusted HR, 1.76; 95% CI, 1.31-2.36) compared with patients who remained prediabetic. In patients with cancer who received ACT, those who had prediabetes at baseline and those who progressed to diabetes at follow-up had an increased risk of MACE. The optimization of cardiovascular risk factor management, including prediabetes, should be considered in patients with cancer who are treated before and during ACT to reduce cardiovascular risk. Patients with cancer who have preexisting diabetes have a higher risk of cardiovascular events, and prediabetes is often overlooked. In this study of 12,649 patients with cancer identified in the Clinical Data Analysis Reporting System of Hong Kong who were receiving treatment with anthracycline drugs, prediabetes was correlated with increased deaths from cardiovascular disease and/or hospitalizations for heart failure. Patients who progressed from prediabetes to diabetes within 2 years had an increased risk of combined hospitalization for heart failure and death from cardiovascular disease. These findings indicate the importance of paying greater attention to cardiovascular risk factors, including how prediabetes is managed, in patients who have cancer and are receiving chemotherapy with anthracyclines, emphasizing the need for surveillance, follow-up strategies, and consideration of prediabetes management in cancer care.

Cardiovascular Risk Management In Patients With Rheumatoid Arthritis: A Systematic Review.

Rheumatoid arthritis (RA) is an autoimmune chronic inflammatory joint disease associated with pain, swelling, and morning stiffness. It not only affects the joints but also exhibits many extra-articular manifestations. It is recognized as an independent risk factor for cardiovascular (CV) abnormalities. The possibility of cardiovascular disease (CVD) risk in patients with RA is about twofold higher compared to non-RA individuals. Therefore, early risk assessment and management of risk factors are crucial to reduce the CV morbidity and mortality associated with RA. This systematic literature review summarizes the data available on the management of CVD risk factors in RA. A total of 61 articles from the most reputable journals published between 2013 and 2023 were reviewed, of which seven papers were selected for in-depth analysis. We tried to eliminate bias using various bias-eliminating tools. This analysis considers the proposed solution for CV risk prevention and management in RA patients. Optimal control of disease activity and persistent monitoring of other factors responsible for increased CV events in RA patients is the ultimate management of CV abnormalities. This study summarizes the recommendations for the management of CV risk factors in patients with RA.

Uncovering atherosclerotic cardiovascular disease by PET imaging.

Assessing atherosclerosis severity is essential for precise patient stratification. Specifically, there is a need to identify patients with residual inflammation because these patients remain at high risk of cardiovascular events despite optimal management of cardiovascular risk factors. Molecular imaging techniques, such as PET, can have an essential role in this context. PET imaging can indicate tissue-based disease status, detect early molecular changes and provide whole-body information. Advances in molecular biology and bioinformatics continue to help to decipher the complex pathogenesis of atherosclerosis and inform the development of imaging tracers. Concomitant advances in tracer synthesis methods and PET imaging technology provide future possibilities for atherosclerosis imaging. In this Review, we summarize the latest developments in PET imaging techniques and technologies for assessment of atherosclerotic cardiovascular disease and discuss the relationship between imaging readouts and transcriptomics-based plaque phenotyping.

Shared Decision-Making in Cardiovascular Risk Factor Management

The effect of shared decision-making (SDM) and the extent of its use in interventions to improve cardiovascular risk remain unclear. To assess the extent to which SDM is used in interventions aimed to enhance the management of cardiovascular risk factors and to explore the association of SDM with decisional outcomes, cardiovascular risk factors, and health behaviors. For this systematic review and meta-analysis, a literature search was conducted in the Medline, CINAHL, Embase, Cochrane, Web of Science, Scopus, and ClinicalTrials.gov databases for articles published from inception to June 24, 2022, without language restrictions. Randomized clinical trials (RCTs) comparing SDM-based interventions with standard of care for cardiovascular risk factor management were included. The systematic search resulted in 9365 references. Duplicates were removed, and 2 independent reviewers screened the trials (title, abstract, and full text) and extracted data. Data were pooled using a random-effects model. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline. Decisional outcomes, cardiovascular risk factor outcomes, and health behavioral outcomes. This review included 57 RCTs with 88 578 patients and 1341 clinicians. A total of 59 articles were included, as 2 RCTs were reported twice. Nearly half of the studies (29 [49.2%]) tested interventions that targeted both patients and clinicians, and an equal number (29 [49.2%]) exclusively focused on patients. More than half (32 [54.2%]) focused on diabetes management, and one-quarter focused on multiple cardiovascular risk factors (14 [23.7%]). Most studies (35 [59.3%]) assessed cardiovascular risk factors and health behaviors as well as decisional outcomes. The quality of studies reviewed was low to fair. The SDM intervention was associated with a decrease of 4.21 points (95% CI, -8.21 to -0.21) in Decisional Conflict Scale scores (9 trials; I2 = 85.6%) and a decrease of 0.20% (95% CI, -0.39% to -0.01%) in hemoglobin A1c (HbA1c) levels (18 trials; I2 = 84.2%). In this systematic review and meta-analysis of the current state of research on SDM interventions for cardiovascular risk management, there was a slight reduction in decisional conflict and an improvement in HbA1c levels with substantial heterogeneity. High-quality studies are needed to inform the use of SDM to improve cardiovascular risk management.

Bridging Metabolic-Associated Steatotic Liver Disease and Cardiovascular Risk: A Potential Role for Ketogenesis.

The prevalence of cardiovascular diseases (CVDs) is a growing global health concern. Recent advances have demonstrated significant reductions in acute cardiovascular events through the management of modifiable cardiovascular risk factors. However, these factors are responsible for about 50% of the global cardiovascular disease burden. Considering that CVDs are one of the top mortality causes worldwide, the concept of residual cardiovascular risk is an important emerging area of study. Different factors have been proposed as sources of residual risk markers, including non-HDL particles characterization, as well as inflammation measured by serum and imaging technics. Among these, metabolic-associated steatotic liver disease (MASLD) remains controversial. Two opposing viewpoints contend: one positing that fatty liver disease merely reflects classical risk factors and thus adds no additional risk and another asserting that fatty liver disease independently impacts cardiovascular disease incidence. To address this dilemma, one hypothetical approach is to identify specific hepatic energy-yielding mechanisms and assess their impact on the cardiovascular system. Ketogenesis, a metabolic intermediate process particularly linked to energy homeostasis during fasting, might help to link these concepts. Ketogenic metabolism has been shown to vary through MASLD progression. Additionally, newer evidence supports the significance of circulating ketone bodies in cardiovascular risk prediction. Furthermore, ketogenic metabolism modification seems to have a therapeutic impact on cardiovascular and endothelial damage. Describing the relationship, if any, between steatotic liver disease and cardiovascular disease development through ketogenesis impairment might help to clarify MASLD's role in cardiovascular risk. Furthermore, this evidence might help to solve the controversy surrounding liver steatosis impact in CVD and might lead to a more accurate risk assessment and therapeutic targets in the pursuit of precision medicine.

Quality of care and clinical inertia in the management of cardiovascular risk factors in patients with type 1 and type 2 diabetes: data from AMD annals.

Cardiovascular disease is the leading cause of morbidity and mortality among patients with diabetes, and for this reason, all guidelines for CV risk management provide the same targets in controlling traditional CV risk factors in patients with type 1 or type 2 diabetes at equal CV risk class. Aim of our study was to evaluate and compare CV risk management in patients with type 1 and type 2 diabetes included in AMD Annals Database paying particular attention to indicators of clinical inertia. This was a multicenter, observational, retrospective study of AMD Annals Database during year 2022. Patients with diabetes were stratified on the basis of their cardiovascular risk, according to ESC-EASD guidelines. The proportion of patients not treated with lipid-lowering despite LDL cholesterol > to 100mg/dl or the proportion of patients not treated with antihypertensive drug despite BP > 140/90 mmhg and proportion of patients with proteinuria not treated with angiotensin converting enzyme inhibitors or angiotensinogen receptor blockers (ACE/ARBs) were considered indicators of clinical inertia. The proportion of patients reaching at the same time HbA1c < 7% LDL < 70mg/dl and BP < 130/80 mmhg were considered to have good multifactorial control. Overall quality of health care was evaluated by the Q-score. Using the inclusion criteria and stratifying patients by ESC/EASD Cardiovascular Risk categories, we included in the analysis 118.442 patients at High Cardiovascular risk and 416.246 patients at Very High Cardiovascular risk. The proportion of patients with good multifactorial risk factor control was extremely low in both T1D and T2D patients in each risk class. At equal risk class, the patients with T1D had lower proportion of subjects reaching HbA1c, LDL, or Blood Pressure targets. Indicators of clinical inertia were significantly higher compared with patients with T2D at equal risk class. Data regarding patients with albuminuria not treated with RAAS inhibitors were available only for those at Very High risk and showed that the proportion of patients not treated was again significantly higher in patients with T1DM. In conclusion, this study provides evidence of wide undertreatment of traditional cardiovascular risk factors among patients with diabetes included in AMD Annals Database. Undertreatment seems to be more pronounced in individuals with T1D compared to those with T2D and is frequently due to clinical inertia.

A289 MAJOR ADVERSE CARDIAC EVENTS (MACE) IN PATIENTS WITH A HISTORY OF LIVER TRANSPLANTATION: A NATIONWIDE ANALYSIS USING THE NATIONAL INPATIENT SAMPLE

Abstract Background Liver transplantation is the preferred treatment for end-stage liver disease. However, in around one-third of transplant recipients cardiovascular disease remains to be a significant contributor to morbidity and mortality. Aims Using data from the national inpatient sample (NIS), this study aimed to assess the prevalence and patient characteristics of MACE in those who underwent liver transplantation. Methods The study used a cross-sectional design to analyze NIS data, comparing MACE prevalence in hospitalized liver transplant patients. MACE included heart-related events. Patients with MACE and liver transplant history were identified using 2013 NIS data and ICD-9-CM codes. Baseline characteristics were compared, and association strength was assessed via logistic regression. Results Out of 33,725 post-liver transplant patients, 26.1% (8,805) had prior MACE. Those with MACE had higher rates of comorbidities: type 2 diabetes (odds ratio (OR) 1.90, 95% CI 1.69-2.13, p ampersand:003C 0.001), hypertension (OR=2.07, 95% CI 1.83-2.34, pampersand:003C 0.001), dyslipidemia (OR=2.27, 95% CI 1.97-2.60, pampersand:003C 0.001), and morbid obesity (OR=1.69, 95% CI 1.39-2.04, pampersand:003C 0.001). Smoking wasn't significantly linked (p = 0.738). Hospitalization with MACE increased in-hospital mortality (3.25%, p ampersand:003C 0.001). Conclusions These findings highlight the importance of proactive cardiovascular risk factor management to minimize the morbidity and mortality of MACE in this patient population. 1: Baseline characteristics of patients admitted to hospital with or without MACE after liver transplantation. Funding Agencies None

Clinical characteristics and degree of cardiovascular risk factor control in patients with newly-diagnosed type 2 diabetes in Catalonia.

Women with type 2 diabetes mellitus (T2DM) face a greater risk of cardiovascular disease (CVD) and encounter challenges in managing cardiovascular risk factors (CVRF); however, limited data are available in individuals with newlydiagnosed T2DM. This study aimed to examine differences between women and men at the onset of T2DM in terms of clinical characteristics, glycaemic status, and CVRF management. This was a retrospective cohort study including subjects with newly-diagnosed T2DM from the System for the Development of Research in Primary Care (SIDIAP) database in Catalonia (Spain). Sex differences (Dif) were assessed at baseline and 1-year post-diagnosis, by calculating the absolute difference of means or proportions. A total of 13,629 subjects with newly-diagnosed T2DM were analyzed. Women were older and had a higher BMI than men. At baseline, women had higher total cholesterol [Dif (95%CI) 10 mg/dL (9.1/10.8)] and low-density lipoprotein cholesterol (LDL-c) [Dif (95%CI) 7 mg/dL (6.3/7.7)], while men had higher rates of smoking and alcohol intake. Lipid target achievement was lower in women, in both primary prevention (LDL-c < 100 mg/dL) [Dif (95%CI) -7.3 mg/dL (-10.5/-4.1)] and secondary prevention (LDL-c < 70 mg/dL) [Dif (95%CI) -8.3 mg/dL (-17.3/0.7)], along with lower statin and antiplatelet prescriptions, especially one year after diagnosis. Changes in clinical and laboratory data one year post-diagnosis revealed that, in the primary prevention group, men experienced greater improvements in total cholesterol, LDL-c and triglycerides, while women had less success in achieving CVRF control targets compared to men. Additionally, cardiovascular events, such as coronary artery disease and peripheral artery disease increased more in men than in women within the first year of diagnosis, especially in primary prevention subjects. Differences between men and women CVRF are already apparent at the onset of T2DM, particularly in primary prevention, with notable differences in lipid profile and target level attainment.

ECCO Grant Risk of cardiovascular disease in patients with inflammatory bowel disease (IBD)

Abstract Background and Aims Although evidence has suggested an increased risk of venous thromboembolism and arteriosclerotic events in patients with inflammatory bowel disease (IBD), there are still substantial knowledge gaps about the long-term risk of cardiovascular disease (CVD) in patients with IBD and how CVD risks vary by disease histological and clinical activity. The aims of this project are: 1) to investigate the long-term risk (both absolute and relative) of CVD in patients with IBD, and 2) to assess CVD risks for patients in different phases of histological and clinical periods of IBD. Methods We will apply epidemiological and statistical methods to tackle the proposed research questions through using data from a comprehensive linkage of a nationwide histopathology cohort, one quality register for IBD, and several nationwide registers in Sweden. Individual informed consent will be waived as the study is register-based. Anticipated Impact The project will address several important knowledge gaps and benefit the IBD community in multifaceted ways. Findings from Aim 1 will help us identify patients with IBD at a high risk of developing CVD and enhance the awareness of screening, management, and treatment of cardiovascular risk factors in patients with IBD among healthcare professionals as well as patients and their families. Findings from Aim 2 will contribute towards an improved comprehension of CVD risk in different periods of histological and clinical activity, which can offer novel insights into guiding current therapeutic strategies aiming to mitigate the risk of adverse cardiovascular events in IBD patients. Overall, knowledge from our project can provide valuable evidence for the development of clinical guidelines for CVD management in patients with IBD. Currently, such guidelines remain underdeveloped.

Modifiers of the Association between E/e' Ratio and Survival among Patients with No Apparent Structural or Functional Cardiac Abnormality

BackgroundThe ratio between early mitral flow wave to early diastolic mitral annulus velocity (E/e’ ratio) varies according to age and sex and is associated with mortality in heart failure. We sought to describe the association between E/e’ and mortality in patients with no apparent structural or functional cardiac abnormality and explore possible modifiers of this association. MethodsA retrospective study of 104,315 patients who underwent echocardiographic evaluation during 2009-2021 in the largest tertiary center in Israel. Patients with cancer, ventricular dysfunction, significant valvular or structural heart disease, or evidence of pulmonary hypertension were excluded. ResultsThe final analysis included 32,836 patients with a median age of 56 (43-66) years, and 13,547 (41%) were female. The median E/e’ was 8.3 (6.8-10.3), and 9,306 (28%) had an E/e’ >10. During a median follow-up of 5.7 (3.3-8.5) years, 2,396 (7.3%) individuals died. E/e’ >10 was associated with mortality (adjusted hazard ratio [HR] 1.16, 95% confidence interval [CI] 1.07-1.27, p<0.001). The mortality risk associated with E/e’ >10 was significantly higher in those aged ≤70 (HR 1.26, 95% CI 1.12-1.42, p<0.001), males (HR 1.34, 95% CI 1.19-1.49, p<0.001), a normal left ventricular mass (HR 1.13, 95% CI 1.02-1.24, p = 0.017), and pulmonary artery pressure <30 mmHg (HR 1.18, 95% CI 1.06-1.30, p = 0.003). ConclusionAn elevated E/e’ is associated with mortality, specifically in younger individuals, males, and those with a normal left ventricular mass and lower pulmonary artery pressure. This suggests that an elevated E/e’ might be a marker of subclinical risk in these subgroups. Further studies are needed to identify whether an elevated E/e' is useful in shared decision-making regarding the management of cardiovascular risk factors.

Periodontitis : An underestimated risk of cardiovascular diseases

Epidemiological studies have identified periodontitis as a contributing factor to cardiovascular risk. Periodontitis is a chronic inflammatory disease that affects the tissues supporting the teeth. Although the nature of the association between periodontitis and cardiovascular disease (CVD) remains to be defined, the low-grade systemic inflammation and chronic bacteremia associated with periodontitis appear to be involved in the development of atherosclerosis and associated cardiovascular pathologies. Periodontal treatment has been shown to improve cardiovascular health parameters. A bidirectional preventive approach, involving the management of both periodontitis and cardiovascular risk factors, could lead to a reduction in morbidity and mortality related to cardiovascular disease.

High Risk of Thrombosis in a Prospective Cohort of Adults with Primary Immune Thrombocytopenia

Background: Patients with primary Immune thrombocytopenia (ITP) have an increased risk of bleeding but paradoxically also an increased thromboembolic risk. Aim: The aim of this study was to prospectively assess the occurrence and risk factors of symptomatic venous thrombotic events (VTE) and arterial thrombotic events (ATE) in patients with primary immune thrombocytopenia. Methods: This study included 160 adult patients with primary ITP enrolled in the Vienna ITP Biobank, a dual-center cohort study (Medical University of Vienna; Hanusch Hospital) that prospectively collects data of patients diagnosed with primary ITP (EC 1843/2016). Patients with primary ITP and a history of VTE or ATE, as well as those who experienced new or recurrent thrombotic events (TE) during the observation period, were categorized into two groups: with-thrombosis and without-thrombosis. The patient characteristics were compared using a chi-squared or Fisher's exact test for categorical and for numerical data were performed using the Mann-Whitney-U-test. The association between clinical risk factors and thrombosis were performed by univariable analyses using logistic regression model. Results: Of the 160 ITP patients (Table 1), 22 patients (13.8%) had 25 documented ATE or VTE. These events consisted of 11 ATE (44%), including 7 acute myocardial infarctions, 3 cerebral vascular events (stroke or TIA), and 1 peripheral artery thrombosis, and 14 (65%) venous events (1 superficial vein thrombosis, 7 deep vein thromboses, 2 deep vein thromboses with pulmonary embolism and 4 cases of isolated pulmonary embolism). 8 (36.4%) of 22 patients had a history of thrombosis. 17 (77.3%) patients experienced TE during the median observation period of 2.2 (1-3) years. Of them 14 (82.4%) patients had a new TE and 3 (17.6%) recurrent TE. The cumulative 1- and 5-year incidence of TE accounting for competing mortality were 1.9 % and 5.0%. Four (18.2%) patients with thrombosis died during the follow-up period. The cause of death was unclear for three patients, while one patient died from pulmonary embolism. Patients with thrombosis were significantly older (p=0.001) and had more comorbidities than patients without thrombosis (Table 1). There was no difference in the platelet counts between the groups. Antiphospholipid antibodies were present in 14.4% of the patients, and their prevalence was higher in the thrombosis group (p=0.002). In the univariable regression analysis, factors such as older age ≥75 years (OR 1.06; 95%CI 1.03-1.09, p=0.001) diabetes mellitus (OR 4.02; 95%CI 1.20-13.413, p=0.024), presence of antiphospholipid antibodies (OR 6.04; 95%CI 2.01-25.63, p=0.003), particularly lupus anticoagulant positivity (OR 5.39 95%CI 1.8-13.0, p=0.002), and splenectomy (OR 3.07; 95%CI 1.13-12.63, p=0.031) were significantly associated with a higher risk of arterial and venous thrombotic events among ITP patients. Body-Mas-Index, disease duration, tobacco use, hypertension, and use of corticosteroids or thrombopoietin receptor agonist (TPO-RA) were not associated with increased risk of VTE and ATE. Conclusion: We observed a high rate of ATE and VTE in our patients with primary ITP. Additionally, ITP patients commonly present with typical risk factors for thrombotic events, suggesting a strict management of cardiovascular risk factors. Close monitoring and tailored treatment strategies should minimize the risk of bleeding and thrombotic events.

Lipoprotein(a): An important piece of the ASCVD risk factor puzzle across diverse populations

Elevated lipoprotein(a) (Lp[a]) is an independent, genetic risk factor for atherosclerotic cardiovascular disease (ASCVD) that impacts ~1.4 billion people globally. Generally, Lp(a) levels remain stable over time; thus, most individuals need only undergo Lp(a) testing through a non-fasting blood draw once in their lifetime, unless elevated Lp(a) is identified. Despite the convenience of the test for clinicians and patients, routine Lp(a) testing has not been widely adopted. This review provides a guide to the benefits of Lp(a) testing and solutions for overcoming common barriers in practice, including access to testing and lack of awareness. Lp(a) testing provides the opportunity to reclassify ASCVD risk and drive intensive cardiovascular risk factor management in individuals with elevated Lp(a), and to identify patients potentially less likely to respond to statins. Moreover, cascade screening can help to identify elevated Lp(a) in relatives of individuals with a personal or family history of premature ASCVD. Overall, given the profound impact of elevated Lp(a) on cardiovascular risk, Lp(a) testing should be an essential component of risk assessment by primary and specialty care providers.

ABC (Atrial fibrillation Better Care) pathway in asian patients: an analysis from the prospective Asia-Pacific Heart Rhythm Society Atrial Fibrillation Registry

Abstract Introduction The "Atrial fibrillation Better Care" (ABC) has been proposed as an integrated approach to improve management in patients with atrial fibrillation (AF) based on 3 pillars: "A" Avoid stroke with Anticoagulation; "B" Better symptom optimisation through rate or rhythm control; "C" Cardiovascular risk factor management. There are limited prospective data on the clinical outcomes associated with ABC pathway adherence from Asian countries. Purpose To investigate the beneficial effect of ABC pathway adherence in the prospective multi-country Asia-Pacific Heart Rhythm Society (APHRS) Atrial Fibrillation registry. Method We investigated 4013 AF patients prospectively enrolled in the APHRS registry. Cox-regression analyses were performed to investigate the association between ABC adherence and clinical outcomes. Primary outcome was a composite of all-cause death, any thromboembolic events, acute coronary syndrome or percutaneous interventional procedures and new/worsening heart failure. Secondary outcomes were each component of the composite outcome and major bleeding. Results In the whole population, 1549 (38.6%) patients were ABC adherent (mean age 66±12 years; 33% female). After 1-year of follow-up, ABC pathway adherent patients had a lower incidence of composite outcome (4.0% vs 8.5%, p&amp;lt;0.001), all-cause death (1.4% vs 4.0%, p&amp;lt;0.001), cardiovascular death (0.3% vs 0.9%, p=0.013) and new/worsening heart failure (1.7% vs 2.7%, p=0.010), when compared to those ABC non-adherent. On multivariable Cox regression ABC pathway adherence was associated with a lower risk for composite outcome (Hazard Ratio 0.72, 95% Confidence Interval 0.53-0.97) and the reduction of the risk increased progressively with the number of the ABC criteria fulfilled. There was no statistically significant interaction in the clinical benefit seen between the different participating countries in the APHRS registry (pint=0.217). Conclusion In a large contemporary cohort of Asian AF patients, ABC pathway adherence was associated with a reduction of the risk for the composite outcome of all-cause death and cardiovascular events. This benefit was seen irrespective of enrolling country.

Physical activity and sedentary behavior patterns in individuals with a bicuspid aortic valve compared to healthy controls

Abstract Background A bicuspid aortic valve (BAV) is the most common congenital heart disease and associated with a higher lifetime risk of cardiovascular morbidity and mortality. Management of cardiovascular risk factors, including habitual physical (in)activity, is therefore key. However, little is known about physical activity (PA) and sedentary behavior (SB) patterns in individuals with BAV compared to healthy controls while there is debate how PA may influence BAV related cardiovascular complications. Purpose To compare objectively measured PA and SB characteristics between individuals with BAV and healthy age- and sex-matched controls. Methods Adults with BAV from our outpatient clinic were approached to participate and matched with age and sex- matched controls from the general population. SB, moderate-to-vigorous PA (MVPA) and step count were objectively assessed for 24 h/day during 8 consecutive days using an accelerometer (activPAL3 micro®) attached to the subject’s thigh. Transthoracic echocardiograms of the BAV participants were used to determine the presence of valvular dysfunction and to measure aortic diameters. Aortic dilatation was defined as &amp;gt;40 mm at the sinus of Valsalva or in the ascending aorta, whereas valvular dysfunction was defined as moderate-to-severe aortic stenosis or regurgitation according to current ESC guidelines. Results We recruited 100 BAV individuals (45±16 years old; 59% male), of which n=12 had valve dysfunction, n=22 had aortic dilatation and n=20 had a combination of valve dysfunction and aortic dilatation. We also included 100 healthy age- and sex-matched controls. SB was comparable between the BAV and control group (9.3 [8.5-10.2] vs 9.3 [8.2-10.2] hrs/day, p=0.84), whereas time spent in MVPA (72 [59-89] vs 98 [75-116] min/day, p &amp;lt;0.001) and daily step count (4,826 [4,004-5,801] vs 6,252 [4,784-7,484] steps/day, p&amp;lt;0.001) were markedly lower in individuals with BAV (Figure 1). Furthermore, no significant differences in SB, MVPA or step-count were found across BAV disease severity subgroups (Figure 2). Conclusion Individuals with BAV are less physically active compared to age- and sex-matched healthy controls. These differences were independent of disease severity, indicating that the lower activity patterns were not due to functional or disease-related limitations.Figure 1.Figure 2.

Insufficient long-term LDL-cholesterol management in patients with familial hypercholesterolemia 5 years after an acute coronary syndrome

Abstract Background Long-term control of cardiovascular risk factors after an acute coronary syndrome (ACS) is a cornerstone in preventing cardiovascular event recurrence. In patients with familial hypercholesterolemia (FH) and ACS, long-term management of LDL-cholesterol has been poorly studied. Purpose To investigate the extent of LDL-c and other cardiovascular risk factor management 5 years after ACS in patients with and without FH. Methods We collected data from 3,201 patients with an ACS from a Swiss multicenter cohort study and with 5-years follow-up data. At hospital admission for ACS, clinical FH was defined based on personal and familial history of premature cardiovascular disease as well as LDL-c levels, using the Dutch Lipid Clinic and the Simon Broome definitions. At the 5-years follow-up visit after ACS, we assessed LDL-c levels, lipid-lowering drugs, and control of cardiovascular risk factors comparing patients with FH and without FH. Results At the time of ACS, mean age of the 3,201 patients was 61.6 years old (SD 12.2), 643 (20.1%) were female, and 740 (23.1%) were diagnosed with clinical FH. At 5-years follow-up post-ACS, mean age was 56.6 years for FH patients and 69.6 years for patients without FH. 5 years after ACS, 15.4% and 33.5% patients with FH had an LDL-cholesterol ≤ 1.4 mmol/l, respectively ≤ 1.8 mmol/l, compared with 21.0% and 44.3% of those without FH (p=0.01, respectively &amp;lt;0.001) (see Figure and Table). Use of statins was similar between groups, but patients with FH were more frequently using high-dose statins compared to patients without FH (51.0% vs 42.9%, p&amp;lt;0.001). Use of lipid-lowering therapy in general such as statins, ezetimibe, fibrates, or niacin was more frequent in patients with FH than in those without FH (91.0% vs 87.0%, p=0.01). Beside LDL-c management, 5-year control of other cardiovascular risk factors tended to be superior in FH patients as compared to patients without FH: 78.5% vs 69.0% p&amp;lt;0.001 for systolic blood pressure (BP) &amp;lt; 140 mmHg; 46.2% vs 38.9% p=0.4 for reaching HbA1c &amp;lt; 7% in patients with diabetes; 46.9% vs 42.7% p=0.27 for smoking cessation, and 28.2% vs 21.0% p=0.1 for reduction of alcohol consumption &amp;lt;14 units/week . Conclusion Five years after an ACS, patients with FH had less optimal control of LDL-c levels despite being younger and more frequently using high dose statins compared to patients without FH. Combination of lipid-lowering therapy needs to be studied for optimal long-term management of patients with ACS and FH.Figure:CVRF 5 years post-ACS FH/non-FHTable:CVRF 5 years post-ACS FH/non-FH