Premature Ischemic Heart Disease Research Articles

Prevalence and management of familial hypercholesterolaemia in patients with chest pain admitted to hospital: a retrospective observational study

ObjectivesPatients with familial hypercholesterolaemia (FH) are genetically burdened by a lifelong elevation of the low-density lipoprotein cholesterol (LDL-C) level, putting them at a very high risk of premature ischaemic heart...

Traditional risk factors and premature acute coronary syndromes in South Eastern Europe: a multinational cohort study

The age-standardized death rates under 65 years from ischemic heart disease in South Eastern Europe are approximately twice as high than the Western Europe average, but the reasons are not completely recognized. The aim of the present study was to address this issue by collecting and analyzing data from a large, multinational cohort. We enrolled 70,953 Caucasian patients with first acute coronary syndrome, from 36 urban hospital in 7 South Eastern European countries and assessed their life expectancy free of acute coronary syndrome and mortality within 30 days after hospital admission from acute coronary syndrome as estimated in relation to dichotomous categories of traditional risk factors (current smoking, hypertension, diabetes and hypercholesterolemia) stratified according to sex. Compared with patients without any baseline traditional risk factors, the presence of all four risk factors was associated with a 5-year shorter life expectancy free of acute coronary syndrome (women: from 67.1±12.0 to 61.9±10.3 years; r=-0.089; p<0.001 and men: from 62.8±12.2 to 58.9±9.9 years; r=-0.096; p<0.001). Premature acute coronary syndrome (women <67 years and men <63 years) was remarkably related to current smoking and hypercholesterolemia among women (RRs: 3.96; 95% CI: 3.72-4.20 and 1.31; 95% CI: 1.25-1.38, respectively) and men (RRs: 2.82; 95% CI: 2.71-2.93 and 1.39; 95% CI: 1.34-1.45, respectively). Diabetes was most strongly associated with death from premature acute coronary syndrome either in women (RR: 1.52; 95% CI: 1.29-1.79) or men (RR: 1.63; 95% CI: 1.41-1.89). Public health policies in South Eastern Europe should place significant emphasis on the four traditional risk factors and the associated lifestyle behaviors to reduce the epidemic of premature ischemic heart disease. None.

Increasing Incidence of ST-Elevation Acute Coronary Syndrome in Young South Asian Population, a Challenge for the World? An Assessment of Clinical and Angiographic Patterns and Hospital Course of Premature Acute Myocardial Infarction

The incidence of premature ischemic heart disease (IHD) is increasing because of urbanization, a sedentary lifestyle, and various other unexplored factors, especially in South Asia. This study aimed to assess the distribution of premature ST-elevation acute coronary syndrome (STE-ACS) with its clinical and angiographic pattern along with hospital course in a contemporary cohort of patients who underwent primary percutaneous intervention at a tertiary care center in the South Asian region. We included consecutive patients of either gender diagnosed with STE-ACS and who underwent primary percutaneous intervention. Patients were stratified based on age as ≤40years (young) and >40years (old). Clinical characteristics, angiographic patterns, and hospital course were compared between the 2 groups. Of the total of 4,686 patients, 466 (9.9%) were young (≤40years). Young patients had a lower prevalence of hypertension (40.8% vs 54.5%, p<0.001), diabetes (26.6% vs 36.4%, p<0.001), metabolic syndrome (14.8% vs 24%, p<0.001), history of IHD (5.8% vs 9.3%, p=0.013) and a higher frequency of smoking (33% vs 24.7%, p<0.001), positive family history (8.2% vs 3.2%, p<0.001), and single-vessel involvement (60.1% vs 33.2%, p<0.001). The composite adverse clinical outcome occurrence was significantly lower in young patients (14.2% vs 19.5%, p=0.006). On multivariable analysis, history of IHD in young, whereas age, Killip class III/IV, intubated, arrhythmias on arrival, diabetes, history of IHD, pre-procedure left ventricular end-diastolic pressure, ejection fraction <40%, and slow flow/no-reflow during the procedure were found to be the independent predictors of adverse clinical outcome in old patients. In conclusion, we have a substantial burden of premature STE-ACS, mostly in male patients potentially driven by smoking and positive family history. Despite favorable pathophysiology, with mostly single-vessel hospital courses of STE-ACS in the young equally lethal in nature.

Declining trends of premature mortality from ischemic heart disease and regional differences in Italy from 2011 to 2017

AimsData regarding the premature mortality (<65 years of age) due to ischemic heart disease (IHD) in Italy are scant. We sought to analyze the incidence of premature death due to IHD in Italy and its time trend between years 2011 and 2017. Methods and resultsWe used the free publicly available EUROSTAT death certificate database to examine premature age-adjusted IHD mortality rates (per 100.000) and relative average annual percentage change (AAPC) in Italy from 2011 to 2017 using ICD-codes I20-I25. Over the study period, the proportional IHD-related mortality rates decline from 8.09% to 7.1% in the entire population (p for trend 0.012), showing a significant reduction in women (from 4.06% to 3.40%, p for trend: 0.02) but not in men (from 10.3% to 9.3%, p for trend 0.062). The age-adjusted IHD mortality rate decreased with an AAPC of −4.1 per year [(95% CI, −5.1 to −3.0), p < 0.001], resulting more pronounced in women [AAPC: −4.4 per year (95% CI: −6.4 to −2.3,), p = 0.001)] than in men [AAPC: −3.7 per year (95% CI: −5.4 to −2.0, p = 0.003)]. Age-adjusted IHD premature death rates above the 90th percentile were distributed in Italian southern regions and islands of Italy while premature death rates below the 10th percentile were clustered in the western and northeastern regions of the country. ConclusionsIn Italy, premature IHD-related mortality remains an important contributor to overall mortality. Age-adjusted mortality declined in the last decade, especially in the northern regions and among women. Moreover, a marked region-level variations were observed.

Platelet adhesion mediated by von Willebrand factor in patients with premature coronary artery disease

Aim To study platelet adhesion mediated by von Willebrand factor (VWF) in patients with premature ischemic heart disease (IHD).Material and methods This study enrolled 58 patients with stable IHD, including 45 men younger than 55 years with the first manifestation of IHD at the age of &lt;50 years and 13 women younger than 65 years with the first manifestation of IHD at the age of &lt;60 years. The control group consisted of 33 patients, 13 men younger than 55 years and 20 women younger than 65 years without IHD. Platelet adhesion to the collagen surface at the shear rate of 1300 s-1 was studied by evaluating the intensity of scattered laser light from the collagen-coated optical substrate in a flow chamber of a microfluidic device after 15-min circulation of whole blood in the chamber. Decreases in platelet adhesion after addition to the blood of monoclonal antibodies (mAb) to platelet receptors glycoproteins Ib (GPIb) to inhibit the receptor interaction with VWF were compared for patients of both groups.Results In patients with premature IHD, the decrease in platelet adhesion following the platelet GPIb receptor inhibition was significantly less than in patients of the control group (74.8 % (55.6; 82.7) vs. 28.9 % (-9.8; 50,5), p &lt;0.001). For the entire sample, the median decrease in platelet adhesion following the GPIb receptor inhibition was 62.8 % (52.2; 71.2). With an adjustment for traditional risk factors of IHD, a decrease in platelet adhesion of &gt;62.8% after blocking GPIb receptors increased the likelihood of premature IHD (OR=9.84, 95 % CI: 2.80-34.59; p &lt;0.001).Conclusion Blocking the interaction of GPIb receptors with VWF in patients with premature IHD and increased shear rate induced a greater decrease in platelet adhesion than in patients without this disease. This suggested that an excessive interaction of VWF with platelets might contribute to the pathogenesis of premature IHD.

Relationship Between Premature Birth and Acquired Heart Disease in Adulthood: A Meta-analysis and Systematic Review

Introduction Premature birth has a causal relationship with hypertension and diabetes, which are significant risk factors for major cardiovascular disease. Nonetheless, little is known whether premature birth portends future risks of acquired heart diseases, for example, ischemic heart disease (IHD), heart failure (HF), and valvular heart disease (VHD). Methods We comprehensively searched the databases of MEDLINE, EMBASE, and Cochrane database from inception to December 2021. Studies with prospective and retrospective cohort designs that reported the association between premature birth and acquired heart disease, including IHD, HF, and VHD, were included. Data from each study were combined with a random-effects model. The results were reported in the hazard ratio (HR) with 95% confidence intervals. Results The selected studies were comprised of 7 studies, with 5 studies involving premature birth and the development of IHD in adulthood and 2 studies involving premature birth and HF. No studies reporting the relationship between premature birth and VHD met our initial inclusion criteria. Our study did not find any association between premature birth and IHD in the adulthood (HR 1.14 95% CI 0.91-1.19, P = .16, I2 = 51%). We found the association between premature birth and acquired HF (HR 1.53 95% CI 1.08-2.16, P = .01, I2 = 0) Conclusion Premature birth was not statistically associated with IHD in adulthood, but there was a significant association between preterm and HF.

Targeted sequencing of a gene panel in patients with familial hypercholesterolemia from Southern Poland.

Familial hypercholesterolemia (FH) is an autosomal dominant monogenic lipid metabolism disorder characterized by a significantly elevated level of low‑density lipoprotein (LDL) cholesterol and leading to premature ischemic heart disease. FH is caused by mutations in the LDLR, APOB, and PCSK9 genes; however, these mutations account for only about 40% of FH cases. In order to obtain a genetic diagnosis of FH, sequencing of other genes involved in the lipid metabolism might be useful. This study aimed to describe genetic variants in genes associated with FH in a group of patients from the Małopolska province in Southern Poland, using the targeted next generation sequencing (NGS) technology. The study involved 90 unrelated adults (age range, 18-70 years) with FH diagnosed clinically according to the Simon Broome Register criteria. A custom‑designed capture assay and the Illumina MiSeq platform were used. The panel included exons and exon / intron boundaries of known FH‑causing genes: LDLR, APOB, and PCSK9, as well as genes previously associated with high cholesterol levels: APOE, ABCG5, ABCG8, LPL, NPC1, LDLRAP1, LIPC, STAP1, and CELSR2. Genetic variants were classified based on in silico predictions and ClinVar reports. We detected 4 patients with variants in the LDLR and APOB genes that had not been previously linked to FH in ClinVar. We also found APOB mutations outside the common LDL receptor-binding region, in exons 26 and 29. Interestingly, we observed a high frequency of pathogenic variants in exon 4 of the APOE gene: rs7412, probably damaging (4 patients) and rs429358, benign (16 patients). NGS is a useful and reliable method to detect new variants in genes related to FH. In addition, the results enable the detection of FH phenocopies and introduction of appropriate treatment.

Economic fluctuations and educational inequalities in premature ischemic heart disease mortality in Argentina.

Although mortality from ischemic heart disease has declined over the past decades in Argentina, ischemic heart disease remains one of the most frequent causes of death. This study aimed to describe the role of individual and contextual factors on premature ischemic heart disease mortality and to analyze how educational differentials in premature ischemic heart disease mortality changed during economic fluctuations in two provinces of Argentina from 1990 to 2018. To test the relationship between individual (age, sex, and educational level) and contextual (urbanization, poverty, and macroeconomic variations) factors, a multilevel Poisson model was estimated. When controlling for the level of poverty at the departmental level, we observed inequalities in premature ischemic heart disease mortality according to the educational level of individuals, affecting population of low educational level. Moreover, economic expansion was related to an increase in ischemic heart disease mortality, however, expansion years were not associated with increasing educational inequalities in ischemic heart disease mortality. At the departmental level, we found no contextual association beween area-related socioeconomic level and the risk of ischemic heart disease mortality. Despite the continuing decline in ischemic heart disease mortality in Argentina, this study highlighted that social inequalities in mortality risk increased over time. Therefore, prevention policies should be more focused on populations of lower socioeconomic status in Argentina.

Prevention and treatment of premature ischaemic heart disease with European Society of Cardiology Guidelines

ObjectiveTo determine if the changes in the European Society Cardiology/European Atherosclerotic Society (ESC/EAS) guidelines improved the identification for primary prevention therapy in young adults at risk of a premature myocardial...

Sudden unexplained death versusnonautopsied possible sudden cardiac death: Findings in relatives.

International guidelines recommend work-up of relatives to autopsy negative sudden cardiac death victims, denoted as sudden unexplained death (SUD) and nonautopsied possible sudden cardiac death (pSCD) victims. This study assesses and compare baseline characteristics and clinical outcome at initial evaluation and during follow-up of relatives to SUD and pSCD victims. We retrospectively included data from systematic screening and routine follow-up of first-degree relatives to SUD and pSCD victims referred to our Unit for Inherited Cardiac Diseases, Copenhagen, 2005-2018. Victims with an antemortem known inherited cardiac disease were excluded. We included 371 first-degree relatives from 187 families (120 SUD, 67 pSCD):276 SUD relatives (age 33 ± 18 years, 54% men) and 95 pSCD relatives (age 40 ± 15 years, 51% men). The diagnostic yields of inherited cardiac diseases in SUD and pSCD families were 16% and 13%, respectively (p = .8). The diagnoses in SUD families were mainly channelopathies (68%), whereas pSCD families were equally diagnosed with cardiomyopathies, channelopathies, and premature ischemic heart disease. Ninety-three percent of diagnosed families were diagnosed at initial evaluation and 7% during follow-up (5.4 ± 3.3 years). During follow-up 34% of relatives with a diagnosed inherited cardiac disease had an arrhythmic event, compared to 5% of relatives without established diagnosis (p < .0001). Channelopathies dominated in SUD families whereas a broader spectrum of inherited diseases was diagnosed in pSCD families. Most affected relatives were diagnosed at initial evaluation. The event rate was low in relatives without an established diagnosis. Long-term clinical follow-up may not be warranted in all relatives with normal baseline-findings.

Sex-Related Disparities in Cardiovascular Health Care Among Patients With Premature Atherosclerotic Cardiovascular Disease

There is a paucity of data regarding secondary prevention care disparities in women with premature and extremely premature atherosclerotic cardiovascular disease (ASCVD), defined as an ASCVD event at 55 years or younger and 40 years or younger, respectively. To evaluate sex-based differences in antiplatelet agents, any statin, high-intensity statin (HIS) therapy, and statin adherence in patients with premature and extremely premature ASCVD. This was a cross-sectional, multicenter, nationwide VA health care system-based study with patients enrolled in the Veterans With Premature Atherosclerosis (VITAL) registry. The study assessed patients who had at least 1 primary care visit in the Veterans Affairs (VA) health care system from October 1, 2014, to September 30, 2015. Participants included 147 600 veteran patients with premature ASCVD, encompassing ischemic heart disease (IHD), ischemic cerebrovascular disease (ICVD), and peripheral arterial disease (PAD). Women vs men with premature and extremely premature ASCVD. Antiplatelet use, any statin use, HIS use, and statin adherence (proportion of days covered [PDC] ≥0.8). We identified 10 413 women and 137 187 men with premature ASCVD (age ≤55 years) and 1340 women and 8145 men with extremely premature (age ≤40 years) ASCVD. Among patients with premature and extremely premature ASCVD, women represented 7.1% and 14.1% of those groups, respectively. When compared with men, women with premature ASCVD had a higher proportion of African American patients (36.1% vs 23.8%) and lower proportions of Asian patients (0.5% vs 0.7%) and White patients (56.1% vs. 68.1%). In the extremely premature ASCVD group, women had a comparatively higher proportion of African American patients (36.8% vs 23.2%) and lower proportion of White patients (55.0% vs 67.8%) and Asian patients (1.3% vs 1.5%) than men. Among patients with premature IHD, women received less antiplatelet (adjusted odds ratio [AOR], 0.47, 95% CI, 0.45-0.50), any statin (AOR, 0.62; 95% CI, 0.59-0.66), and HIS (AOR, 0.63; 95% CI, 0.59-0.66) therapy and were less statin adherent (mean [SD] PDC, 0.68 [0.34] vs 0.73 [0.31]; β coefficient: -0.02; 95% CI, -0.03 to -0.01) compared with men. Similarly, women with premature ICVD and premature PAD received comparatively less antiplatelet agents, any statin, and HIS. Among patients with extremely premature ASCVD, women also received less antiplatelet therapy (AOR, 0.61; 95% CI, 0.53-0.70), any statin therapy (AOR,0.51; 95% CI, 0.44-0.58), and HIS therapy (AOR, 0.45; 95% CI, 0.37-0.54) than men. There were no sex-associated differences in statin adherence among patients with premature ICVD, premature PAD, or extremely premature ASCVD. This cross-sectional study revealed that women veterans with premature ASCVD and extremely premature ASCVD receive less optimal secondary prevention cardiovascular care in comparison with men. Women with premature ASCVD, particularly those with IHD, were also less statin adherent. Multidisciplinary and patient-centered interventions are needed to improve these disparities in women.

Higher illness burden is associated with reduced heart rate variability in bipolar disorder

IntroductionBipolar disorder (BD) is associated with premature death and ischemic heart disease is the main cause of excess mortality. The predictive power of heart rate variability (HRV) for mortality has been confirmed in patients with or without cardiovascular disease. While several studies have analyzed the association between HRV and BD, their results are incongruent; and none has analyzed the effect of the clinical factors characterizing illness burden on HRV.ObjectivesTo assess the association between HRV and the following factors characterizing illness burden: illness duration, number and type of previous episode(s), duration of the most severe depressive or hypomanic/manic episode, severity of episodes, co-morbid psychiatric disorders, family history of BD or suicide, and duration and polarity of current episode in participants experiencing one.MethodsWe used a wearable device in 53 BD participants to assess the association between HRV using 4 measures (RMSSD, SDANN, SDNN and RR Triangular Index) and the abovementioned clinical factors characterizing illness burden. For each of the 4 HRV measures we ran 11 models, one for each burden of illness clinical factor as an independent variable.ResultsLonger illness duration, higher number of depressive episodes, and family history of suicide were negatively correlated with HRV; in the 14 participants experiencing a depressive episode, the MADRS score was negatively correlated with HRVConclusionsOur study analyzed the association between burden of illness and HRV in BD, while controlling for functional cardiovascular status, age, sex, BMI, education, and treatment. Our results showed that high illness burden is associated with reduced HRV.DisclosureNo significant relationships.

Reduced heart rate variability is associated with higher illness burden in bipolar disorder

BackgroundBipolar disorder (BD) is associated with premature death and ischemic heart disease is the main cause of excess mortality. Heart rate variability (HRV) predicts mortality in patients with or without cardiovascular disease. While several studies have analyzed the association between HRV and BD, none has analyzed the association of HRV with illness burden in BD. Methods53 participants with BD I and II used a wearable device to assess the association between HRV and factors characterizing illness burden, including illness duration, number and type of previous episode(s), duration of the most severe episode, history of suicide attempts or psychotic symptoms during episodes, and co-morbid psychiatric disorders. We ran unadjusted models and models controlling statistically for age, sex, pharmacotherapy, baseline functional cardiovascular capacity, BMI, years of education, and marital status.We also explored the association between HRV and an overall illness burden index (IBI) integrating all these factors using a weighted geometric mean. ResultsAdjusted and unadjusted models had similar results. Longer illness duration, higher number of depressive episodes, longer duration of most severe manic/hypomanic episode, co-morbid anxiety disorders, and family history of suicide were associated with reduced HRV, as was bipolar depression severity in the participants experiencing a depressive episode. Finally, a higher IBI score was associated with lower HRV. ConclusionsHigh illness burden is associated with reduced HRV in BD. While the IBI needs to be validated in a larger sample, it may provide an overall measure that captures illness burden in BD.

Impact of the 2003 to 2018 Population Salt Intake Reduction Program in England: A Modeling Study.

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Worldwide prevalence of familial hypercholesterolemia: Meta-analyses of 11 million subjects

Abstract Background Despite the greater prevalence of familial hypercholesterolemia (FH) in subjects with ischemic heart disease (IHD), premature IHD, and severe hypercholesterolemia (low-density lipoprotein ≥190 mg/dl), overall prevalence estimates are not available. Objectives The aim of this study was to provide worldwide estimates of FH prevalence in subjects with IHD, premature IHD, and severe hypercholesterolemia compared with those in the general population. Methods In this systematic review and meta-analyses, Embase, PubMed, and the Web of Science were searched until June 3, 2019, for peer-reviewed papers and conference abstracts reporting heterozygous FH prevalence in nonfounder populations, revealing 104 studies eligible for inclusion. Results Estimates of FH prevalence were pooled using random-effects meta-analyses and were 0.32% (95% confidence interval [CI]: 0.26% to 0.39% [corresponding to 1:313]) among 10,921,310 unique subjects in the general population (33,036 patients with FH) on the basis of 44 studies, 3.2% (95% CI: 2.2% to 4.3% [1:31]) among 84,479 unique subjects with IHD (2,103 patients with FH) on the basis of 28 studies, 6.7% (95% CI: 4.9% to 8.7% [1:15]) among 31,316 unique subjects with premature IHD (1,471 patients with FH) on the basis of 32 studies, and 7.2% (95% CI: 4.6% to 10.8% [1:14]) among 17,728 unique subjects with severe hypercholesterolemia (920 patients with FH) on the basis of 7 studies. FH prevalence in the general population was similar using genetic versus clinical diagnoses. Seventeen of 195 countries (9%) in the world have reported FH prevalence for the general population, leaving 178 (91%) countries in the world with unknown prevalence. Conclusions Compared with 1:313 among subjects in the general population, FH prevalence is 10-fold higher among those with IHD, 20-fold higher among those with premature IHD, and 23-fold higher among those with severe hypercholesterolemia. The prevalence of FH is unknown in 90% of countries in the world.

Diagnostic findings in relatives to victims of sudden unexplained death or non-autopsied possible sudden cardiac death

Abstract Introduction Sudden cardiac death (SCD) may be caused by several inherited cardiac diseases and screening and treatment of relatives may be lifesaving. Sudden unexplained death (SUD) victims have been autopsied, whereas non-autopsied possible SCD (pSCD) victims are only filtered on manner of death and medical records. Screening of relatives may identify an inherited cardiac disease. Purpose To assess the diagnostic yield at initial evaluation and during follow-up of relatives to SUD and pSCD victims. Furthermore, to evaluate the outcome in the relatives. Methods We retrospectively included first-degree relatives to SUD and pSCD victims referred to our tertiary center from 2005 to 2018. Probands with known antemortem inherited cardiac disease were excluded. Data from systematic screening and routine follow-up of the relatives were registered. Results We included 371 first-degree relatives from 187 families: 276 SUD relatives (age at initial evaluation 35±17 years, 54% men;) and 95 pSCD relatives (age at initial evaluation 40±15 years, 51% men). The diagnostic yield among SUD families was 18%, among pSCD families 13% (p&amp;gt;0.05 between groups). The diagnoses in SUD families were mainly channelopathies (68%), whereas the pSCD families were diagnosed with cardiomyopathies, channelopathies, and premature ischemic heart disease (Figure 1). The vast majority of diagnosed families (93%) were diagnosed at the initial evaluation and only two families were diagnosed during the mean follow-up of 5.4 years. During follow-up, 57 (15%) relatives had a cardiac-related hospitalization, 12 (3%) relatives had a cardiac device implanted, three (1%) relatives died of non-cardiac causes, and one (0.5%) relative had a myocardial infarction. There was no significant difference in cardiac event rates between the SUD and pSCD groups (all p&amp;gt;0.05). Conclusion One in 6–7 families with SUD or pSCD victims obtained a diagnosis based on screening of relatives; we mainly diagnosed channelopathies in SUD families and a broader spectrum of inherited cardiac disease in the pSCD families. The majority of affected relatives was diagnosed at the initial evaluation and clinical follow-up may not be warranted in all relatives with normal findings at initial screening. Figure 1. Family diagnoses in categories, n (%) Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): The Capital Regions Research Foundation and The A.P. Moeller Foundation.

Healthcare utilization and hospital variation in cardiac surveillance during breast cancer treatment: a nationwide prospective study in 5000 Dutch breast cancer patients

BackgroundVarious breast cancer (BC) treatments, such as chemotherapy and targeted therapies, increase cardiotoxicity-risk and lead to premature ischemic heart disease and heart failure among survivors. Reducing this adverse risk through early recognition and (preventive) treatment is therefore important. Conversely, we feel that screening for cardiotoxicity is currently insufficiently standardized in daily practice. A fundamental first step in identifying areas of improvement is providing an overview of current practice.ObjectiveThis study aims to describe current cardiac surveillance for women with BC during and after cardiotoxic cancer treatment, using routinely collected hospital data in the Netherlands. The study also describes hospital variation in cardiac surveillance.MethodsThis observational study was performed on claims data provided by Statistics Netherlands. From the data, newly diagnosed BC patients in 2013 (N = 16,040) were selected and followed up until 2015. Healthcare utilization analyses were performed for all cardiac and oncologic healthcare activities but with a specific focus on cardiac surveillance healthcare activities. In addition, differences between types and individual hospitals were evaluated.ResultsAlmost one third of all BC patients received high risk cardiotoxic treatments (N = 5157), but cardiac surveillance was rarely performed. Cardiac care provided to patients mainly consisted of ECGs (52.0%) and MUGA scans (26.5%). Cardiac MRI was performed in 0.7% of the patients, echocardiography in 17.7%, and measurement of Troponin and NT-proBNP in 5.1 and 5.8%, respectively. Moreover, we observed a substantial variation in cardiac surveillance between different hospital types and between individual hospitals.ConclusionThis study shows that women treated for BC with cardiotoxic treatments do not receive recommended cardiac surveillance. Standardized approaches in clinical care are lacking, resulting in low rates of diagnostic testing and a substantial variation in surveillance between hospitals. A structured approach and increased interprofessional collaboration could lead to tailored cardiac surveillance for early detection of cardiotoxicity and therefore start of treatment.

Worldwide Prevalence of Familial Hypercholesterolemia: Meta-Analyses of 11 Million Subjects

BackgroundDespite the greater prevalence of familial hypercholesterolemia (FH) in subjects with ischemic heart disease (IHD), premature IHD, and severe hypercholesterolemia (low-density lipoprotein ≥190 mg/dl), overall prevalence estimates are not available. ObjectivesThe aim of this study was to provide worldwide estimates of FH prevalence in subjects with IHD, premature IHD, and severe hypercholesterolemia compared with those in the general population. MethodsIn this systematic review and meta-analyses, Embase, PubMed, and the Web of Science were searched until June 3, 2019, for peer-reviewed papers and conference abstracts reporting heterozygous FH prevalence in nonfounder populations, revealing 104 studies eligible for inclusion. ResultsEstimates of FH prevalence were pooled using random-effects meta-analyses and were 0.32% (95% confidence interval [CI]: 0.26% to 0.39% [corresponding to 1:313]) among 10,921,310 unique subjects in the general population (33,036 patients with FH) on the basis of 44 studies, 3.2% (95% CI: 2.2% to 4.3% [1:31]) among 84,479 unique subjects with IHD (2,103 patients with FH) on the basis of 28 studies, 6.7% (95% CI: 4.9% to 8.7% [1:15]) among 31,316 unique subjects with premature IHD (1,471 patients with FH) on the basis of 32 studies, and 7.2% (95% CI: 4.6% to 10.8% [1:14]) among 17,728 unique subjects with severe hypercholesterolemia (920 patients with FH) on the basis of 7 studies. FH prevalence in the general population was similar using genetic versus clinical diagnoses. Seventeen of 195 countries (9%) in the world have reported FH prevalence for the general population, leaving 178 (91%) countries in the world with unknown prevalence. ConclusionsCompared with 1:313 among subjects in the general population, FH prevalence is 10-fold higher among those with IHD, 20-fold higher among those with premature IHD, and 23-fold higher among those with severe hypercholesterolemia. The prevalence of FH is unknown in 90% of countries in the world.

4117Cardiac surveillance during breast cancer treatment; a snapshot of current practice

Abstract Background Breast cancer (BC) is the most common type of cancer in women. Over the past decades survival rates increased up to 90% at 5 years and 83% at 10 years. The various BC treatments, such as radiotherapy, chemotherapy and immunotherapy increase cardiotoxicity risk, leading to premature ischemic heart disease and heart failure amongst survivors. Both affect women's daily routine and quality of life. Reducing this adverse risk, by early recognition and (preventive) treatment, is therefore important. Despite, screening for cardiotoxicity is currently insufficiently standardized in daily practice. A fundamental step in identifying areas of improvement is providing an overview of current practice. Purpose This study aims to describe current cardiac surveillance for women with BC during and after cancer treatment, using routinely collected hospital data in the Netherlands. Methods An observational study has been performed on Dutch hospital data from 2012 up to 2015, provided by Statistics Netherlands. Information about cardiology and oncology diagnoses, diagnostic procedures, treatments and preventive measures were available. Newly diagnosed female patients with codes malignant neoplasm of the breast (ICD-10, C50.0-C50.9) in 2013 and without any comorbidities since 1–1-2012 were included in the analyses. In follow-up data up to 31–12 2015, we mapped all types of care the patients received for BC and cardiology related indications. Results We included 16040 newly diagnosed BC patients in 2013, with a mean age of 65.9 (sd 12.9). A total of 5084 (31.7%) received chemotherapy, 1385 (8.6%) immunotherapy and 7870 (49.1%) radiotherapy. Amongst all included patients, 4376 (27.3%) received any type of cardiac care. Cardiology specific laboratory tests (e.g. Troponin) were performed in 96 (0.6%). Imaging procedures, such as echocardiography and MUGA occurred in 1853 (11.5%) and 1544 (9.6%) patients, respectively. Of the 5084 patients receiving chemotherapy 1862 (36.6%) received any type of imaging or cardiac care, of the 1385 patients receiving immunotherapy 689 (49.7%), and of the 7870 patients receiving radiotherapy 2401 (31.7%). Conclusions This study shows that only a quarter of Dutch women treated for BC receive cardiac surveillance. Diagnostic procedures or laboratory tests to detect cardiotoxicity are not structurally performed in women receiving cardiotoxic cancer treatments (e.g. chemo- and radiotherapy). A more structural approach and individual risk assessment is needed to provide more tailored cardiac care during BC treatment.

Improving Access to Safe Anesthetic Care in Rural and Remote Communities in Affluent Countries.

Inadequate access to anesthesia and surgical services is often considered to be a problem of low- and middle-income countries. However, affluent nations, including Canada, Australia, and the United States, also face shortages of anesthesia and surgical care in rural and remote communities. Inadequate services often disproportionately affect indigenous populations. A lack of anesthesia care providers has been identified as a major contributing factor to the shortfall of surgical and obstetrical care in rural and remote areas of these countries. This report summarizes the challenges facing the provision of anesthesia services in rural and remote regions. The current landscape of anesthesia providers and their training is described. We also explore innovative strategies and emerging technologies that could better support physician-led anesthesia care teams working in rural and remote areas. Ultimately, we believe that it is the responsibility of specialist anesthesiologists and academic health sciences centers to facilitate access to high-quality care through partnership with other stakeholders. Professional medical organizations also play an important role in ensuring the quality of care and continuing professional development. Enhanced collaboration between academic anesthesiologists and other stakeholders is required to meet the challenge issued by the World Health Organization to ensure access to essential anesthesia and surgical services for all.